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Case commentary 1

In his analysis of the case study of Sam, an 80-year-old man with advanced Alzheimer’s disease, Gary Mitchell states that ‘Nursing professionals each have their own unique take on the therapeutic lie which has served to make practices inconsistent as demonstrated in the case of Sam’. A variable standard of care does obviously not meet Sam’s needs or the needs of the other patients in the dementia unit; it would be desirable to provide consistently excellent care based on sound principles. In my comment, I explore the practical plausibility of this ideal aim. Mitchell also states that ‘The dilemma in Sam’s care is therefore around the clash of beneficence and veracity’. I think that the problems in Sam’s care are more complex and that simple sets of principles cannot provide for practical solutions. I will analyse the dilemma from three different, competing perspectives and try to look at the bigger picture of how we care for ageing individuals. This entails posing many more questions but hopefully will provide some tentative answers as well. As a retired registered nurse with 20 years of aged care experience at three Tasmanian nursing homes (and 40 in total in nursing), I can admit to having administered Risperidone tablets to patients without their consent on countless occasions. As a philosopher committed to acting morally, not just sitting in my armchair by the fire like one of my illustrious predecessors, Descartes, I was aware of the moral principles that conflicted with my professional nursing practice; moral distress was a constant issue. As the eldest of three daughters, and the only nurse in the family, with a mother with Alzheimer’s disease in a Finnish nursing home dementia unit, I was constantly clashing not only with the staff of the unit but also with my sisters and their husbands about the kind of care they and I thought she should be receiving. Sam has been admitted to the facility recently after being cared by his wife Elizabeth for several years. How does the couple feel about this significant change in their lives? It is fair to assume that both grieve for their old way of life and that they are unhappy to be separated after decades of marriage. Do they have children, how do they feel about the situation? Have they colluded with Elizabeth in administering Sam’s Risperidone on the pretext that it is a blood pressure tablet? How do Sam and Elizabeth find the resources available in the dementia unit? In my experience, the units are a small part of a larger nursing home of 70–90 people, the patients with dementia are cared for by one or two care assistants rather than by registered nurses who only administer the medications. In other words, do Sam and Elizabeth trust the staff of the unit and do they feel that they can communicate with them openly and that they are listened to? A trusting relationship is something that can only develop over time; in a busy unit, this can be a problem, care can become task oriented, and adhering to the ‘metric straight jacket’ takes priority over individual needs. When you are in a hurry to administer numerous medications to a large number of patients, it is easier, and common practice, to crush them and administer them in a small amount of food. Settimio Monteverde terms practices adopted from peers ‘the informal ethics curriculum’ involving ‘the dynamics of professional socialization’. Both as a nurse and the daughter of a mother with dementia (my mother died in June 2002),