Phoebe is a 72-year-old widow. She has suffered episodes of depression and anxiety all her life and once spent five weeks as an inpatient at the local mental health hospital (now Trust), following the birth of her youngest child. She lives alone in a small apartment in a popular coastal village in Northumberland, England. She went to school and raised her family there with her husband Donald, who she met at university in the 1960s. Long-standing residents are friendly and supportive of each other, knitted even more tightly by their desire to stand apart from the shifting but ever-present tourist population.
Phoebe’s children and grandchildren live close by. The family meets up most days and holidays together as well.
Phoebe has become increasing confused over the past few months, causing much concern to her family. She has been started on acetylcholinesterase inhibitors following investigations for suspected early-stage dementia. Though her confusion is a significant worry to her kin, she does have periods of lucidity.
Phoebe was recently treated for a UTI, which was possibly adding to her confusion, however she has improved after a week of treatment with trimethoprim.
Her daughter Wendy normally accompanies her when she visits Dr. Miller, the family’s GP. During a recent routine examination, the doctor found a lump in Phoebe’s breast. He reassured her that it was probably nothing to worry about but arranged for her to be seen in the breast assessment clinic for further investigations, as the lump was firm and immobile. After a few days the biopsy results showed Phoebe had early-stage breast cancer.
The oncologist wrote to Dr. Miller who called Phoebe and Wendy in. He was gentle with Phoebe and explained the result sparsely. He explained that a growth was found but that there were lots of therapies and the health team would work out the very best treatment. He did not use the word ‘cancer’. Dr. Miller prescribed tamoxifen and related therapies as recommended by the consultant. Phoebe and her daughter left the surgery calmly.
The next day Wendy asked for a consultation on her own, which was granted.
As she sits down today, she exclaims:
“I’m sorry doctor but this is not about me, it’s about Mum. I don’t think she understands her diagnosis. She’s not mentioned it at all, so I think it would be best if you monitor her of course but please don’t go into any further detail about her cancer. This will only upset her and after a while she’ll probably forget anyway…..” Dr. Miller agrees to be discreet if he can, within the bounds of his clinical responsibilities.
Wendy leaves the GP surgery, which has a pharmacy next door. As she is passing Wendy pauses, then enters. She and Pheobe are regular clients. She finds the pharmacist. Aware that her mother will be visiting shortly Wendy stands to one side of the counter, out of the way of other customers. She explains the situation:
“I’m sorry I know this is rather awkward but please understand that as a family we are all pulling together for Mum. We think this is just too much for her to handle so we want to take the pressure off her. We know she’s elderly and sick. We want her to enjoy the time she has left without worry. She gets confused so if she talks to you could you please just not discuss anything with her that might upset her?”
The pharmacist doesn’t know what to say. Then before she has had time to gather her thoughts Wendy says a loud ‘thank you’ and leaves the premises.
A little later Phoebe is in the pharmacy to collect her prescription, accompanied by Wendy. While Wendy is browsing the cosmetics counter Phoebe speaks to the pharmacist.
“I’m having trouble remembering to take my tablets, sometimes. I’m a forgetful old lady these days!” She laughs. “The doctor says its nothing to worry about. My children say not to worry either, they will take care of me…..”
She whispers conspiratorially, “They think I’ve lost the plot but… oh..!” Suddenly remembering she says, “Sorry I know what it was now, the doctor said he has sent my prescription over, and I am to ask you for it.”
She looks across at Wendy on the other side of the shop, lowering her voice. “I’m a bit confused about what all this is for, sorry. I know my lot don’t want me to fret, but could you please tell me what my medicine is for?”
The pharmacist looks up her prescriptions. One is for donepezil. Another is for tamoxifen. Donepezil is to help with memory, tamoxifen is a treatment for breast cancer.
The family has made their wishes clear – they want to protect their elder. Phoebe has also been clear, for the most part. She does have escalating cognition issues, but she has always been independent and assertive.
Phoebe has asked the pharmacist a direct question. Wendy, representing the family as a collective, has asked the pharmacist not to answer it in full. Neither Wendy nor any other family member has applied for power of attorney over Pheobe.
What should the pharmacist do? Should she explain to Phoebe that tamoxifen is a cancer treatment. Or should she support the family view, in Phoebe’s best interests?