Seriously ill geriatric who refuses to go to hospital.

Case history

Mrs Gladys Smith, aged 91, has had recurrent cellulitis of the legs, which normally improves with oral antibiotics. This time, however, she has not responded and her renal function is deteriorating. She does not seem confused, but she is refusing hospital admission, and seems unable to care for herself adequately. Dr Steve Brown discusses.

How should I react? I need to explore the reasons for her refusal. Has she had a bad experience of hospital? Does she simply want to die at home? Is she truly able to make an informed decision? What family support is there? I need to build a good relationship with her because I can sense some difficult decisions ahead.

What initial assessment is needed?

I need to re-evaluate my clinical diagnosis, while remembering to make detailed and accurate medical notes. Am I sure she has cellulitis? Could she have a DVT, or a ruptured Baker's cyst, or a more rare condition such as erythema nodosum? I need to check her compliance with the antibiotics I have prescribed, and consider adding another antibiotic or changing my original prescription. I might contact the microbiologist for advice. An MSU could give clues to her deteriorating renal function.

Who else could help me in this difficult situation?

I need to ensure she is mentally stable. I would do a formal mental state examination, and even if she scores full marks on a mini mental test score it would be useful baseline information. If I were not sure, an opinion of a psychiatrist or an elderly medicine consultant would be sought, via a home visit. The latter would also be able to advise me on medical management - for instance how frequently to monitor her renal function.