Case 1:

An 86-year-old female patient admitted to hospital due to an increasing inability to cope at home and recent fall in which she suffered a broken hip. She has previously been diagnosed with COPD, hypertension and increasing cognitive deficits. While in recovery in hospital, an abdominal mass has been found (malignancy suspected but not confirmed), she has had a decrease in her ability to care for herself, difficulty swallowing with increasing aspiration risk, early stages of renal failure and an exacerbation of her cognitive issues.

The patient does not have a formal Advance Directive nor has she assigned a Power of Attorney. She has three daughters and one son who is a cardiologist and lives out of the province. The daughters have demanded that the patient be a full code, requested that transfer be made to ICU with a PEG tube placed and dialysis started should it be required. The son phoned you over the weekend and stated that given his mothers age and complex medical situation he expects that she would be provided symptom management and comfort care but that no aggressive measures should be undertaken to interfere with the natural decline and progression of his mother’s diseases. He has requested regular updates regarding her status and any interventions or treatments proposed.

What are some of the ethical issues in this case?

  • Does ‘increasing cognitive defects’ = lack of capacity?
  • Are any ethical principles in conflict? Autonomy? Beneficence? Nonmaleficence?
  • Can an SDM demand treatment?
  • Who is responsible for proposing a plan of care?

 

Case 2

Due to a steady decrease in total influenza inoculations among staff within the organization, leaders are searching for a way to reasonably increase those levels to protect vulnerable patients. A proposal is made to impose a mandatory influenza policy at the organization. How might you navigate this issue ethically?

What are some of the ethical issues you should consider?

  • Who should be consulted in this decision?
  • Are any rights at risk of being compromised?
  • What values need to be considered? Those of the organization? The patients and families? Staff? Board of directors?
  • Who is accountable for the decision?
  • Will this decision be made transparently, based on best evidence and justifiable reasons?

 

 

Case 3

Due to unexpected structural repairs, and a decrease in LHIN funding for the next fiscal year, your organization must ‘find’ $500,000 in savings in order to balance the annual budget. The operational team is looking to the Board for guidance.

How do you decide?

Things to consider:

  • Guiding principles at your organization – Guidance from your Ethics framework?
  • Mission, Vision, Values
  • Cornerstone programs – Can any be decreased, moved, or cut?
  • Possible criteria for allocation
    • Medical need
    • Medical benefit
    • Clinical efficacy/effectiveness
    • Cost-effectiveness
    • Practice guidelines and health care policies
  • Will the organization be transparent and accountable in their decisions?
  • Will you engage staff, patients, and the community in the decisions?

 

Case 4:

Mr. Smithwick is an 86-year-old patient who lives alone, and who was admitted to your hospital after a fall left him with a fractured hip. He has had multiple admissions to Emergency that were the result of mobility issues, and being able to safely move about in his three-storey home. He is well aware of the risks of living in his current residence, and is capable of making decisions involving his health care, including discharge. Although Mr. Smithwick no longer requires medical care from your hospital, the team feels uncomfortable discharging him home, and believes that he would benefit, and be at far less risk of falls in long-term care.

What are some of the ethical issues in this case?

  • Does the team have an obligation to protect Mr. Smithwick from (potentially) avoidable risk?
  • Does Mr. Smithwick, on the other hand, have a right to live at risk?
  • What safeguards are in place to ensure Mr. Smithwick is making an informed decision?

 

Case 5:

Mrs. Green, a 75-year-old patient with renal failure, currently on dialysis, who also has COPD, moderate dementia, diabetes and a new diagnosis of stage one breast cancer. There is also a past history of depression according to the family. She has been admitted to your ICU after falling down her stairs at home and is in critical condition with multiple fractures to her hip, ribs, wrists and neck. Mrs. Green does not have the capacity to make her own medical decisions and has recently started to refuse eating. Upon discussion with GI Specialists, the team agrees that the patient is not an appropriate candidate for a PEG (feeding) tube. The patient’s daughter, who is her POA, insists that the you proceed with the placement of the PEG, stating that if the tube is not placed she will contact her lawyer and proceed with legal action against the physician and hospital.

