When a 72-year-old white male with MS heard the doorbell ring he manually opened the door. A visitor entered the residence and introduced himself as a GAL who is a paid state employee appointed by a judge. The MS patient responded that he would not have time to talk to the GAL because he had been scheduled at a Daycare Surgery Center for a suprapubic cystostomy. Realizing that there would not be adequate time to talk, the GAL left an envelope filled with papers that could be read by the individual after his appointment. The GAL said that he would return to meet with the MS patient after he returned from the hospital following surgery.
Because the patient had been developing excessive urine in his bladder that became infected with Pseudomonas aeruginosa, his urologist prescribed ciprofloxacin (500 mg PO BID), which did not eliminate his fever of 102 F. Suprapubic cystostomy is very popular because it is an easier technique for people with MS who have limited mobility as well as patients with spinal cord injuries. Suprapubic cystostomy creates a tunnel from the abdominal wall of the bladder. A catheter is then inserted into the bladder through the tunnel. The catheter drains into a sterile collection bag and is irrigated daily with sterile saline.
According to Torres-Salazar and Ricardez-Espinosa, it is ideal to change the catheter every two weeks. The authors also advise that patients with a permanent suprapubic cystostomy have the catheter changed before cultures are taken to reduce the amount of antimicrobials prescribed, and lessen the increase in microbial resistance.
After placement of the suprapubic cystostomy, the patient became afebrile and was allowed to return to his residence without further treatment. Because he was now afebrile, personal care could be easily provided to him by certified nursing assistants that were familiar with the Guldmann ceiling lifts located adjacent from the patient's bed, as well as in the bathroom. Using these modern lift systems, he was able to be transferred by his certified nursing assistants who also wear back braces to reduce the chance for potential injury to their backs. On his scheduled meeting with the GAL, the GAL informed the patient that there was a meeting with the judge about the guardian ad litem case. A petition had been given to the MS patient by the GAL, in which his two children wanted to monitor and take control of his investment and real estate assets. The GAL advised the MS patient that his own attorney should be in the courthouse. The GAL indicated that he should select an attorney that focuses primarily on litigation on GAL cases.
Since 1890, the adverse effects of hyperthermia in patients with MS have been recognized. While most patients with MS experience reversible worsening of their neurologic deficits, several individuals experience irreversible neurologic deficits. In fact, hyperthermia can be caused through sun exposure, exercise, and infection especially a urinary tract infection.
The patient with MS selected a skilled attorney who specializes only in GAL cases, and was willing to represent the individual at the hearing and until settlement of the litigation. The patient, now with a suprapubic cystostomy, was transported by a handicap accessible van to the courthouse for the hearing. The judge made it very clear to the patient that he was responsible for paying his attorney fees, the salary of the GAL, the attorney for the GAL, and the attorney fees for his two children. In addition, he would need an evaluation by a psychologist selected by the GAL. The psychologist met with the MS patient and found normal communication skills, unless the consultation room had an elevated temperature. Finally, the judge indicated that he should receive personal care assistance 24 hours a day by a nursing home service selected by the GAL. The patient seated in the wheelchair explained that he did not need nursing provided people care in his home 24 hours a day because he had trained certified nursing assistants working between 7:00 am and 7:00 pm in his residence. In addition, he had an emergency medical alarm system from ADT home monitoring in his residence that was connected to either a wristband or a necklace with a medical alert button that could be pressed to alert emergency medical technicians in an ambulance service to take him to the hospital to treat his life-threatening illness. This system also responds to the presence of smoke or intruders of the home. After the nursing assistant would leave at 7 pm, he was able to contact the individual's cell phone and request any further assistance. In the past, he had never needed the nursing assistant to return for personal care. The judge ignored this suggestion and encouraged the GAL to request that the new nursing home service start providing care 24 hours a day. After the judge made this decision, the MS patient now had two personal care assistants working in his residence.
The individual with MS was now cared for from 7:00 pm until 7:00 am by relatively untrained licensed personal care assistants. When he found that the new nursing home services had no protective back braces and had never transferred a patient from a wheelchair using an overhead ceiling lift, he realized that he could be dropped inadvertently from the ceiling lift. During the three months of his experience with the appointed nursing home services, he had two challenges with hyperthermia induced by the nursing home services staff in his residence. In one case, the nursing home service closed his bedroom door causing a dramatic increase in the temperature in his bedroom. When he developed life-threatening hyperthermia, he had to call on the telephone one of his own hired nursing assistants to come to his home to reduce his body temperature. She opened the door of the bedroom and then removed the patient's pajamas that were soaked with sweat. She than had to wipe his body with cool water, dry his body, and put new dry clothing back onto the patient.
In the next episode, the employee from the nursing home service inadvertently turned off the switch in the bedroom that activated the overhead ceiling fan. When the patient with MS called out for her help, he surprisingly learned that she had a hearing deficit and could not hear his request to turn on the electricity to the overhead fan so he could control it with his remote. Because he now could not use his remote control unit for the fan, he had to call his same hired nursing assistant to return to his home to take care of his elevated body temperature.
Because the hired nursing assistant came to the patient's home to treat him for hyperthermia without contacting the nursing home service, the nursing home service requested that Adult Protective Services file a misconduct or criminal charge against his employee. The attorney for Adult Protective Service's refused to read the scientific publication listed as reference number eight. The attorney expressed no interest in the dangers of hyperthermia in patients with MS and was only interested in processing the litigation case against the employee who saved the patient's life.
The patient's attorney requested that he contact another attorney who specializes in financial settlements. This attorney developed settlement agreements with the GAL and his attorney, the children's attorney, and the nursing home services. The amount of the final bill for the GAL case was US$62,412.52 (Table 1). The attorney for the patient gave the list of the expenses that were approved and signed by the Judge in written documents. It is important to point out that the two petitioners were not asked to reimburse payment for the GAL or the GAL's attorney.