57. CASE: Caregiver Stress

Dr. Morrison has been the only physician in his small community of 1,500 people for about 15 years and is known as the “Town Doc.” When he first moved to town, he quickly became friends with many people and involved in the community. However, the longer he practiced, the more awkward his social life became.

He helped coach the baseball team for several years. But then he treated one of the boys on the team for chlamydia and the boy stopped coming to practice. Dr. Morrison didn’t sign up to coach the following year. He began to turn down social invitations, as more friends became patients. Eventually he began to feel burdened and overworked but unable to decrease his workload. He attended to numerous horrific farm and motor vehicle accidents, often as the only provider for multiple patients, resulting in increasing mental trauma and distress.

He felt indebted to the community but also began to feel resentful. Where he once took pride in the fact that people looked to him for support, he began to feel overwhelmed and useless. He recognized that he was depressed but had no idea where to turn for help. His patients began to notice that he seemed tired and irritable. At the nearby critical access hospital, where Dr. Morrison is affiliated, the administrators were increasingly concerned about his ability to practice and feared he might even resign.

[From Rural Health Ethics: A Manual for Trainers. William Nelson & Karen Schifferdecker. https://geiselmed.dartmouth.edu/cfm/resources/ethics/%5D

  • What, if anything, should the administrators say or do?
  • What steps can rural health care providers take to avoid isolation and burnout?
  • What steps can rural health administrators and community leaders take to avoid isolation and burnout among their health care providers?
  • What resources could Dr. Morrison access to assist in this situation?


Some Values and Ethics Issues to Consider

  • Community and family relationships
  • Respect for privacy and confidentiality
  • Resource allocation
  • Patient-provider relationships
  • Professional boundaries
  • Honesty, trust and truth-telling
  • Duty to provide care
  • Moral distress among health care providers
  • Overlapping roles and responsibilities
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56. CASE: Family Friends/ Family Doc

Dr. Jones has been a close friend of the Smith family since coming to town 18 years ago. The Smith’s oldest child, Sally (15 years), has come to the office to have a physical to be on her school’s track team. Her mother has brought her to the office, but as usual, Dr. Jones sees Sally alone.

After taking the history and doing an exam, it is evident that Sally wants to talk about something. In response to a question about whether she has started dating, she explains that she has been dating JJ for the last six months. She says that she really likes him a lot, and although they “haven’t done it yet, they have been thinking about it a lot.” She is wondering if she could start taking birth control pills.

Sally also explains that her parents do not know anything about it. She said that when she has tried to talk with her mother, her mom just, “got weird—talking about babies having babies, and nobody having morals any more.” She says her mother would be very upset if she knew Sally was talking about it, and asks that this information not get back to her parents.

[From Rural Health Ethics: A Manual for Trainers. William Nelson & Karen Schifferdecker. http://geiselmed.dartmouth.edu/cfm/resources/manual/manual.pdf%5D

  • Is it ethical to prescribe birth control without parental permission to a patient who is below the legal age of consent for sexual activity?
  • Should Dr. Jones try to separate her role as Sally’s physician with her role as a friend of her parents?
  • What is the main ethics question in this case? What are the conflicting values?
  • How should Dr. Jones proceed and why?


Some Values and Ethics Issues to Consider

  • Community and family relationships
  • Respect for privacy and confidentiality
  • Patient-provider relationships
  • Professional boundaries
  • Honesty, trust and truth-telling
  • Duty to provide care
  • Overlapping roles and responsibilities

55. CASE: What is My Obligation?

A family physician in a small, remote community assesses a patient, who is a local schoolteacher, as developing a post-partum psychosis. He feels he lacks adequate training or experience to manage her care.

He recommends she seek treatment at a distant large mental health centre but she refuses to travel to the centre because of the distance involved. He feels uncertain about caring for the patient when the treatment is outside his area of competency.

  • How should the physician proceed with the patient’s care? Should he treat the patient when he feels it is is outside his area of competency?
  • If the patient is unwilling to disclose her health issues to her employer, as a healthcare professional and/or a member of the community, should the physician report them to school authorities?
  • What ethics issues are at play here?
  • What resources could the physician seek to assist with this situation?