What are some of the ethical issues in this case?

  • Do we know the patient’s wishes, or values?
  • Will the fact that the team feels the patient is not medically appropriate (considering risks, benefits, and likelihood of success) for a PEG tube be the deciding factor? That is, can the daughter demand the PEG tube and expect that the team provides it?

 

Case 6:

Mr. Wilson, a 51 y.o. male patient, is admitted to the Intensive Care Unit in critical condition after a motor vehicle accident. He presented unconscious and is therefore unable to make his own medical decisions. The family of this patient provided a detailed formal advance directive which indicated that in the event of a traumatic injury such as this one, where the outcome is uncertain, the patient would consent to aggressive medical intervention in an attempt to stabilize and determine the severity of his injury. Life-sustaining interventions were therefore pursued.

After a myriad of test and a set of neurologic assessments were performed, it was determined that an anoxic brain injury occurred and it was not clear whether the patient would ever regain consciousness. The team needed some time to clearly establish a diagnosis, and the family members were kept informed of any progress that was made.

Several weeks passed as the patient stabilized, and the health care team was finally confident that the patient had met the criteria for being in a Persistent Vegetative State, a diagnosis that was presented to the family. According to the advance directive, if the patient were ever in a situation where their continued existence would be in such a state, he would want all life-sustaining intervention withdrawn, and be allowed to die. The family (spouse is no longer in the picture, 18 y.o. daughter, 20 y.o daughter, and 14 y.o. son) are presented with this formal diagnosis of PVS and are willing to continue to assume the responsibility of SDMs. The 14 y.o. son is adamant that his father is a ‘fighter’ and demands the team continue to ‘do everything possible’, and provide the most aggressive care they can. The 18 y.o. daughter agrees with the son, but the 20 y.o. daughter wants to respect her father’s wishes and refuse further life-sustaining measures.

What are some of the ethical issues in this case?

  • Who is(are) the designated SDM(s)?
  • Who do we listen to when they disagree?
  • Can the SDM(s) consent to a decision that would mean the death of the patient?

 

Case 7:

A 75-year-old healthy male was working on the roof of his house when he slipped and fell 10 ft. to the ground. He was knocked unconscious. When the paramedics arrived he was awake but confused. His vital signs were stable (e.g., Glasgow Coma Scale [GCS] score of 14). He was immobilized with a C-collar and backboard and taken to the ED. Shortly after arrival in the ED he became more confused, then sleepy. His GCS score decreased from 14 to 10. The attending emergency physician was concerned that perhaps the patient had a significant head injury and was in the process of arranging for a CT scan when the patient’s wife arrived. The patient’s condition continued to deteriorate, to a GCS score of 8. The emergency physician prepared to intubate him, but when she discussed this with the patient’s wife, the wife became upset and stated that her husband had a “living will,” which specifies that, if he became critically ill, he would not want any resuscitative interventions, including intubation.

*From: Pauls, M. et al. (2002). Ethics in the Trenches: preparing for ethical challenges in the emergency department. CJEM, 4:1, Pg. 45.

What are some of the ethical issues in this case?

  • Was the patient adequately informed when they declared their wishes? Did they put these wishes into a particular context? That is, were they intended for reversible, or irreversible illness?
  • Is the patient’s wife required to make a decision in the best interests of the patient? Who decides what is ‘best’?

 

Case 8:

An 82-year-old female patient with congestive heart failure and moderate dementia requires elective hip replacement surgery. Surgeon A and anesthesiologist A, however, considered her to be too high of a risk for surgery. Later in the week, surgeon B, who practices with surgeon A, has an anesthesiologist approve the patient for surgery even though the patient’s attending physician expresses extreme concern regarding the patient. On the morning of surgery, the patient suffers premature ventricular contractions, which the nurse in the preoperative waiting area notes in the chart. The nurse also notes that the patient’s husband is wary of the entire surgical process, stating that “everything had better go okay.” After speaking with the patient’s husband, the nurse realizes that he is unaware of the conflict between the surgeons involved with the case. Surgeon B is scheduled to leave town for a month the next day, so he is adamant about performing the surgery before leaving. The nurse discusses the patient’s unstable cardiac status with the surgeon. The surgeon listens attentively, but proceeds with the surgery anyway. The patient suffers a cardiac arrest during surgery. She is resuscitated and transferred to the intensive care unit, but she dies two days later.

