Aunt is refusing treatment in a psychiatric unit/hospital, how long can she stay there under this circumstance?

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I am a relative that is involved in giving advice/help to my cousin for his ailing mother. I work in healthcare, but he can't come to terms with what I am telling him is going on. He is in complete denial about her cognitive decline. Along with myself and my sister, we've tried countless times to convince him to get adequate care. She has been in and out of LTC rehab facilities after falls and a stroke but he always brings her back home. He has cared for her nonstop in the home for over 4 years since her first fall other than her stays at the facility. The home is not equipped to handle my ailing aunt, nor is my cousin. WE believe this has been to her detriment. She has symptoms consistent with dementia/Alz. as well as depression, but he refuses to recognize her behaviors. It has escalated to paranoia/delusions and she thinks she is being poisoned or poisoning others. She can't get to her second floor where her bath/shower are, so she has had neither one since being in a facility last June. My cousin does clean her up at the sink in the kitchen though. She has crying spells. She thinks her husband that died over 25 yrs ago just died. She is telling delusional and untrue stories related to him. She is barely ambulatory. She will go on and on about the same subject for hours and demand an answer. Once she is finally satisfied with an answer, she resumes the same line of questioning on the same subject hours later or the next day. She has started rummaging behavior. She has retreated from family even though she has very little. She has refused to see us for months. It would be helpful to assess and see what state of mind she is during a visit. The latest thing to happen, she has said she tried to commit suicide even though there is no way this could have happened. Her physician abruptly stopped her opiate that she takes due to pain from her previous injuries. I realize that a narcotic in the elderly can present a whole other set of problems, but to abruptly stop seems negligent. With the discontinuation of the opiate, came the start of Prozac all in the same weekend. So what I am wondering...is this a psychosis related to a possible dementia diagnosis, narcotic withdrawal, Prozac side effect, or a combination of all of the above? As my question states, she is now in the hospital after the suicide threat and been placed in the psychiatric unit for an undisclosed period of time. With her refusal to see the psychiatrist, how do they expect her to have improvement or feel better, if she continues to refuse treatment? She can't even get a proper diagnosis if the psychiatrist isn't able to perform his job and evaluate her. Any advice would be much appreciated. Thank you in advance.

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Hi there MaggieJane Thanks for the additional details. Just my thoughts here but if he is spending all his time with mom then I'm sure that is being noted by the staff. It sounds like a mutual codependency. As to what can happen about the diagnosis and her being unwilling to cooperate, a court ordered mandate can be given by the county court to administer the needed medication by shot until she is willing to take it by mouth. When a person has been in and out of psychiatric hospitals, they learn the lingo. They learn they can stonewall the staff and do what they want. They think they are protecting themselves. Maybe sometimes they are. But if the drs who are treating her have to, they can seek authority to force treatment. Surely not talk therapy but administering drugs can happen. I'm thinking that they see they have two patients in this case. They might be watching for mania or further acting out now that she is off the opiate. What has crossed my mind is what will happen to cousin once aunt is gone? As his family members, will you and your sister try to assume his care? Does he go to a dr of his own for help? He sounds like he will be lost without her. Maybe therapy for yourself will help you gain some perspective and clarity on your role in your family. You are a good cousin and niece. A cousin can be like a sister I think. They are lucky to have you and your sister watching over them. Try to get him out for a meal. Her treatment most likely will have to run it's course for now. One last thought. In spite of HIPPA laws, sometimes drs are really appreciative when they can gain access to additional information about patients. You might call and leave your name and number for aunts doctor. Let them know you are available if they need to speak with you. I have been told that HIPPA laws are a little different for mental health than for medical.
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This sounds like a case of a son who has a very unhealthy relationship with his mom--to the point he can't see the forest for the trees. She sounds as if she needs to be in some kind of facility 24/7 and not with an untrained (tho loving) caregiver. He also probably feels very, very protective of her and also has attached his sense of self worth to his ability care for her. He's never worked? He is actually OK with this lifestyle at age, 50? he's not likely to change.

Your concern about your aunt is legitimate. She can be held in a psych ward for 72 hours on a "hold", but can actually be there a lot longer. In my state, a suicide risk patient can be monitored as long as the psych drs want, then they have to undergo a lot of testing, and eventually the decision is made as to what long term TX will be. It could be that the son will not even have a chance to weigh in on her long term care. She may be placed in a psych hospital/care facility without his "consent" if she is deemed too sick to return home.

