Case 1:

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 2:

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 3:

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 4:

Mr. George, 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?