What are some of the ethical issues in this case?

  • What is the obligation of the nurse in this case?
  • Was consent informed?
  • Who decides if the surgery is too risky?
  • Is the patient capable?
  • Has information been only been disclosed to the appropriate people?

 

Case 9:

A 90 year old female, Mrs. Ruth, from home with her daughter, is admitted to hospital after sustaining a hip fracture. She has a history of chronic obstructive pulmonary disease on home oxygen and moderate to severe aortic stenosis. (Obstruction of blood flow through part of the heart) She undergoes urgent hemiarthroplasty (hip surgery) with an uneventful operative course.

The patient and her family are of Jewish background. The patient’s daughter is her primary caregiver and has financial power-of-attorney, but it is not known whether she has formal power of attorney for personal care. Concerns have been raised to the ICU team about the possibility of elder abuse in the home by the patient’s daughter.

Unfortunately, on postoperative day 4, the patient develops delirium with respiratory failure secondary to hospital acquired pneumonia and pulmonary edema. (Fluid in the lungs) Her goals of care were not assessed pre-operatively. She is admitted to the ICU for non-invasive positive pressure ventilation for 48 hours, and then deteriorates and is intubated. After 48 hours of ventilation, it was determined that due to the severity of her underlying cardio-pulmonary status (COPD and aortic stenosis), ventilator weaning would be difficult and further ventilation would be futile.

The patient’s daughter is insistent on continuing all forms of life support, including mechanical ventilation and even extracorporeal membranous oxygenation (does the work of the lungs) if indicated. However, the Mrs Ruth’s delirium clears within the next 24 hours of intubation, and she is now competent, although still mechanically ventilated. She communicated to the ICU team that she preferred 1-way extubation (removal of the ventilator) and comfort care. This was communicated in writing to the ICU team, and was consistent over time with other care providers. The patient went as far to demand the extubation over the next hour, which was felt to be reasonable by the ICU team.

The patient’s daughter was informed of this decision, and stated that she could not come to the hospital for 2 hours, and in the meantime, that the patient must remain intubated.

At this point, the ICU team concurred with the patient’s wishes, and extubated her before her daughter was able to come to the hospital.

The daughter was angry at the team’s decision, and requested that the patient be re-intubated if she deteriorated. When the daughter arrived at the hospital, the patient and daughter were able to converse, and the patient then agreed to re-intubation if she deteriorated.

What are some of the ethical issues in this case?

  • Who should make decisions in this situation?   Should the ICU team have extubated the patient?
  • Do religious beliefs constitute a justification for demanding treatment when it is not indicated?
  • Does the change in the patient’s decision mean that she lacked the capacity to make the decision in the first place, or that she was not well informed?

 

Case 10:

A 65 year-old female patient was admitted to hospital in mid-July with a diagnosis of Metastatic Stomach Cancer and for not being able to meet her caloric intake at home. This patient is married, with three adult children (two in town, one in a different city, 6 hours away). She is a very proud and attentive grandma to two grandchildren, her own mother is still alive, and she has four siblings all living in Montreal. This patient has been followed in Montreal by an Oncologist for the past 3 years. 80% of her stomach was removed, and she currently has a CADD pump for pain – a small pump designed to deliver medication when patient’s are up and about. In developing a treatment plan with this patient, her physician first considered two options: 1) Peg tube – This was not considered medically appropriate because of the significant risks involved, or 2) Naso-Gastric tube – This was not an acceptable option, according to the patient, because of the risks involved and impact on her quality of life.

