Mr. Parker is an 88-year-old resident of your LTC home with end-stage Alzheimer’s. He is wheelchair bound and spends most of his days sleeping in his wheelchair near a window facing the garden. He needs to be spoon fed but has recently started to refuse to eat. Mr. Parker has three children, one of whom is very involved in the care of her father. The team approaches the daughter about her father refusing to eat, and feels that his refusal is legitimate. Thus, they propose changing the plan of care to palliation. The daughter absolutely refuses, claiming that “you cannot kill my father, I want everything done to keep him living!”

What are some of the ethical issues in this case?

Do we know whether the resident is capable to make his own health care decisions?

Are there any known wishes from Mr. Parker? What would he want? What are his values?

Is his daughter the substitute decision-maker? Can she, in this role, demand treatment and expect that you comply?

Mrs. Beaudoin, who is 97 years old, was admitted to your LTC facility 6 years ago. Shortly after becoming a resident, she suffered a cardiac arrest and was found to be unresponsive by the staff; CPR was initiated for a total of 20 minutes prior to return of spontaneous circulation. She has an advanced directive stating that she agrees to “transfer to an acute care facility”, but other options, such as CPR and intubation, were not explicitly addressed in this document. She has no formal Power of Attorney.

Initially, Mrs. Beaudoin had lived at your facility watching TV for most of the day. She was wheelchair bound and required assistance with most activities of daily living (ADLs). Her husband lives at your facility with her and is quite frail with moderate dementia. Mrs. Beaudoin is frequently visited by her large extended family, which comprises 4 children and 5 grandchildren. She is known to have cancer throughout much of her body, moderate dementia, a very bad heart, and type-2 diabetes.

After her cardiac arrest and a short stay in the Hospital ICU, Mrs. Beaudoin is brought back to your facility able to breathe on her own, but with a moderate -severe brain injury caused by lack of oxygen after her cardiac arrest; this has left her unable to communicate in any meaningful way with others. She is receiving thickened fluids as her source of nutrition and hydration, but is only able to consume about half of the calories that would be needed to keep her at her current weight. Unfortunately her health begins to decline further shortly after returning.

The team decides to hold a family conference with the resident’s children, and proposes a plan of treatment that would focus on comfort care only, excluding CPR if needed again. The patient’s eldest daughter does not agree and states that her mother is “a fighter” and wanted to live to be 100 years old so that she could receive a letter from the Queen. The daughter asks that her mother be transferred back to the acute care hospital to receive the care of “experts” and so that she could be seen by a surgeon for surgery and chemotherapy for her cancer.

The treating physician discusses the case with the intensivist on call at the hospital over the telephone. The intensivist agrees that the prognosis is extremely poor and likely the resident would not benefit from further invasive treatment. The intensivist at TOH holds a family conference with the family and team at the LTC home over the telephone. He identifies himself as an expert in the field. The older daughter, reiterates their requests to the intensivist.

What are some of the ethical issues in this case?

Who is the appropriate substitute decision-maker (SDM) in this case?

If there is more than one SDM, what should you do if they disagree?

Because we know Mrs. Beaudoin’s desire to live to be 100, must we ensure that “everything is done” in an attempt to prolong her life?

After 7 years of caring for his wife with severe Alzheimer’s disease at home, Mrs. Dowd is admitted to a LTC home. Upon returning to visit his wife, Mr. Dowd finds her walking hand-in-hand with a male resident. Staff report Mrs. Dowd has been observed following this male resident into his room which is right next to her room. Mr. Dowd becomes angry and states, “Look, it is your job to protect my wife. Get that man out of here right now. I don’t want her involved with any other man. That’s why I admitted her here.”

*From: http://www.alz.org/documents/mndak/406Sexuality_in_Care_Setting_Case_Studies.pdf

What are some of the ethical issues in this case? What should we do?

Is Mrs. Dowd able to understand and appreciate her actions with the male resident?

Do the staff have an obligation to intervene to protect Mrs. Dowd? Or at the request of Mr. Dowd?

If Mrs. Dowd was capable (competent), would the responsibility of the LTC home staff remain the same?

Mr. Sam and Mr. Brown had been together for years. They had a strong social network of friends who provided support and friendship over the years. Unexpectedly, Mr. Brown suffered a debilitating stroke with resulting vascular dementia. After months of rehabilitation that did little to help, Mr. Sam was forced to move Mr. Brown in to a long-term care home.

Mr. Sam is unsure how the staff might treat Mr. Brown if they learn that he is homosexual, so he does not reveal their true relationship. He makes sure not to show too much affection when staff are present. Staff sense there is more to their relationship than just life-long friends and housemates. Staff begin to talk among themselves about Mr. Sam and Mr. Brown being gay, and some now feel uncomfortable caring for Mr. Brown because of their own personal values.

*From: http://www.alz.org/documents/mndak/406Sexuality_in_Care_Setting_Case_Studies.pdf

What are some of the ethical issues in this case?

Can the staff object to caring for Mr. Brown based on his sexual orientation? Is there a right to conscientious objection, or is this discrimination?

How far might the rights of Mr. Sam and Mr. Brown extend? If they required physical assistance to be intimate, for example, would staff be able to object?

What steps can the LTC home take to ensure Mr. Brown is treated fairly, and no differently because of his sexual orientation?

Case 1: Mr. Jones is alert, aware, and capable of making his own health care decisions. Although there is an order for medications to treat his heart condition, Mr. Jones refuses these medications daily. On one visit, his family members notice that he is not receiving these medications, and demand that you hide them in his mashed potatoes so that he receives them.

Case 2: Mr. Smith is a resident on your unit with advanced dementia who is no longer able to appreciate and understand his health care decisions. Because of this, he has his eldest daughter – who is his Power of Attorney (POA) – making these decisions on his behalf. Like Mr. Jones, Mr. Smith has an order for medications to treat his heart condition, but refuses these medications daily and swings at any staff member who attempts to come close with those medications; he has thus not been receiving them. On a visit from his POA, she notices that he is not being made to take his medication, and demands that you hide them in his mashed potatoes so that he receives them.

What are some of the ethical issues in these cases?

Is there a moral difference between these two cases in the attempt to deceive either resident?

Is it perhaps more wrong to deceive Mr. Jones than Mr. Smith, or vice versa?

Other general questions:

Does this resident have the ability to make their own health care decisions?

Why would we consider telling a ‘white lie’ to this person in the first place?

Is there any benefit to telling a ‘white lie’?

What harm will come by telling the resident this ‘white lie’?

What harm would come to the resident if we do not tell them the ‘white lie’?

Will the benefits of telling a ‘white lie’ in this situation outweigh the harms?

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?

56-year-old male resident of your long-term care (LTC) home who is married with three children under age 18. He was formerly in the Canadian Armed Forces and served in Afghanistan. He has suffered from an intracranial aneurysm 2+ years ago, and due to his increasing care needs his wife had to place him in LTC. He has significant brain damage with frontal disinhibited behaviors including; sexual disinhibition, repetitive verbal outbursts, wandering. Because of this, he attempts masturbation frequently in public areas, and has just developed a still platonic relationship where he and a female resident hold hands. He also often seeks her out and has tried going into her room at night. Staff have expressed significant concerns.

What are some of the ethical issues in this case?

Should LTC homes respect this resident’s privacy?

How should LTC homes address sexual and intimacy needs of residents with dementia? Should they assist?

Does the LTC home, or do any staff, have an obligation to protect vulnerable residents such as this one?