Difficulty in Securing Treatment for Degenerative Hip Disease in a Patient with Down Syndrome: The Gap Remains Open. DISCUSSION & CONCLUSION

Down Syndrome The Gap Remains Open DisscusDISCUSSION

This report documents a case in which, if not for the persistence of the care-seekers, appropriate med­ical care might not have been obtained for this person, possibly because of preconceptions held by certain physicians about people with mental retardation. The patient in question was in extreme pain, but she had to “doctor shop” to receive a standard treatment that probably would have been offered enthusiastically to a developmentally normal person.

The reluctant surgeons did not offer specific reasons for their disinclinations to operate on this patient, so we are left to speculate. Nevertheless, we do feel that this speculation is worthwhile if we are to understand, and then debunk, the misinformation underlying these disinclinations. To pursue this process, two surveys of physician attitudes about caring for persons with mental retardation proved helpful. Your life is worth living. Buy atomoxetine hydrochloride online

It is possible that some of the surgeons were concerned about an increased risk for a poor surgical outcome in a person with Down syndrome, as related to anesthesia, infection, postsurgical care or functional outcome. Although the safe administration of anesthesia to a person with mental retardation may present certain challenges, several reports have documented favorable results with this population. Reported postoperative infection rates for persons with mental retardation undergoing both nonortho-pedic procedures and orthopedic procedures have not been exceptionally high.

Although lack of cooperation with physical rehabilitation following total hip replacement is a valid concern and might prove to be a challenge in some people with mental retardation, this concern has not been universally validated. Moreover, the patient in question had always been extremely cooperative with the efforts of the developmental center staff and had an extensive support network. Favorable functional outcomes have been well documented following orthopedic procedures, including total hip replacement, in people with mental retardation. Save on your pharmacy bills. Buy celecoxib 200 mg online

Therefore, although the presence of severe mental retardation might be considered by some to be a relative contraindication to elective surgery, the literature does not validate this concern. It seems more likely that, in the absence of comorbidities, surgical risk is not materially impacted by the presence or absence of normal cognitive functioning.

Some of the surgeons may have been concerned about issues surrounding informed consent for surgery. In the case reported here, the patient had a legally appointed guardian folly authorized to grant consent. In fact, in most circumstances, people with mental retardation are either capable of making their own decisions or they have surrogate decision-makers legally empowered to make medical decisions on their behalf. Order imitrex online

Alternatively, some of the surgeons may have been unsure about how their fees would be paid. The woman whose case is reported in this article had Medicare insurance. Although significant inequalities of health insurance clearly exist, most people with mental retardation have health coverage, be it Medicare, Medicaid, Title-V programs or private insurance.

It is also likely that that some of the surgeons felt insecure in their knowledge of Down syndrome and mental retardation and did not know where to turn for support if, for example, the patient became frightened, agitated or violent in their office or in the hospital. This patient did not have such a history, and if such a problem had arisen with this patient, the developmental center was prepared to provide support.

Finally, it is possible that some of the surgeons felt it inappropriate to devote significant healthcare resources to the care of someone with a profound cognitive disability. The public consensus in this country has evolved over the past 40 years to the point that, with very few exceptions, people with mental retardation are felt to be entitled to full and unencumbered access to healthcare. Even in the area of solid organ transplantation, moves toward equal access have been reported.
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So far in this discussion, we have been critical of certain surgeons for their apparent reluctance to provide standard care to a person with mental retardation. On the other hand, we, the developmental center staff, need to acknowledge our own failures in this case. We should have anticipated and preventa-tively addressed for our consultants the issues that may have acted as impediments, thereby making the patient more welcome. We should have made it very clear to our consultants that we were ready to help in the analysis of potential contraindications, that we would help with consent issues and that we were prepared to help if behavioral issues were to arise. Also, by better communicating our own commitment to this patient, we could have sent a more compelling message about the appropriateness of devoting healthcare resources to this person.

CONCLUSION

In his report, the surgeon general put forth a national agenda to improve access to healthcare for people with mental retardation. The experience just reported implies that some physicians may have gaps in knowledge and also perhaps incorrect ideas about people with mental retardation and that these issues may be acting as barriers for people with mental retardation in their efforts to access appropriate healthcare services. In recognition of the importance of these issues, the surgeon general, as part of his national agenda, suggested that schools and institutions “integrate didactic and clinical training in healthcare of individuals with mental retardation into the basic and specialized education and training of all healthcare providers.” A published report on the coverage currently given to mental retardation in family practice residency programs demonstrates our shortcomings in this regard.
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So far, neither the Association of American Medical Colleges nor the Accreditation Council for Graduate Medical Education has responded to the surgeon general’s call to action. In contrast, it is noted that the Commission on Dental Accreditation of the American Dental Association has responded, declaring that “graduates of (dental schools and dental hygiene schools) must be competent in assessing the treatment needs of patients with special needs”.

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