At this point Total Parenteral Nutrition (TPN) was initiated as the only appropriate option to fulfil the patient’s nutritional needs. TPN is a method of feeding that bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs. The method is used when a person cannot or should not receive feedings or fluids by mouth.

The patient remained in hospital and received TPN, with the goal of receiving home TPN through the local home-care provider. A referral was made for this home service, but due to the short life expectancy of the patient, she did not meet the required criteria and was not added to the waiting list. Despite this the patient’s goals remained consistent: enjoy an acceptable quality of life, be with and see her grand children, and be able to go home so that she can spend her final days with her family.

What are some of the ethical issues in this case?

  • Without having more information, can we know if the process for assessing home-TPN eligibility is fair?
  • Without knowing that TPN would not be provided at home, was this patient fully informed in making a decision to consent to the initial TPN in hospital? That is, would her decision to initially pursue it have changed, if she knew that she would be required to receive it in hospital?

 

Case 11:

At your organization, a long-service nurse, that has no history of disciplines, is the subject of recent concern. She is well liked by her coworkers, and is well known to post frequently to social media, including Facebook. Many coworkers are “friends” on Facebook with this particular nurse, and have noticed several concerning posts. In particular, the nurse in question reacted to some of the recent world events regarding Syria, and the increase in refugees entering Canada.

The posts content included: Feelings that “they” should stay in their own country, and concern that Canada could experience an attack similar to the one in Paris unless strict security controls are in place.

These posts have been reported to the manager by coworkers because they are concerned about the potential treatment of patients that such posts refer to. In fact, one of the co-workers characterized the posts as “racist”.

What are some of the ethical issues in this case?

  • Can your personal life and actions that take place outside of work impact your work life?
  • Is personal ideology that is not communicated at work, related to work?
  • Is it enough to know how an employee feels vs how the employee acts?
  • Are these comments damaging to the Organization?
  • Is there a question of how this RN will treat patients of this ethnic decent?
  • What is the college of nursing’s obligations in this matter?
  • Does the nurse have a right to privacy and/or freedom of expression? To what extent?
  • Must you weigh the importance of perception versus intent? Does intent matter?

 

Case 12:

A patient is brought to your local Emergency Department after police found her in the middle of the street striking herself in the abdomen. She presents at 8 months pregnant and an underlying mental health issue has her believing that there is a tumor, rather than the fetus, inside of her. Additionally, the treating physician is unsure that the patient is being completely honest in her responses to his assessment questions regarding drug use (so that he may try to avoid any adverse drug interaction in his recommended treatment), and upon believing that he has heard her name in the local media as being charged with possession of illicit drugs, decides to ‘google’ her. Despite this, the team determines that the patient does not fit the criteria for a Form 1 (Mental Health Act) and thus decides to discharge her since her behaviour has stabilized and she no longer has an acute need. The team continues to be concerned about the patient’s well-being, and considers informing the police or local shelter in her area just to keep an eye on her.

What are some of the ethical issues in this case?

  • Should you ‘google a patient’? Are there ethical concerns with doing so?
  • Where does respecting patient privacy become ‘muddy’ in your experience?
  • Are there ever situations in which it might be ethical to violate privacy even though that may contradict the law?

 

Case 13:

Mr. Jameson is a former patient of yours who has recently deceased. Several days after his death, his son, who you have met on several occasions before and who had a good relationship with his father, comes to the unit to thank you for taking such good care of his father when he was under your care. The son does not have a good relationship with his sister, who was their father’s Power of Attorney (POA), and thus has not received any details on how his father died. He requests this information from you.

What are some of the ethical issues in this case?

  • Even though the son is not the POA, can you provide information on his father’s death to him?
  • Is consent required to release Personal Health Information after death?

 

Case 14:

A 30-year-old female who is 37 weeks pregnant is admitted under a “Form 3” to inpatient psychiatry for acute psychosis, severe substance abuse, and uttering death threats about her unborn child. (A Form 3 allows the patient to be held for up to two weeks.) After being re-assessed by Psychiatry, progress notes indicate that the patient is “legally competent”. Some of the nursing staff have voiced that they disagree and that she is not always capable of making informed consent decisions related to herself and/or her fetus.