It sounds like this son is completely clueless about his mother's health. You keep getting called, can you sit down and really talk to him? (You probably already have done this...)

Yes, you can call APS on an anonymous basis. I don't know how much they can do. Maybe just check the living space and make sure Aunt is safe.

So sorry for you being dragged into this. Families make such drama in our lives. We'd never put up with this from strangers!
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MaggieJane....due to a situation that occurred with our father we did call APS due to spousal abuse. They were immediate with their response. You mention in your reply some real concerns( much much more concerning than ours)....HIS inability to care for his mother, her inability to maneuver, fall hazards, cleanliness and smoking. These are concerns that APS can listen to and address.And maybe they will not have the answers but at least it is another way to get some help and viewpoints. Your cousin does not need to know who called, even though it might be assumed it was family as no other people visit the home. Maybe he will think it was the cleaning people. You might want to see if the transition planners can make that call. Calling in third parties can be a necessary step when all else has failed.



Loving them is different than supporting them. If you are content with the way care is being given then by standing back you will show you are supporting them. If you think that changes can be made for the better then maybe you are not only supporting them but also letting them know that your love for them is why you are suggesting changes .

And yes, it can be tough to jump in and it can be tough to stay back. It is a choice.
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Maggiejane, your aunt and cousin have developed a relationship over the years that is impossible to understand without being privy to their interactions. Why this developed is impossible to guess. Maybe the aunt has knowledge about her son that she has never shared and she has felt the need to protect him. On the other hand the relationship may be totally unhealthful.
A psychiatric hospital is certainly the best place for her at the moment and hopefully the staff is sufficiently experienced to make a correct diagnosis.

Your family clearly respects your medical knowledge as you state everyone comes to you for advice. May I ask exactly what your medical background and experience is?
Your concern is admirable but unfortunately you have no power in this situation.

My suggestion would be to talk to the social worker at your aunt's hospital. He/she can certainly answer general questions about someone in your aunt's situation without breaching any HIPPA laws. The SW will know the Medicare guidelines for such a situation.

Your cousin may not have legal power over his mother is she has not specifically given it to him. Given their long intertwined lives it is possible she still thinks of him as a defendant child not capable of making decisions for her medical care. Legal advice was obviously taken at some point to put their affairs in order, which is excellent.
It also sounds as though the stroke your aunt suffered accelerated her condition and of course any surgery for an 80 year old certainly can adversely affect the patient's cognitive abilities even if only temporally.

People on this forum have wide experience not only about your current concerns but professional life in general so on first reading the first impression (at least mine was) is to step back and allow the professionals to do their jobs. If it is possible to visit your aunt as a loving relative i would see that as a good move as long as she is willing to see you. I certainly see your frustration but sometimes the best thing to do is sit quietly, observe and listen.Blessings.
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Anne1017, I appreciate your compassionate response and ability to see how dysfunctional their relationship is. Never in a million years do any of us in the family presume that we can change that dynamic. It is beyond repair for sure. However, we love them and support them. They have been there for us in our time of need too.

There are no dangers in the house as far as cleanliness as they have a service that has cleaned their house for 20 plus years, so no issues there. The home issues are his inability to care for his ailing mother, her inability to maneuver around safely and we worry about fall risks, not being on a level of the house to bath which hasn't happened since June of 2015(clean up done at the sink supposedly on a regular basis), her smoking which presents a fire hazard in her state of mind, he must leave at times when 24hr care is needed, those are the things I can think of off the top of my head. We have discussed Adult Protective Services as an option. This is just so tough because we don't want to cause extra problems for them. If anyone has experience with APS, please feel free to let me know.

I mentioned in my response back to Babalou that the financial affairs are not an issue in this situation.
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Gladimhere, I respect and hear everything you are saying, but with all do respect, I am not your sister or anything like her. I never asked to be part of this mess. I am merely trying to do the right thing. I will advocate for any patient that isn't being treated fairly, abused, neglected, or treated inadequately. Morally, that is what one should do. In a professional setting, one has an ethical responsibility, but I am not her caregiver in that way. So, It wouldn't be unethical for me to give my input, lend my help, support my family member, as I do not work/care for her in a professional medical setting. I guess I fail to see your point on that. I don't want POA. I don't want to be the healthcare surrogate. I don't want to control anyone's affairs. For the sake of not trying to be redundant, I will just say refer back to my initial post if anyone can give us guidance on what to expect in the psychiatric facility, what it looks like for any future she may have, and if anyone has experience with these symptoms in their loved one.