Some Values and Ethics Issues to Consider

  • Community and family relationships
  • Respect for privacy and confidentiality
  • Patient-provider relationships
  • Professional boundaries
  • Honesty, trust and truth-telling
  • Patient safety
  • Equality of access
  • Resource allocation
  • Duty to provide care
  • Intellectual honesty
  • Respect for professional integrity
  • Professional competence
  • Overlapping roles and responsibilities

54. CASE: Professional Role

While doing a weekday home visit to an elderly patient, a VON nurse in a small community finds the patient’s son at home. The patient has mentioned that her son teaches at the local elementary school, but he has never been present during any of the nurse’s previous visits to the house.

On a weekday visit he appears to be drinking heavily and the patient seems uncomfortable and ill at ease.  During the next few weeks the son is there on several more occasions and appears to be either drunk or “hungover”. The nurse is also a member of the town’s school board.

  • What is this health professional’s responsibility to her patient? To her patient’s son?
  • What should her immediate concerns be?
  • What is her responsibility as a member of the school board?
  • How should she proceed in this situation?
  • Can/should this individual segregate her role as a nurse with her role as a school board member?
  • Should she mention what she knows about the son/teacher to her colleagues at the school board?
  • How are the ethics issues at hand affected by the rural setting?


Some Values and Ethics Issues to Consider

  • Professional boundaries
  • Duty to provide a safe work environment
  • Living at risk
  • Duty to accommodate
  • Duty to provide care
  • Community and family relationships
  • Respect for human dignity
  • Respect for professional integrity
  • Compliance with policies and procedures
  • Respect for privacy and confidentiality
  • Overlapping roles and responsibilities
  • Patient safety

53. CASE: Disease Stigma

A patient has been followed by you, his family doctor, for several medical issues and is being seen for a minor work-related injury. He is very negative and tearful but will not acknowledge his symptoms when asked.

You believe he is depressed and you know you can provide treatment for his depression. However, the patient is uncomfortable seeking treatment or having you document your findings in his record because of the stigmatizing effect of having a mental health disorder known in a remote community.

  • What steps should you take to address his depression?
  • What factors external to your family practice must be considered?
  • Do you think that it is likely or unlikely that the patient’s concerns about confidentiality are valid?
  • What policies and procedures should be in place to maintain privacy and confidentiality in rural communities. How should these be enforced?


Some Values and Ethics Issues to Consider

  • Respect for privacy and confidentiality
  • Respect for patient autonomy
  • Community and family relationships
  • Respect for human dignity
  • Honesty, trust and truth-telling
  • Patient-provider relationships
  • Patient safety
  • Stigma
  • Vulnerability
  • Equality of access

52. CASE: Community Values

A patient in your rural community that you have treated for COPD for several years missed her last two appointments. When you speak with her after church, she indicated her husband lost his job as a logger and no longer has family health insurance to cover the cost of the treatments. She refuses to accept charity but does indicate she will be willing to clean your home and office as “payment” for your healthcare services.

  • Should a healthcare professional accept bartering as payment?
  • What ethics issues should be considered here?
  • How are these ethics issues affected by the rural context?
  • Should the health of the patient take precedence over compliance with your organizational policy and/or your professional code of conduct?
  • What other creative solutions are there that will allow the patient to receive the treatments?

 

Some Values and Ethics Issues to Consider

  • Social justice
  • Professional boundaries
  • Duty to provide care
  • Community and family relationships
  • Respect for human dignity
  • Respect for professional integrity
  • Compliance with policies and procedures
  • Respect for privacy and confidentiality
  • Overlapping roles and responsibilities
  • Patient-provider relationships
  • Equality of access

51. CASE: Confidentiality and Privacy

Joanne Baker, a nurse practitioner in a small community, prescribed a partial opiate agonist to a young man, Brian, for treatment of prescription opiate dependence. Brian is talented and plays on the same soccer team as Joanne’s son.

Three weeks later, Brian is found unresponsive after an overdose of opiates, requiring intubations and medical evacuation to a city three hours away. He recovered and didn’t want others in the community to discover that he had attempted suicide. He began to spread rumours that Joanne was incompetent and prescribed a medication that she didn’t know how to use.

Another patient brought up these rumors during his own appointment with Joanne. Joanne wishes she could set the record straight, and explain that Brian obtained opiates from a provider in a neighbouring city and had taken these in large quantities in a suicide attempt. She is unsure of how to discuss the situation without breaching Brian’s patient confidentiality.

  • How should Joanne proceed in this situation?
  • How can she clear her name/ reputation without breaching confidentiality?
  • What are the competing values in this case?
  • What role/ responsibility should Brian have in the outcome of this situation?
  • What is the specific ethics conflict or question in this case?
  • How is this ethics conflict affected by the rural context?
  • What resources are available to help Joanne address the situation?


