6. CASE: To Feed or Not to Feed?

You receive a call on the ethics line about a patient’s relative (next-of-kin and legal decision-maker) force-feeding her sister who is a patient on the unit (pushing food into the patient’s mouth and then holding her mouth closed, pinching her nose, etc. until she swallows). Apparently, this was not an uncommon approach to getting her to eat in the group home where she had lived very happily for 10 years prior to admission (she is 58 years old). The charge nurse feels this is abusive and dangerous behaviour, not acceptable in the hospital setting, and has told the relative this. The patient currently receiving TPN-GI does not feel she is a candidate for a peg-tube. The psychiatrist has assessed the patient as depressed and medication has been started- it takes several weeks to reach full effect, so the team is waiting to see how this will go. The option of ECT has been looked into also, but the anaesthetist feels the patient is too fragile to receive the sort of sedation needed for this procedure. The team does not feel the patient is appropriate for the acute care orthopedics unit (she is unlikely to walk again, is incontinent, immobile, dependent for ADLs with little sign that this will ever change, so not likely to get back to a group home situation in the community). The team’s concern appears to be “we need our beds for patients we can operate on and fix”, although they have not voiced this opinion explicitly. The charge nurse has learned the patient’s relative is angry with the team because she feels the patient is being discriminated against on the basis of her cognitive and physical disabilities so that PT and OT are not working hard enough with her. Staff says this is not the case- the patient is refusing to participate (originally she was told that if she walked and ate she could get back to her group home- this has not happened and the nurse feels she has given up, and is exerting the only sort of protest she can by not eating or cooperating with staff efforts any longer). Finally, there is concern about the possibility of a feeding tube down the road – should the patient get one if she continues to refuse to eat, even after the depression is adequately treated? Is this a decision the relative can make? There are also questions about the possibility of modifying the patient’s diet to be more palatable to her, realizing that this is also more dangerous given her high risk of aspiration.

• How would you work through this case?
• Which issues are ethics issues and which are medical decisions?
• Who needs to be involved in making necessary decisions to move forward?

Some Values and Ethics Issues to Consider

• Patient-family relationships
• Respect for professional integrity
• Moral distress of health care providers
• Resource allocation
• Substitute decision-makers
• Respect for dignity
• Staff morale
• Quality of life
• Duty to provide care

5. CASE: Caring for a “Difficult” Patient

A female patient in her mid-forties has been on the GI service for several months now due to severe Crohn’s Disease, which has left her with multiple draining abdominal fistuli. She has recently moved out of the province but her condition could not be treated adequately in the local hospital so she was transferred back to Nova Scotia. She has no GP. She has one sibling, a sister, who lives elsewhere in NS.

The patient does much of her own care, refusing nursing care inconsistently off and on. She is also unpredictably non-compliant in regards to medications and other treatments. Staff members describe her as extremely demanding and emotionally abusive to them, particularly when it comes to nurses and residents. She has a history of depression and anxiety, but has refused psychology support. As a result of her long hospital stay she is now VRE+ and MRSA+ so is being cared for in isolation. She has experienced 2 admissions to ICU during this admission and has had a cardiac pacemaker inserted. Interestingly, her behaviour has showed marked improvement following each of these ICU admissions, i.e., less abusive, more appropriate.

Nursing staff is feeling extremely frustrated, manipulated, and abused. They are asking for this patient to be transferred off the GI unit. The ethics consult requestor (charge nurse) feels GI is the most appropriate service for her to be on given her diagnosis and severity of her chronic illness, but also concerned for staff morale.

• Is this an appropriate situation for an ethics referral? Why or why not?
• If yes, what are the ethics issues?
• Should the health care providers be asking for the transfer? Do they have a duty to provide care?
• What ethics issues arise around the patient’s mental health and non-compliance issues, and how do they factor into this case?
• How would you respond to this request?

Some Values and Ethics Issues to Consider

• Duty to provide care
• Duty to provide a safe work environment
• Moral distress among health care providers
• Responsibility for health
• Respect for autonomy
• Respect for professional integrity
• Staff morale
• Organizational culture
• Responsibility for health

4. CASE: Expectations for Care

Ned is an elderly patient with relatively advanced dementia who is recovering from surgery to repair a hip fracture. He spends most of every 24-hour period screaming unless someone familiar sits with him. Staff members on the unit are becoming increasingly frustrated and stressed. The unit manager has received numerous complaints, verbal and written, from other patients on the unit and from some of their family members. She decides to call the ethics line.

• What are the ethics issues?
• What are the non-ethics issues?
• What underlying values are at stake?
• How would you respond to this call?

