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

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