68. Case: Big Yellow Taxi

Following the bankruptcy of the local taxi service, a community hospital recognized that several of its frail, elderly patients who don’t drive had exceedingly limited options for getting to the hospital for their appointments. A few community volunteers were able to help out in the short term, but increasingly found that they were not necessarily able to keep up with the need or cover all of their gas and insurance costs on their own. Some hospital leaders argue that paying for these transportation costs may actually decrease overall costs for the organization, as this should lead to fewer emergencies and a greater involvement by these patients in maintaining their health. However, finding the money to cover the transportation costs and determining more concretely who will or will not qualify for this service will not be easy. Others argue that this isn’t a cost that the hospital should take on and that this is something that the community or the province needs to address.

What ethics issues do you identify in this case?

What values are involved in this case (e.g., equity, fairness, trust, good care…)?

How might this issue be different in a rural setting as compared to an urban setting? Is this a relevant factor to consider in determining what should be done?

Resources:

Asthana, S., A. Gibson, G. Moon, and P. Brigham. 2003. Allocating resources for health and social care: the significance of rurality. Health and Social Care in the Community. 11:6 486-493.

Danis M. 2008. The Ethics of allocating resources toward rural health and health care. In Klugman C, and Dalinis P eds. Ethical Issues in Rural Health Care Johns Hopkins University Press Baltimore Maryland 71-98.

69. Case: On The Road Again

Judy and Richard live in a rural community where the closest hospital is a four hour drive away in good weather. Travelling to the hospital for specialist appointments often entails an overnight stay and additional time away from work for both Judy and Richard. In discussing the recent trips to the hospital with their family doctor, Judy indicates that she is not sure how much longer she can keep doing this and asks about options for care closer to their community. The family doctor is aware that this is an issue for several of her patients, and is advocating for a different approach to some forms of specialist care, such as making more use of telehealth and other technological options as well as the possibility of travel subsidies for some patients. Richard asks about whether arranging for some specialists to come to the community once a month might be another option…

What ethics issues do you identify in this case?

What are some of the different perspectives around issues of access to care that may impact whether and how we provide health care in a variety of urban, urban-rural, rural and remote settings?

What values are involved in this case (e.g., equity, fairness, trust, good care…)?

How should Canada, with its large rural and remote areas, address issues of access to care?

Resources:

Browne, A. Issues Affecting Access to Health Services in Northern, Rural and Remote Regions of Canada. http://www.unbc.ca/assets/northern_studies/northern/issues_affecting_access_to_health_services_in_northern.pdf

Laurent, S. 2002. Rural Canada: Access to health care. http://publications.gc.ca/Collection-R/LoPBdP/BP/prb0245-e.htm

Rural Health Services Review Committee. 2015. Rural health services review: final report. Edmonton: Government of Alberta. http://www.health.alberta.ca/documents/Rural-Health-Services-Review-2015.pdf

70. Case: Desperado

A few of Gary’s friends cornered you at the curling rink last week. They are very concerned about how Gary is doing and wonder why “you and the other folks you work with” aren’t doing something more for him. “Can’t you see how he is going downhill? What’s it going to take for you to intervene?” They clearly feel that Gary shouldn’t be at home, but also admit that he has rebuffed their attempts to talk to him too. Gary has refused to have meals provided, yard work done, etc. What Gary says is that he is able to do it himself, it’s his life, and why doesn’t everyone just get off his back about it?

Gary is coming in for another check-up tomorrow…and you also know that his friends will corner you again next week at the rink

What’s going on in this case?

What do you see as the key (ethics) issues?

What options do you have to address this situation?

What would you do next? Why, and what values are you using to support this approach?

Resources:

Austin, W., V. Bergum, S. Nuttgens, and C. Peternelj-Taylor. 2006. A Re-visioning of boundaries in professional helping relationships: exploring other metaphors. Ethics & Behavior 16:2 77-94.

Kullnat, M. 2007. Boundaries. Journal of the American Medical Association. 297:4 343-344.