 Some Values and Ethics Issues to Consider

• Moral distress among health care providers
• Distributive justice
• Resource allocation
• Patient-centered care
• Capacity
• Empathy
• Respect for human dignity
• Quality of life

3. CASE: Superbugs

Jeannette Cutler is an 83-year old woman admitted to hospital after falling and breaking her arm.  She reports that she fell because she passed out, and so further investigations are being conducted.  She has mild dementia but is otherwise seemingly healthy.  Upon admission, she screens positive for MRSA and is subject to strict isolation procedures as per hospital policy.

Jeannette was a long-time volunteer at the hospital where she is now a patient. Jeannette is having trouble adhering to the isolation protocol, and several times a day she gets up and starts going into other patients’ rooms to “visit”.  The team has had discussions with her regarding the need for her to remain in her room, but they have failed to achieve the desired effect.

Staff is concerned that she is spreading MRSA and are considering various means of confining her to her room.  They aren’t sure how best to express respect for Jeannette while also ensuring that other patients are not unnecessarily exposed to harm.  They have contacted the ethics committee and the legal department asking for help in working through this case.

• What ethics concerns are you thinking about as you respond?
• Who should be involved in making this decision?
• What are some competing values that arise in this case?
• Should the well-being of others take precedence over Jeannette’s freedom of     mobility?
• What potential creative solutions can you think of to resolve this issue?

 Some Values and Ethics Issues to Consider

• Respect for individual liberty
• Patient-centered care
• Distributive justice
• Policy compliance
• Respect for autonomy
• Responsibility for health
• Quality of life
• Respect for dignity
• Capacity
• Beneficence and non-maleficence

2. CASE: Treatment and/or Termination? Tough Choices

Melanie is a 21 year old who was recently involuntarily committed after she started a serious fight at a local shelter, thinking that one of the leaders was trying to steal her favourite T-shirt. Melanie has schizophrenia and is well-known to both the police and mental health care providers. She has been living on and off the streets since she left home when she was 16 years old, and has a rather strained relationship with her parents. They have been trying to support her and often provide money for her medications. When Melanie is taking her medications, she is able to find work and has talked about going back to school. However, Melanie finds the side effects of the medications awful and stops taking them, leading to being kicked out of apartments or friends’ places when she gets too aggressive.

In doing Melanie’s work-up upon admission, it was discovered that she is about 7-8 weeks pregnant. While trying to determine what to do with respect to the pregnancy, she is placed on medications that minimize teratogenic effects for the fetus, and that may have some success in stabilizing Melanie’s condition (although it is recognized that this is not the “gold standard” treatment). Melanie’s mother, Krystine, was named by Melanie as her substitute decision-maker (witnessed by her psychiatrist at the end of her previous admission), despite some of the challenges in their relationship, and she endeavours to do the best for her daughter. The team has been in discussion with Krystine about treating Melanie and about her pregnancy.

Melanie has indicated that she doesn’t know who the father is, as she has had several partners over the last few months. She also alternates between saying that she wants the baby to saying that the baby is cursed and she should be rid of it. Krystine indicates that Melanie has not talked to them about having children, only about trying to get well to go back to school.

Both Krystine and the health care team have some questions and concerns about how to move forward with Melanie’s treatment. The health care team calls for a clinical ethics consultation.

• If the medication regime doesn’t stabilize Melanie, would it be ethical to move to a different treatment plan, knowing that this might cause substantial harm to the fetus?
• Should the possibility of terminating the pregnancy be discussed further?
• Should an attempt be made to find and notify the biological father?
• How do the dynamics if Melanie’s family relationships factor into this case?
• Can or should someone other than Melanie make these decisions?

Some Values and Ethics Issues to Consider

• Capacity
• Respect for patient autonomy
• Living at risk
• Vulnerability
• Patient-family relationships
• Substitute decision-makers
• Beneficence and non-maleficence

1. CASE: Sensitive Information

John is a young man with a traumatic spinal cord injury that has resulted in paraplegia. He is leaving the rehab hospital on a weekend pass and has confided to his chaplain that he intends to kill himself. The chaplain calls the ethics service for assistance.

• Should the hospital issue the pass?
• What are the ethics issues involved?
• What information do you need to find out to move forward?
• Who would you invite to a discussion about this issue?

Some Values and Ethics Issues to Consider 

• Respect for autonomy
• Beneficence
• Non-maleficence
• Duty to provide care
• Living at risk
• Moral distress
• Compliance with policy
• Respect for privacy and confidentiality