Mrs. P, 80 years old, lives in an apartment in an urban area and relies on the help of an in-home caregiver who spends 8 hours a day with her. In the past, Mrs. P has had difficulty finding competent helpers to assist with some of her daily activities. Mrs. P's daughter, who lives out of town and cares for a severely disabled child, helped hire her current in-home helper, Margaret. The last time Mrs. P's daughter visited her mother, she noticed her mental and physical health had deteriorated. She scheduled an appointment with her mother's doctor, Dr. Perkins, whom she has visited infrequently. Unbeknownst to her daughter, Mrs. P. has begun to increase her intake of alcohol in recent months as a way to cope with depression and feelings of isolation.

Mrs. P arrived late for the doctor's appointment accompanied by her in-home caregiver, who said she had trouble finding the doctor's office. In the exam room, Margaret said Mrs. P had requested she assist in talking to the doctor because Mrs. P frequently forgot details of her health conditions. Margaret said Mrs. P has been confused and anxious for more than 1 year. Furthermore, Margaret said Mrs. P was having more difficulty walking. On one occasion, Margaret said that when she arrived at Mrs. P's apartment in the morning, Mrs. P couldn't get off the bathroom floor. Since then, Mrs. P has been fearful of doing anything on her own and depends more and more on Margaret. Margaret says that since the fall, Mrs. P's daughter asked she move in with her mother and take on more responsibilities, including running errands and paying bills.

During the physical exam, the doctor noticed numerous bruises and abrasions in various stages of healing. Throughout the exam, Mrs. P was extremely agitated and continued to ask for Dr. Martin, her former family doctor who retired 10 years earlier from the practice.

Dr. Perkins prescribed antibiotics for an infected sore on Mrs. P's forearm, ordered lab tests, and scheduled an appointment for the next week to review the test results and conduct an assessment to rule out dementia.

When Mrs. P failed to arrive for the rescheduled visit and the doctor's office called her home, Margaret told the nurse that she had forgotten about the appointment. When Margaret finally brought Mrs. P for the follow-up visit, Mrs. P registered high blood pressure and her infection had worsened. During the visit, Margaret answered all the questions for Mrs. P. The staff determined the prescription for the antibiotics was never filled. Margaret continued to reassure the staff that Mrs. P was doing better, and that the infection had disappeared and only recently flared up again. At this point, Dr. Perkins initiated a home visit by a social worker.

One week later, Margaret brought Mrs. P to the emergency room, explaining she had fallen getting out of bed. An X-ray revealed Mrs. P had a broken arm, and an examination showed she was severely dehydrated. In consultation with the doctor, Margaret explained Mrs. P was difficult, incoherent, and demanding. Margaret further complained that Mrs. P was lazy, useless, and slept all day while she cleaned her home and did her laundry. Nonetheless, Margaret continued to insist she was the only one who knew how to handle Mrs. P. Throughout the exchange with the hospital staff, Mrs. P stroked her arm and asked for Dr. Martin.