Several days into her admission, the patient begins to experience mild contractions. The staff have many questions: What is the birthing plan? Can patient consent to one? How will patient rights be protected? How will the OB GYN and Nursing Staff be protected? How will the baby be protected?

OBGYN states she wants patient to consent to caesarian section (C/S), as it is felt this is safest for the patient, the unborn baby, and the staff involved.

At a visit on day 4 of admission, Social Work feels that the patient now wants to protect her unborn baby from harm. In addition, they believe that it would be a great time to have an open conversation about plan of care with the patient. The OBGYN and SW visited the patient to ensure she was able to understand, and the OBGYN determined at this time that the patient was capable to provide consent. The patient decided to sign for caesarian section, if necessary.

At this point, the team and patient made the decision to investigate who the substitute decision-maker would be, should the patient again lose capacity. Joint decision makers were found, in the patient’s parents, who were listed as next of kin. They were asked to jointly make/ agree upon a plan of care for both their daughter and their unborn grandchild. The patient remained on inpatient psychiatry unit until the baby was born two weeks later, by caesarian section.

What are some of the ethical issues in this case?

  • Should the substitute decision-makers (SDMs) have been present earlier in this admission? Who was providing consent for the patient, when incapable, when the SDMs were not involved?
  • What rights does the fetus have under the law?
  • While the patient agreed to C/S in advance, what happens if she changes her mind in the moment?

 

Case 15:

The situation:

  • Current occupancy at an acute care hospital is 125%. Specifically, volume includes:
    • 18 “Unfunded beds” that have been opened, including some located in hallways,
    • 15 admitted patients who are currently residing in the emergency department (in rooms and hallways),
    • 5 surgical patients waiting for OR,
    • 1 patient with hip fracture that has been waiting for a bed for 2 days,
  • 3 patients who are due to return from another hospital since care needs have decreased,
  • 34 ALC patients (22 confirmed waiting for long-term care, and 4 others pending)
  • Anticipated capacity includes:
    • 2 discharges from the medicine unit
    • 1 discharge from surgery
    • 2 CCU beds if the organization can transfer 2 elsewhere
  • Compounding issues:
    • Some of the overcapacity is additional hallway spaces on the inpatient units
    • 1 medical patient on surgical floor approached and advised will be moving to a hallway space to make room for another patient with higher needs, however, she has indicated she will sign herself out Against Medical Advice. Her bloodwork demonstrates critical issues.
    • Staff shortages abound, and many patients are arriving to emergency with failure to cope / failure to thrive.
    • There are no crisis beds available to divert avoidable admissions for non-acute care reasons, and patients/families are refusing retirement homes and remaining in hospital to wait for LTC.
    • There has been a reduction in CCAC services and increase in wait listing.
    • There are some available beds at two hospitals within 40 minutes of this particular organization, but patients are reluctant to consent to be transferred/admitted there.

What are some of the potential ethical issues in this scenario?

  • Limited access to limited inpatient resources: Who decides who will receive the resource, and how is this determined?
  • Do patients have a right to refuse transfer within the hospital? For example, can they refuse to be moved into a hallway?
  • Patients signing out AMA when still needing care: is this a failure to provide due care, or simply the right of a capable patient to do so?
  • ALC Management: How can patients who do not require acute care be transferred to an appropriate care setting, or more appropriately managed, when waitlists exist?

 

Case 16:

Mr. Dunn, an 87-year-old patient admitted to hospital one year ago with suicidal ideation. As per organizational policy, a “flag” is implemented in this patient’s chart to indicate these ideations to future care givers, and a red “S” is added to the whiteboard at the nursing station beside the patient’s name. The Mental Health Care Team does not have the capacity to see him immediately, so he is referred to the Geriatric Emergency Management (GEM) team. Upon admission, the patient’s daughter remains at his side reading a book. The patient is quite intent on all the activity around him, as he has a clear view of the trauma bays and the nurses station. Despite the reason for his admission, he is very pleasant, smiling, makes good eye contact, and answers all questions clearly.