Some Values and Ethics Issues to Consider

  • Professional boundaries
  • Community and family relationships
  • Respect for professional integrity
  • Compliance with policies and procedures
  • Respect for privacy and confidentiality
  • Overlapping roles and responsibilities
  • Patient-provider relationships
  • Professional competence
  • Transparency
  • Stigma
  • Vulnerability
  • Respect for human dignity

50. CASE: Overlapping Relationships

During a routine physical examination at your rural practice, one of your teenage patients shares that he has seen another teenage patient using cocaine at your neighbour’s house.

  • What are your ethical responsibilities as a physician?
  • What are your ethical responsibilities to your neighbour? The law?
  • Do these roles conflict?
  • How would you proceed in this situation and why?
  • How are the ethics issues in this case affected by the rural context?


Some Values and Ethics Issues to Consider

  • Community and family relationships
  • Compliance with policies and procedures
  • Respect for privacy and confidentiality
  • Overlapping roles and responsibilities
  • Patient-provider relationships
  • Professional boundaries
  • Honesty, trust and truth-telling

49. CASE: Reality Check?

A clerk and resident are frustrated after a morning of taking histories from and doing physical examinations of patients referred to the GI Clinic. As you (the attending clinic gastroenterologist) are going over the morning’s work with them, the clerk and resident complain that most of the patients seem to have less clinically significant symptoms and physical findings than were described by their attending family physicians in the referral notes to the clinic.

They start an argument (which looks to you like it’s on its third round) about whether it’s the patients or the referring physicians who are responsible. Adding to their frustration, the Department Head interrupted them just as the clerk was beginning with one patient – who she was already thinking might be the healthiest person she’d seen in her entire rotation – and insisted on doing the history and physical himself. The resident, who recently arrived from out of province, gets some local information from the clerk, who tells him the significance of that particular patient’s family name (major regular contributor to the Hospital Foundation).

The clerk thinks several of the morning’s problematic referrals came from the same family physician, and that there should be repercussions for that physician, e.g., putting his patients at the bottom of the waiting list, or calling him up to complain. The resident defends the referring physician and speculates that it’s the patients who are causing the problem.

You’re wondering how to get them to focus on something more productive and professional.

  • Should you communicate to them that practice in the real world is like this, and that they should get on to the next patient? Or is this a teachable moment in some way?
  • Is this a clinical practice issue or an ethics issue? 

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Compliance with policies and procedures
  • Respect for professional integrity
  • Patient-provider relationships
  • Health care provider relationships
  • Honesty, trust and truth-telling
  • Professional boundaries

48. CASE: Shared Experience

You have recently started working as an RN in cardiology at the local pediatric health centre. One of the first cases you are involved with hits a little close to home. It involves a 2-year old patient named Kira who has a congenital cardiac abnormality. The clinical circumstances are similar to what you experienced with your son, Bradley, about four years ago. Bradley spent several weeks in hospital for investigations and you and your partner were faced with a difficult decision about whether to proceed with cardiac surgery. With some understandable trepidation and anxiety, you and your partner agreed to the surgery and Bradley came through it just fine. However, given the nature of the cardiac abnormality, you know how easily it could have turned out differently. You now see Kira’s parents faced with the same difficult choice. They are struggling with what decision to make and are very anxious.

  • Should you discuss your own experience with Kira’s parents?
  • If so, what might you choose to disclose?
  • What biases might you contribute to the situation – should you try to minimize their influence?
  • How will you balance your professional expertise and personal experience?

Part 2

It is about a year later and you run into Kira’s parents in the hallway outside the cafeteria. They have just come from the parents’ bereavement group and are having a tough time living without their daughter. They are organizing a charity event in their community to celebrate their daughter’s life and to generate funds for the pediatric cardiology program. Both parents express how much they would appreciate it if you came to the event and spoke at it in the capacity of one of the individuals who cared for their daughter. The event is scheduled for six weeks from now and the parents indicate that they need to know as soon as possible whether you can participate.

Should you go to this event? If so, should you be a speaker? 

Some Values and Ethics Issues to Consider

  • Compliance with policies and procedures
  • Respect for professional integrity
  • Patient-provider relationships
  • Honesty, trust and truth-telling
  • Overlapping roles and responsibilities
  • Family and community relationships
  • Professional boundaries