Case 1:

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?

 

Case 2:

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 3:

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?

 

Case 4:

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? Is it fair?
    • 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 5

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?

 

Case 6:

A worker (who we will name Sue) approached a friendly work colleague (who we will name Donna) and asked to have a “confidential conversation.” Donna agreed to keep the conversation confidential. During that conversation, Sue disclosed to Donna that she feels she is being harassed by an ex-boyfriend, who is also an employee, and that she believes her personal safety may be at risk.

Donna tried to convince Sue to report the issue to her supervisor, but Sue did not agree.

Worried about her colleague’s safety, Donna took it upon herself to report the matter to Sue and Donna’s supervisor. The supervisor initially agreed to keep this information confidential, but is now having second thoughts and is not sure what is “the right thing to do” in this situation.”

What are some of the ethical issues in this case?

  • Do you agree with the actions Donna took? Why?
  • What do you think the supervisor should do next? Why?

 

Case 7:

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?