The treating team began a Geriatric Depression Scale (GDS), which indicated that:

  • Yes, he is satisfied with his life.
  • No, his life isn’t empty of meaning.
  • He is not bored, and is not feeling helpless or worthless.
  • He has no concerns about decline in memory.
  • He claims that some people are better off than him, but that he is very grateful for what he has.

Some “red flags” that brought about concerns include:

  • Yes, some of the patient’s activities have been dropped,
  • The patient prefers to stay in,
  • He does not feel good about being alive right now, and
  • He has no energy right now

The patient is cared for and returns to LTC after a short stay. One year later, at present day, this patient returns to hospital with a fractured hip. Staff notice the “flag” in his chart indicating that he has had suicidal ideation, and once again begin the GDS work up.

What are some of the ethical issues in this case?

  • Is it appropriate to add a “flag” to a patient’s chart?
  • Does the addition of the “S” to the whiteboard beside the patient’s name compromise his right to keeping personal health information private?
  • If a “flag” is implemented, should the patient be informed, and should there be an opportunity for a patient to request its removal?

 

Case 17:

The patient, Mr. Ramsey, is a 97-year-old man who lives alone. His son lives in an apartment upstairs and visits almost daily. Both the son and daughter of this patient are designated as Power of Attorney for personal care. Past medical history included atrial fibrillation, chronic heart failure, COPD, and deafness and visual impairment for which, a communication board is normally used. Mr. Ramsey came to the emergency department with fever and cough; admitted with chronic heart failure in June of last year. A chest x-ray was performed and Mr. Ramsey was put on antibiotic treatment; two weeks later an additional chest x-ray showed marked improvement

At this juncture Mr. Ramsey’s family noted that he was no longer talking, unable to eat or weight bear on his right side. A CT scan initially showed nothing, but 2 days later a stroke was found in the left brain. Speech-language pathology was asked to see the patient that day.

The SLP assessment revealed the following:

  • Patient was essentially non-verbal, he could not use communication board from home, and he had weakness on the right side of his body.
  • The patient’s son and/or daughter were usually present during assessment.
  • With regard to swallowing, the patient had a poor arousal level, and SLP was unable to assess swallowing safely. Mr. Ramsey had not had food or liquids by mouth (NPO) for three days, however, he was on IV fluids.

With the above findings, SLP recommended the following:

  • That Mr. Ramsey remain NPO with IV fluids, and introduced to the family the potential for tube feeding. It was noted that this is considered Best Practice for Stroke if a patient is NPO after 48 hours. Because Mr. Ramsey was now NPO for three days, and due to the severity of the swallowing problem (dysphagia), SLP also informed the family that NG (nasogastric) feeding was going to be recommended to the patient’s physician as an option. SLP encouraged the daughter, who was present at the time of the SLP assessment, to discuss with her brother whether a feeding tube would be something their father would want and to let the doctor know. These recommendations were communicated to the doctor that day at rounds.

After rounds the following day, the patient’s son came to speak to SLP and the physician about feeding tubes, and told the doctor that they would like to consent to the NG that was proposed. The doctor informed the son that it was too late in the day to get a surgical consult, so a decision made to wait.

The events that followed:

  • Day 4 – SLP asked to re-evaluate the patient, no change in recommendation.
  • Day 5 – Insertion of NG was deferred, and doctor was to discuss with family.
  • Day 6 – SLP again recommended NG; doctor’s note to discuss patient’s poor prognosis with family.
  • Day 9 – SLP was again asked to re-evaluate. Patient was alert, still severe communication difficulty but able to swallow sips of water only with some difficulty. Made recommendation to doctor to keep Patient NPO, recommended NG while continuing to work with Patient to increase his oral intake
  • Day 10 – At rounds, a discussion of day 9 events was raised, and doctor requested family meeting be arranged. A meeting was arranged for day 11. The patient’s daughter wrote her consent for NG in the doctor’s progress notes of chart.
  • Day 11 – Doctor first attempt at NG insertion, but was unable; surgeon was notified but did not come that evening; Patient’s condition worsened.
  • Patient’s son called the unit, and a nurse informed him of his father’s condition. The son agreed to have the doctor on call contacted, and both the son and daughter agreed to make Patient comfort care only.

