Mrs. Potter is a 93-year-old resident of your long-term care home who once traveled the world as a culinary expert, sharing her love of food with many. She now has end-stage Alzheimer’s. In the last year it has worsened to the point that she is no longer capable of making her own medical decisions, and she has begun to experience difficulty swallowing solid foods. Three months ago a daughter of Mrs. Potter, her Power of Attorney, consented to have her mother be provided a pureed diet in order to reduce the risk of choking. At present time, however, this daughter believes that the pureed diet is affecting the quality of her mother’s life (even though Mrs. Potter has not expressed this herself). After being completely informed of the risks and benefits, she requests that her mother be given solid foods. The staff feel uncomfortable with the daughter’s request due to the real possibility that Mrs. Potter will choke on solid foods, and are unsure of what to do.

What are some of the ethical issues in this case?

Does a resident have the right to live at risk?

Does a substitute decision-maker (SDM) have the right to consent to their loved one living at risk? Does it matter if this is what their loved one would have wanted?

What mechanisms can be implemented to address the potential moral distress of staff?

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?

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?