Q: I have a patient that I have been seeing for quite a while for MS. After some pretty good years she has declined rapidly and has moved in with her sister, who is her caregiver. The problem is that she is now developing bed sores. I’m treating these in the office but that is not adequate and she needs at-home wound care.  However, she refuses to let me put her in for nursing visits. Her insurance would cover it, so money is not the issue. I have explained over and over that we can deal with this before it gets too severe but all that my patient says is that she is fine as she is and that her sister’s help is all that she needs.  Meanwhile, her sister, who comes to all appointments and is even present (at my patient’s request) on telemedicine visits, just sits there shaking her head when I suggest nursing care. As serious as my patient’s condition is, her quality of life does not have to be nearly as bad as what it is now becoming and this could eventually become life-threatening.  I think that she is actually profoundly depressed but she is competent, so what can I do?

A: Actually, based on your description, she may not be competent as regards this point.

That someone may have a serious mental condition but not be globally impaired usually comes up when consent is needed from a patient with a mental illness. In that setting, a patient who believes that he is Napoleon but who can understand what appendicitis is and the risks and benefits of surgery could sign his own operative consent form.

The current situation, though, is the opposite presentation: your patient may be able to manage her affairs generally but depression has likely impeded her ability to perceive her true condition and its risks.  She therefore falls short of the baseline requirement in competency statutes that a person must be able to perceive that they have a problem and to understand its nature. She therefore cannot engage in informed refusal of care because that requires the ability to evaluate the options against the extent of the condition before refusing

There is also the very serious question of whether the sister, out of misplaced good intentions or actually malign ones, is exerting an overweening influence on your patient’s choice as far as wound care, also impeding her ability to engage in a competent choice.

Your state’s requirements for mandated reporting therefore come into play

You could report at this point but since you believe that there is a treatable underlying issue you do have the option to offer referral to a psychiatrist or psychologist to assess her for depression and to treat her for such.  A positive change in her attitude to in-home wound care, backed by the consultant’s evaluation, would correct the problem and eliminate the reporting requirement. If, however, she refuses or the sister intervenes to block the process then your duty would require reporting.

This should be explained to your patient, emphasizing that your duty to her as her doctor means that you cannot continue to simply provide care that you know to be inadequate and that you also have a statutory duty to report in her interests.

This is not using reporting as a threat to coerce her into what you want her to do, which would be grossly unethical no matter how good your intentions were.  It is actually a recognition of her dignity and autonomy as a patient – which you clearly respect – before you introduce her into an outside process that you will not be able to control the course of.

Hopefully, she will accept evaluation for depression and you will be able to get her care back on a medically acceptable course.