What are some of the ethical issues in this case?

  • Was the standard of care met with apparent delays in treatment?
  • Was a communication failure responsible for the apparent delays?
  • What steps can be taken to ensure and encourage providers to have difficult conversations, especially at the end of life?

 

Case 18:

A 75-year-old female patient is newly diagnosed with mild Alzheimers Disease Dementia. The patient’s family requests that the diagnosis not be disclosed to the patient, as the patient is very fearful of receiving just this diagnosis. She has seen the progression of Alzheimers Disease into the severe stages in her own mother, and her family feel that a potential for this future would be devastating for her. Her family is concerned that knowing the diagnosis will create undue anxiety, and may lead to depression and hopelessness.

What are some of the ethical issues in this case?

  • 1) What is the physician’s responsibility in disclosing the diagnosis in full to patients, in the case of this request from the family?
  • 2) If there was a risk of self-harm or other serious consequence, can the physician use clinical judgment and the principle of beneficence and/or non-maleficence to withhold the full diagnosis?

 

Case 19:

73-year-old female admitted to hospital with aspiration pneumonia and sepsis.  Past medical history of multiple CVA’s, PEG tube feeding, multiple pressure ulcers.  Patient able to open eyes but not able to follow any commands or respond verbally.  Patient came to hospital from home with her wife.  On admission, the wife was adamant that the patient be a full code. Wife seemed to be unclear regarding patient’s current medical/functional condition, and the health care team felt that due to unrealistic expectations of the wife, the patient was suffering.  The team was struggling with the goals of care that were demanded. Goals of care were only changed when a new physician took over the care of the patient, and was willing to intervene.

What are some of the ethical issues in this case?

  • Must the physician/health care team acquiesce to all demands by a substitute decision-maker? What were the reasons she provided for wanting “full code”?
  • What would the patient want in this case if she could tell the team? What would it mean to support her wishes?
  • What reasons were given by the first physician to not make the patient full code? And from the second physician for agreeing to full code?

 

Case 20:

You have recently been speaking to your nursing colleagues about Mr. Goodwin, a patient from the community to comes to hospital once per week to receive a nurse-administered medication. You have been wondering whether it is appropriate to keep treating Mr. Goodwin in hospital, given that he would be eligible for community care support to have his medication administered in the home. The reason that he has continued to come to hospital to receive this medication is that it is not covered by any Ministry of Health program, and the hospital absorbs the cost for Mr. Goodwin at each treatment. You are not sure whether this is an appropriate use of resources since there are significant wait times for other procedures, and cost savings initiatives are being pursued in all other departments.

What are some of the ethical issues in this case?

  • Why was the decision made to treat Mr. Goodwin in hospital in the first place?
  • Can the hospital cover the cost of similar medications for other patients, or are there concerns of justice/fairness?
  • How are decisions regarding prioritization made organizationally? Are there agreed upon frameworks or ethical principles that are used?

 

Case 21:

78-year-old patient airlifted from his small first nations community to the closest trauma center after involvement in motor vehicle accident, where he sustained multiple fractures and traumatic brain injury. Luckily, impairment of cognitive and psychosocial functions was only temporary, and the patient returned to near-baseline after several months of intensive care. While a good deal of his physical health was able to be restored, the team diagnosed CHF, diabetes, dementia, and masses that were suspected to be malignant. In addition, upon discharge the patient will likely be required to use a walker, and pursue intense physiotherapy due to the severity of fractures to his hip and legs.

While being treated at the trauma center awaiting discharge, the patient suffered an acute mental health event, and was transferred to the Mental Health Centre 10 minutes from the current hospital for further assessment and treatment.