For the record, my family believes this is a blessing that she ended up in a psychiatric unit. That isn't what I am trying to debate here. Nor am I questioning the staff at this particular facility. I support their efforts in ultimately getting her diagnosis and proper medication management. I am not her physician, and I am not trying to diagnose her. That is not my place. As I stated above, I don't understand from a legal standpoint how long they are obligated to keep her if she continues to refuse treatment. Most of our society is aware that there are not enough facilities to treat the mentally ill, and there are people waiting in the wings to get their opportunity to get the help they so desperately need. I am worried her refusal will get her booted out before ever getting treatment. If this happened to be a 72 hr hold, I assume this would be the case.
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Babalou, thank you so much for your response. My cousin has been seeking my advice for years. Her first fall came 4 years ago and I was asked to rush to the hospital. I am always the one called first because of my background in healthcare. No, he has never held a job. He is not special needs either. It doesn't make sense that my cousin never sought gainful employment. That is a whole other story in itself! Their financial situation allows them to live comfortably.

They both have private insurance. Medicare is her secondary of course. When she has gone into skilled nursing for rehab after the falls, stroke, etc, they pay out of pocket for services not covered. The facility that she stays in doesn't even accept Medicaid. I don't know the particulars, but they may even have long-term care insurance. My assumption is that they have all this decided anyway when estate planning was done.

I am all too familiar with HIPAA laws, but what you said about talking to someone in the facility we have been discussing that already. We thought possibly speaking to the social worker. We fear that the entire story has not been told by my cousin in regards to how much she has actually declined over this time. He does this to protect her, keep her out of a LTC facility, and respect her wishes, but we continue to believe this has only been to her detriment. Every time she was discharged from skilled nursing in the past, my aunt and cousin told them nursing care would be provided in the home, which was never the truth. Once, one of our family members did alert skilled nursing to the level of care or lack there of at home and that the home was not set up properly to handle her needs, but she was discharged anyway. I will add that her cognitive function wasn't affected at that time and her mind still sharp. The DON at the facility said it was "safe enough" for her to go home. Needless to say, we were appalled, but our hands were tied so to speak.
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MaggieJane....Your description of the situation and the relationship between your aunt and her son is probably one you have no control over. It sounds like your Aunt has nurtured her son to be totally dependent on her for everything....and maybe she has been a roadblock in denying him a life of his own. Her refusal now for help, his refusal or inability to make better decisions are all signs of a family structure you cannot change. The suggestion of at least enlightening the discharge planners is a good one....and even if they pretend that you have no say in this situation I would bet they will hear you. The fact that the at home care seems less than adequate.....cleanliness?, possible dangers to her or her son?.... might signal a call to protective services. And Babalou makes a good point about the financial aspect of this situation. You might not be privileged to know any of that information but does anyone else? Maybe you should talk to them. Your intentions are admirable but it may be that you are limited in your involvement.
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Maggie, I have a twisted sister that claims to be in the medical profession and as such should be the one to make decisions about, not just my mom with alz, but every family member, immediate and extended. I have told her and other family members that this is unetical for her to do. Medical profession? She is a counselor, so I guess this should be mental health profession. She is the sick one, narcissistic. But, she will not stop. She has diagnosed others with everything from ADD, to depression to codependent. You name it. Just stay out of it. Your job is to be a loving niece and cousin and to offer support to all those involved. How would you feel if you had a patient you were caring for thaf questioned how you did your job? You should be supporting the medical pros providing care for your aunt and encouraging others to do the same. I am sure you are only trying to help with your assessment. But do not do it. You are too close to the situation. Ever hear that doctor's make the worse patients? This is why.

Step back support HER med pros let them do their jobs. This is what is going to help your cousin and all others involved the most!
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MaggieJane; this sounds like a very painful situation for all involved.

Who is seeking your advice? Your cousin? He's never held a job, at age 50? That's an interesting situation. What will happen to him when his mom dies? It sounds as though she will need long term care at some point; are they "generationally wealthy", i.e., millions of dollars in brokerage accounts?

If not, her assets are going to be used for NH care and then she'll be funded by Medicaid, who will put a lien on her property. Has a Special Needs trust been set up for the son? If he hasn't paid into SS, I don't believe he'll be eligible for that or for Medicare.

If there's anyone you should be talking to (and they won't be able to GIVE you any information, but you can give it) it's the discharge planners at the facility she's in right now. You should alert them to the level of "care" that she'd be going back to if they discharge her to home.
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