Mr. Paul is a 67-year-old client with your home health care organization who suffers from moderate dementia. After providing the required personal health services to him, the attendant is asked by his substitute decision-maker (who just happens to be there that day) to walk Mr. Paul’s dog. It is a very cold and icy day and Mr. Paul does not feel comfortable going outside with his wheelchair. In the past, out of compassion and wanting to do a good deed, the attendant did walk Mr. Paul’s dog and engage in other activities that were outside of Mr. Paul’s care plan, and that put the attendant a little bit behind in their schedule. For example, the attendant cleaned the fridge and dishes and cooked a meal or two. Furthermore, Mr. Paul has heard about other clients receiving similar help with their pets and other special unusual requests. Today however the attendant feels uncomfortable to satisfy his request because they are concerned with slipping on the ice and frostbite. In addition, they are running late for their next client.

What are some of the ethical issues in this case?

What is the impact of the attendant’s past behavior on service delivery and expectations for this and all clients?

Should the attendant meet Mr. Paul’s / the SDM’s expectation to continue fulfilling special requests?

Is it the attendant’s responsibility to tell the client “no”?

Are there exceptions or exceptional circumstances to provide services outside the standard of care or scope of practice?

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?

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?

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?