Upon admission, the team at the Mental Health Centre had difficulty obtaining informed consent from this patient; partially due to English being the patient’s second language, but also because of the patient’s differing perception of mental health and well-being. In addition, the patient’s capacity to consent to treatment was questioned due to a recently diagnosed dementia. Fortunately, a translator from the same community was available to facilitate this process. The patient was successfully treated and discharge was planned. Placement in long-term care (LTC) was suggested along with follow-up with local mental health resources.

While planning discharge, it was discovered that the patient was unsure how he would get home. He was airlifted to the trauma center (300kms from his community), did not have the ability to drive, and lacked funds for a bus or other transportation ticket. Furthermore, no family existed to assist. In addition, the Social Worker planning discharge discovered that no permanent mental health resources exist in the patient’s home community. Instead, two nurses, and two crisis workers are deployed on 6-day rotations from the closest city. As well, the nearest LTC home is 220km away, and the patient refuses to leave his home community. If discharged back to his home community, you know that there is a high likelihood that he will not receive the mental health support he needs, and that there is additional physical risk to him now that he requires a walker.

What are some of the ethical issues in this case?

  • Lack of access to adequate services/continuum of care when patient resides in rural areas – Does distributive justice require that all citizens have access to acute mental health services? (Equality) Does distributive justice require that all citizens have access to acute mental health services, to address their specific needs, in their communities? (Equity)
  • Is there shared accountability between those who are responsible for providing health care services (Federal Government/First Nations Communities), to ensure the above?
  • Does the patient have the right to refuse long-term care and remain in his home community to live at risk? Is this an entirely voluntary choice?

 

Case 22:

The patient is a 27-year-old man who has severe schizophrenic illness and type-I diabetes. Before treatment in your secure treatment unit, he was treated successively in different settings with good success. He had been brought to your secure treatment unit after a near-fatal assault on a patient in another hospital. His stay has been characterised by periods of relative health alternating with periods of withdrawal and aggression, at which time he would become very depressed. During these periods, he talks about hearing “voices” which he claims were the reason he attacked others physically, including staff, in the past.

He also refuses to accept his insulin during periods of depression but agrees to his schizophrenia medication; this is appropriately managing the illness, despite the periods of withdrawal and aggression. The only treatment that helps him to recover to some degree from his depressive episodes is electroconvulsive therapy (ECT), even though he had once expressed his wish to not receive it when he was capable. Although he has been found incapable of consenting to treatment during depressive episodes, he refuses ECT each time it is presented, and he has to be forcibly restrained while his insulin is administered.

The staff find it distressing to have to forcibly restrain the patient so often, and to inject him with insulin against his will. They feel that restraining him compromises their caring relationship with him. Also, they feel uncomfortable in having to inject him with insulin, which he needs for his type-I diabetes, since he is adamantly refusing. Unfortunately, this is the only way to keep him from ketoacidosis until he recovers from his depression after a few weeks of ECT.

What are some of the ethical issues in this case?

  • Which of the treatments (if not all) should/should not be administered?
  • When capable, what did the patient refuse exactly? What did his refusal mean?
  • What documentation is available?
  • Do prior expressed capable wishes apply only to somatic disease or do they also apply to mental health conditions?
  • Does the patient have the right to refuse psychiatric intervention in prior expressed wishes from a mental health point of view? If so, what if he becomes violent?
  • Would this only apply to mental health patients with periods of stability? What if the patient became permanently incapable?
  • What alternatives are available to this patient (to the ECT) and were these provided to him as options when capable and deciding?

 

Case 23:

Video monitoring offers the possibility to provide better care for the patient being monitored, for example, by helping to detect and prevent falls or self-inflicted harm. It may also permit better care for other patients by freeing up staff resources or help hospitals to address other staffing challenges. Your organization is considering a proposal for a pilot program that adds video monitoring options for patients at risk for safety (falls, self-harm, etc.) and needs your recommendations.

What are some of the ethical issues involved in video monitoring patients?

  • What are the clinical ethical issues?
  • What are the organizational ethical issues?
  • How would you justify monitoring? Or not?