Moules, N., M MacLeod, L Thirsk, and N Hanlon, 2010. “And then you’ll see her in the grocery store”: The Working relationships of public health nurses and high-priority families in Northern Canadian communities. Journal of Pediatric Nursing 25: 327-334.

Pugh R. 2007. Dual Relationships: Personal and Professional Boundaries in Rural Social Work.  British Journal of Social Work 37: 1405-1423.

Pugh, R., B. Cheers. 2010. Rural Social Work: An International Perspective. Policy Press.

Schank J., Skovholt T. 2006. Ethical practice in small communities: Challenges and rewards for psychologists. Washington D.C.: American Psychological Association.

Townsend T. 2009. Ethics Conflicts in rural communities: privacy and confidentiality.  In W. Nelson ed. Handbook for rural Health Care Ethics: A Practical Guide for Professionals. Hanover, NH: Dartmouth College 126-141. https://geiselmed.dartmouth.edu/cfm/resources/ethics/

71. Case: With A Little Help From My Friends

Kerry is a long-time volunteer with palliative care services in her community. With the distances and difficulty of travel that some palliative care patients may face, she is glad to be part of a team that works to support patients who want to die at home. While every effort is made to provide all patients with the same level of support as they need it, Kerry has noticed that some patients and families seem to get a bit more in terms of members of the team going the “extra mile” to ensure that a medication is delivered or staying longer at the home. Most troubling for Kerry is the fact that this seemed to happen for the biggest health care fundraiser in the community, while a relative newcomer to the community seemed to get less of this type of attention. Kerry isn’t sure about whether and how to raise this as an issue with the broader team.

What assumptions, questions, and/or examples come to mind in relation to this case?

What do you identify as the ethics issues in this case?

What would you say to Kerry if she asked you what she should do? Why, and what values are you using to support this approach?

Resources:

Castleden, H, V. Crooks, N. Schuurman, N. Hanlon. 2010. “It’s not necessarily the distance on the map …”: Using place as an analytic tool to elucidate geographic issues central to rural palliative care.” Health & Place 16 284-290.

Crooks V, H Castleden, N Hanlon, N Schuurman. 2011. ‘Heated political dynamics exist…’: Examining the politics of palliative care in rural British Columbia, Canada. Palliative Medicine 25(1): 26-35.

Pesut B, Bottorff, Robinson C. 2011. Be known, be available, be mutual; a qualitative ethical analysis of social values in rural palliative care. BMC Medical Ethics 12:19.

72. Case: My Way

You are part of team preparing for an upcoming accreditation visit. In meeting the listed standards, there has been much discussion among the team about the expectations for smaller rural facilities in relation to these standards. When there are fewer resources (people, equipment, budget) for meeting some of the standards as compared to larger urban facilities, is this taken into account? Many on the team have argued that the focus should be on demonstrating that the spirit and intention of a given standard has been met, and may be done so through adaptive, innovative ways as well as the standard approaches. Recognizing that the standards are there to help ensure quality, good health care for all patients, there is still some concern about whether the standards were written primarily from an urban perspective and whether there will be some flexibility in their application in a rural setting…

What do you identify as the ethics issues in this case?

What values are involved in this case (e.g., equity, fairness, trust, good care…)? Do we all mean the same thing when we talk about, for example, “good care”?

What is your perspective on standards for health care and how these may apply (or not) across different practice settings?

What are some of the innovative and/or adaptive approaches that you are aware of that your health facility has undertaken?

Resources:

Niemara, D. 2008 Ethical Dimensions of the Quality of Rural Health Care.  In Klugman C, and Dalinis P eds. Ethical Issues in Rural Health Care Johns Hopkins University Press Baltimore Maryland 119-131.

Rural Health Services Review Committee. 2015. Rural health services review: final report. Edmonton: Government of Alberta. http://www.health.alberta.ca/documents/Rural-Health-Services-Review-2015.pdf