Case Scenario 9 – Mrs. Winnifred Smythe Carruthers
Mrs. Winnifred Smythe-Carruthers is an 86-year-old, right-handed, English-speaking
Canadian woman. While attending a social dinner at the Boca Raton Golf & Country
Club in Boca Raton, Florida, she suffered an embolic right hemisphere cortical cerebral
vascular accident (CVA). Mrs. Smythe-Carruthers had comprehensive medical insurance
coverage provided by an independent Canadian health care insurance company, so she
was taken to a private hospital in Boca Raton where she was admitted immediately to an
acute care unit. She underwent a complete medical work-up including magnetic
resonance imaging (MRI), complete lab tests, and a neurological examination at the time
of admission.
The neurological examination revealed a dense left upper and lower limb hemiparesis,
with the upper limb more severely affected and in spastic contraction. MRI revealed a
dense cortical lesion in the right inferior frontal gyrus, expending posteriorly to include
antierior temporo-parietal and middle parietal lobe regions. No subcortical extensions
were noted. She displayed “la belle indifference”, difficulty dressing, constructional
apraxia, right-left discrimination problems, and slight slurring of speech production. Her
spontaneous language was tangential and verbose.
History taking revealed the following: long-standing hypertension for which she takes a
diuretic; hysterectomy age 45; hormone replacement therapy (i.e., estrogen); benign
metanoma removed from her upper back 5 years ago; bilateral sensorineural hearing loss
with a completely-in-the-canal (CIC) hearing aid for her left ear which is not usually
worn “unless she has to” ; non-insulin dependent diabetes mellitus. Otherwise she is in
relatively good health.
The Neuro-Rehabilitation team members met the day after Mrs. Smythe-Carruthers’s
admission to discuss the findings on admission, to determine which discipline specific
assessments were needed, and to begin the initial development of an integrated,
interdisciplinary plan of action.
The team consisted of a neurologist, nurse practitioner, occupational therapist, physical
therapist, speech-language pathologist, social worker, clinical neuropsychologist,
dietitian, and recreation therapist. Other medical, health and social care professionals
were available for consult as needed. It was agreed at the first team meeting that
comprehensive assessments were needed from physiatry, occupational therapy, physical
therapy, speech-language pathology, nursing, social work, and psychology. All team
members felt quite positive at the outset concerning the potential for recovery, despite the
severity of findings obtained at admission and the fact that Mrs. Smythe-Carruthers was
wheelchair bound.
A social history assessment conducted by the social worker revealed that Mrs. SmytheCarruthers married her second husband (a 78 year old man) 12 years ago. She has 3
children from her first marriage; two sons (56 and 59 years of age) and 1 daughter (63
years old). She also has five grandchildren and two great grandchildren. She has never
worked outside of her home. She completed her senior matriculation (Grade 13) and
completed one year of college during her youth in Canada.
Mrs. Smythe-Carruthers and her husband own a cottage in the Muskokas, a condominium
in Boca Raton Florida, and a condominium in downtown Toronto. Their primary country
of residence is Canada.
She is an Honorary President of the Horticultural Society. She has an extensive cadre of
friends and is quite meticulous about her appearance. She and her husband are well off
financially. She did drive prior to her stroke.
The attending internal medicine specialist encouraged Mrs. Smythe-Carruthers’s husband
to have her remain in hospital until her condition is stabilized and then have her
transferred to the hospital’s affiliated rehabilitation unit to begin intensive therapies. The
consulting neurologist however, examined her for a second time 3 days post-stroke and
felt that her condition was stabilizing and that she could be discharged from the hospital
within 10-14 days. The conflict in the recommendations between the two physicians
created some anxiety for Mrs. Smythe-Carruthers and her husband.
Mrs. Smythe-Carruthers’s children were contacted immediately by their stepfather
following their mother’s stroke. The children insisted that their mother return to Canada
as soon as possible to receive medical treatment. Mrs. Smythe-Carruthers’s granddaughter, a physician, consulted with her grandmother’s internist in Canada. He advised
the grand-daughter that her grandmother should come home as soon as her condition is
stable. In spite of the conflicting advice provided by the Florida internal medicine
specialist and the neurologist, Mrs. Smythe-Carruthers remained in the hospital and was
transferred to the hospital’s affiliated rehabilitation unit. Mrs. Smythe-Carruthers
Husband was pleased with this decision as he was under great stress given his wife’s
condition. Moreover, he was reluctant to travel with her in her present condition, even if
it was by Medivac Air Ambulance.
After two weeks in the rehabilitation unit where she received occupational and physical
therapies daily, Mrs. Smythe-Carruthers’s medical insurance company began to insist that
she return to Canada for long-term therapy. The cost of the Medivac to bring her back to
Canada would be far less costly than an extended stay in the US stroke rehabilitation
programme.
On the basis of the possibility of having her medical expense coverage revoked, Mrs.
Smythe-Carruthers returned home four weeks after her CVA via Medivac Air Ambulance
and was admitted to the Stroke Rehabilitation Unit at the Sunnybrook Health Science
Centre in Toronto. The team members (including an internist, neurologist, nurse,
occupational therapist physiotherapist, neuropsychologist, social worker, dietitian, and
recreation therapist) completed their assessments and discussed treatment options with
Mrs. Smythe-Carruthers, her husband, one son, and the grand-daughter. It appeared from
the assessment and progress reports filed by the US Neuro-Rehabilitation team that the
therapists had been using treatment approaches that were not used by their Canadian
colleagues at this facility
When Mrs. Smythe-Carruthers and her family were informed that her therapy programme
would change, they were confused as to why the treatment should be altered. They asked
the team for an explanation. The explanation that they received was unsatisfactory.
There was an extended discussion by Mrs. Smythe-Carruthers’s family, with heated
debate among them as to which treatment approaches would best serve her recovery
(those used by the Florida clinicians versus those used by the Toronto clinicians).
Adapted from Case Studies in Gerontology for the Applied Health Sciences: An
Education Resource developed by J.B. Orange, S. Hobson, M.F. Cheeseman, A.A.
Vandervoot, and M.E. Black, July, 1997.