HoNOS65+ case study written vignette - Mr Whareraia

Admission notes - ED

Putunga o te ra Whareraia is a 65-year-old, overweight elderly man. In the last six months, Mr Whareraia has been taken to ED services on five occasions for a number of accidents that have occurred in his home and local Marae.

Mr Whareraia has had two previous admissions to a general medical ward over the past six months.

Mr Whareraia was brought to the ED following a fall. He has suspected concussion. Admit general ward. Urgent referral for assessment made to Mental Health Services for Older People (MHSOP)

First assessment – MHSOP (includes notes obtained from ward file)

Ward notes

Mr Whareraia has been in the general medical ward for 72 hours. Staff in the general medical ward feel that Mr Whareraia should be placed in a nursing home to receive appropriate monitoring, assessment and treatment of his mental state and physical ailments. When this was raised with Mr Whareraia, he became physically aggressive towards the staff to the point that they restrained him. Hospital staff also noted that Mr Whareraia has become increasingly irritable and aggressive. On admission to the ward, when a female doctor attempted to do a physical examination, Mr Whareraia assaulted her with his walking stick.

Two days ago a staff member reported finding Mr Whareraia sitting in the lounge with his shirt off, scratching at his chest and talking loudly in Māori. He had scratched his chest to such an extent that it was bleeding. Staff are concerned that Mr Whareraia is purposefully endangering himself because he is depressed and wants to die in order to be with his wife who died two years ago. His family have reported that in the last week he has been talking to his dead wife and telling her that he will be with her shortly. The staff nurse reported that over the past 72 hours Mr Whareraia has had difficulty sleeping at night and is often observed dozing during the day.

Mr Whareraia has a number of physical ailments including gout in his leg, diabetes that he purports to be self-monitoring, and incidents of respiratory difficulty. Mr Whareraia appears to have a history of missing appointments with the diabetes nurse and heart specialist. When Mr Whareraia’s family came to collect him from hospital, they spoke for him and appeared to support his wishes to go back home and not receive the medical attention he requires.

MHSOP psychologist

Mr Whareraia’s son, Mana, said that since their mother died, their father has always talked to her and claims to see her. Mana also noted that his father had lost his appetite over the past month and that he had lost weight.

According to Mana, his father believes in rongoa (herbal or healing remedy) and has been using ‘some leaves’ to treat his gout. Mana stated that his father did like the odd drop of waipiro (alcohol), and had consumed alcohol for much of his adult life. He reported that last week Mr Whareraia had drunk more alcohol than was usual for him. His father told Mana that it helped him with getting to sleep at night.

Over the past two weeks Mr Whareraia has had increasing difficulty with sleeping at night.

Mr Whareraia’s first language is Māori. Mana reported that as his father gotten older he had chosen to speak Māori rather than English. Mr Whareraia has consistently refused to read and sign consent forms for treatment.

In the last two weeks, Mr Whareraia has attempted to walk to the nearby Marae for hui but has been unable to remember how to get there. Mana reported that because Mr Whareraia is one of the few kaumatua (elders) left who is able to do the speeches, he has many obligations to fulfil at the marae (Māori meeting place), for example tangihanga (funerals). Mana disclosed that on two occasions over the past two weeks Mr Whareraia had trouble remembering what the occasion was when he stood to do his speeches.

Mr Whareraia suffered a minor stroke one year ago and since then has had difficulty remembering information such as needing to collect his moko’s (grandchildren) from the Kohanga (preschool) and the way to get to the shop.

Over the past two weeks Mr Whareraia has needed to use a walking stick.

Mr Whareraia was observed scratching at his chest and talking in Māori. Mana reported that his father thinks that his old rugby mates are present in the room and that they are doing a special haka they learnt. Mana said the whanau (extended family) only stop Mr Whareraia when he makes his chest bleed.

Mr Whareraia appears to be untidily dressed. Mana stated that it is the grandchildren’s job to help ‘dress their koro’ (grandfather). Mana stated that whilst his father had a few problems, the whanau are supportive of Mr Whareraia and do all they can to assist him, for example preparing his meals and transporting him to where he wants to go.

Second assessment – Māori mental health service case manager

Mr Whareraia’s son, Mana, reported that his father had told him in the last week that his tinana (body) was dying and that he feels his wairua (spirit) was growing very weak. Mana reported that his father had been taken to visit the tohunga (Māori doctor) recently to help with his breathing difficulties. Mana identified that over the past two weeks there had been at least two occasions when his father had been approached by people who obviously knew him but his father did not recognise them. Mana observed that his father felt embarrassed by this.

Mr Whareraia’s whānau often leave their children in his care and although this can sometimes be tiring for Mr Whareraia, Mana stated that ‘the moko’s (grandchildren) are what keep his father going.’Mr Whareraia has a large family, many of whom live with him at his ‘papakainga’ (house on whānau land). His son stated that 10 people live in the 3-bedroom house. Because they live semi-rurally, it has been difficult to travel back into town for hospital appointments. The house has power and heating but does not have a telephone.

Mr Whareraia does not wish to live in the city, even though this may make it easier to receive the specialist care he requires. He has good relationships with his whānau and enjoys living with them on his papakainga.

Mr Whareraia is regarded as one of the kaumatua for his tribe. He attends all the hui (meetings) at the local Marae and is often called upon to officiate at openings of new buildings and blessings in the area. Several of these hui have been disrupted due to Mr Whareraia either being unwell or forgetting the hui are on. On a number of occasions Mr Whareraia has enlisted the assistance of his son to help explain to other kaumatua why he has not been at the hui. Mr Whareraia’s son expressed concern about the impact of this on his father. His father has expressed to him on many occasions, one as recently as last week, how he feels that his not attending hui and being able to meet his obligations as kaumatua brings shame on him and the whole whānau. His son noted his father was tearful when talking to him about this