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A piece of my mind. The "right" to fall.

The “Right” to Fall WHEN I SAW CARLA WALK INTO THE CLINIC WITHout her mother Marianne (not their real names), I knew it would be a long day. Carla is the daughter of an octogenarian patient who I had reluctantly discharged from the hospital late Friday afternoon with strict instructions for her to return to my clinic first thing Monday morning. When Marianne heard that I had agreed to release her, a rare smile came to her wrinkled face blooming with variegated bruises of green and yellow, blue and black hues. The senior medical resident nodded in concurrence, the intern slipped out of the room and sped to the nurses’ station to print out the discharge summary, and the case manager discreetly reached into her pocket and pressed the speed dial of her cell phone for an ambulance to take the patient home. There was only one person in the room who disagreed with my plan. Defeated, Carla leaned back against the wall, arms crossed, shoulders slumped, eyes cast toward the linoleum floor. Carla assumed a similar posture today, declining my offer of a seat, except this time her red-rimmed eyes were staring at me. She told me that her mother had refused to come with her to this appointment. “She fell again,” Carla reported in a monotone. “I told you she would. She didn’t hurt herself this time because I was there to catch her, but it’ll be just a matter of time until she breaks something again . . . or worse.” It wasn’t the first time Carla and I had disagreed on issues surrounding the medical care of her mother. Just a few months earlier, she admitted that she should have listened to my admonishment of being firm about asking Marianne to give up driving. A fender bender and several tenuous mother-daughter confrontations later, the garage was emptied and an alternative transportation plan was put in place. Anyone who has ever had to take away the car keys from an aging parent will tell you that it is one of the most difficult tasks that a child must undertake; in many cases, elderly persons either are unaware of the problem or are unwilling to acknowledge it, thereby leading to a conflict between parent and child, society’s safety and the older driver’s autonomy. Despite this difficulty, however, the shared goals of ensuring the safety of a loved one and the welfare of society compel most individuals to intervene. In some states, reporting an unsafe driver to the registry of motor vehicles is the law, making it easier for a well-meaning relative or responsible health professional to do the right thing. However, while many unfit drivers still ply our roads today, in the privacy of many homes and behind the confidential walls of hospitals countless other decisions are being made that lead to behaviors that are equally unsafe—but only to the individual in question. Fractures from preventable falls, life-threatening medication errors, a signed consent form for a medical procedure or clinical trial without a full grasp of possible complications and viable alternatives are some of the nefarious outcomes that arise from poorly made health care decisions. In Marianne’s case, she had refused our repeated recommendations to go to a rehabilitation facility to receive physical therapy that could improve her strength and balance and reduce her risk of future falls and dismissed our suggestion to have her daughter take over her medication management to keep her from doubling up on her blood pressure medicines. Each time Marianne ended up in the hospital, Carla begged us to go one step further—to commit her mother to a nursing home against her will. Buoyed by the written recommendations of the hospital ethics team, we refused to do this and instead abided by the advice of the hospital’s legal counsel to have Marianne sign an against medical advice form, file it in her chart, and send her on her way. Older folks certainly don’t have a monopoly on bad health care decisions, and in a free society many would agree that everyone beyond the age of reason is entitled to make poor judgments as long as they are willing to live with the consequences, provided these consequences do not affect another person. Thus, some individuals with emphysema continue to smoke, survivors of myocardial infarction refuse to exercise, and countless diabetics still revel in sugary and fatty foods. But can a decision truly be made without affecting another person? Carla would argue that her mother’s refusal of sound medical advice affects her—Carla—because she constantly worries that something bad is going to happen to Marianne. And what if poor decisions are made out of character? Marianne, as mother and schoolteacher, had made lifelong logical choices but now appears to make choices that are illadvised despite multiple falls and costly hospitalizations. Should we as a society act proactively and encroach on a person’s autonomy when she is putting only herself at risk of harm? With the rapid graying of the population, the issue of when and how to assess a person’s ability to make choices about his or her own health and safety has come to the forefront. Decisional capacity is a broad and complex concept that spans medicine, law, psychology, anthropol-