Marcus Hill is the temporary practitioner in a large nursing home in a city of 25,000 in the Midwest. He is filling in for Julie Anderson, who is on medical leave. Marcus is a tall, African-American man in his 30s. He has 6 years of experience as a nursing home practitioner and now works for a private company that provides social service consulting to nursing homes. He will be working for this nursing home for 3 months. Ann Paul, the Director of Nursing, stops by Marcus's office just as he is arriving on his second day of work at the facility. She is a Caucasian woman in her early 50s with short, dark hair, dressed in a suit. According to Julie, Ann has a reputation for being an organized but somewhat distant manager. The nurse aides are somewhat intimidated by her and try to stay out of her way as much as possible.

ANN: Marcus, I wanted to thank you again for filling in for Julie while she is on medical leave. I know you have only just gotten started, but I'd like to tell you about a resident that could really use your help. In our facility, we like the Social Services Director to get involved with residents as much as possible so they know them well when major problems arise. Unfortunately, we now have a serious problem before you have had a chance to get to know our residents.

Ann goes on to describe Bill Lee, a 48-year-old resident with ALS who has lived in the facility for about a year. Bill, who has never been married, is the designated health care representative for his mother, Yue, who is also a resident.. He is her only listed relative. There are no other contacts for Bill besides his mother. Bill has refused to even discuss making anyone his designated health care representative. Ann thinks that is something to work on later after they address decisions about his mother's care.

MARCUS: This is really an unusual situation! Tell me more about Yue.

ANN: Yue is an 86-year-old Chinese-American who was cared for by Bill at their home until last year when his condition made it impossible for him to continue to care for her. At that time, they both moved here to the nursing home. Yue has dementia and end stage COPD. She is unable to make any decisions for herself. Her doctor talked to Bill about beginning hospice services for Yue and about her code status which is currently full code. The doctor is concerned about what will be done to extend Yue's life if she should stop breathing or have other symptoms that would result in her being sent to the hospital for what the doctor thinks would be inappropriate treatment. He obviously can't discuss this with Yue, so he tried to talk to Bill about it yesterday. Bill was very hostile when the subject was brought up, so Dr. Saed backed off. Since Dr. Saed is the doctor for both Bill and Yue, he didn't want to alienate Bill by pushing him about this, so he asked for the practitioner to talk to Bill about it instead.

MARCUS: So Bill knows what Dr. Saed wants but is not in agreement?

ANN: I'm not sure exactly what Bill thinks. He can be difficult at times and complains a lot about the poor care here. I know it is hard to jump in on such a complicated situation, but it really needs to be dealt with as soon as possible. Dr. Saed is counting on it. One good thing, I think it might help that you are a man discussing this "man-to-man" with Bill. I know he wasn't that friendly with Julie, so maybe you'll have better luck.

MARCUS: You know, I think I have seen Bill in the dining room. I spent some time there at lunch yesterday and noticed a very thin Asian-American man slumped over in a wheelchair. His clothes seemed about two sizes too large and much dressier than you typically see in a nursing home. He kept beating his hand on the arm of the wheelchair as the aide tried to feed him. It seemed like he wanted to yell at her but didn't have the energy.

ANN: That sounds like Bill. He gives everyone who tries to care for him a hard time. On the other hand, Yue is the perfect patient - cooperative and docile. Well, I have to get going, so good luck!

MARCUS: Thanks, I'll talk to Bill sometime this morning.

Questions:

1. What are your preliminary impressions related to the case?

2. What are the key facts in the case?

3. What are some of the questions you might want to explore with the client?

4. How might your own spiritual, gender, culture, or ethical beliefs influence interacting with this client?

5. Do you have any biases, prejudices, or stereotypes related to this client? See the first posting under this discussion area for the description of Bill's case. Over the next week, have a discussion with the other members of your group on this board