97. Case: A Conversation About Vaccination with a New Parent

You are a nurse practitioner working in a family practice.  A first-time parent brings their child in for a 2-month checkup.  The parent seems nervous when vaccines are mentioned as a routine part of the appointment.  You ask the parent specifically about vaccination, and the parent is hesitant.  They say that they “can’t get idea of something bad happening to the baby because of the vaccination out of [their] head”.  You have a strong commitment to vaccination as a part of good health care practice and to adhering to the standard public health vaccination schedule.  How do you proceed with this conversation?

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You are a first-time parent taking your 2-month-old baby into your doctor’s office for a checkup.  You are told when you arrive that the nurse practitioner, whom you’ve met before and liked, will be seeing you today.  You don’t have any concerns about your baby’s growth and development and are excited to see how much weight they’ve gained since their last appointment.   You are surprised when the nurse mentions vaccination; you had thought that you didn’t have to worry about that until the next appointment.  Since your baby was born you’ve been very aware of all the ways that they could be harmed, and you’ve been intent on avoiding all the risks you can; you have even stopped driving with your baby in the car unless absolutely necessary.  You know that the risks associated with vaccination are low but wonder if they could nonetheless be reduced or avoided somehow.  You experience the nurse’s questions about vaccination as a type of threat and feel defensive, although you also recognize that’s not the nurse’s intent.  How will you respond to the nurse practitioner?

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Discussion Questions:

• How did your response to the case shift when you read about it from a different perspective?
• What do you see as the most important values for each person involved in the conversation?
• What are some of the other values and principles that are relevant when considering how to proceed in cases like this?
• Which factors contribute to making this a difficult conversation?
• What would the best possible outcome in this case look or sound like?

References:

Halperin, S.A.  2000. How to Manage Parents Unsure About Immunization. CME. January 2000; 62-75. https://www.ucalgary.ca/paed/files/paed/4-halperin-article3.pdf

Zimlich, R. 2018. 4 Tools to Frame Conversations about Vacccines. Contemporary Pediatrics, November 13, 2018.   https://www.contemporarypediatrics.com/pediatric-immunization/4-tools-frame-conversations-about-vaccination

Centers for Disease Control and Prevention. Talking with Parents about Vaccines for Infants. Provider Resources for Vaccine Conversations with Parents. [Accessed March 12, 2019]  https://www.cdc.gov/vaccines/hcp/conversations/talking-with-parents.html

Paterson, P., Meurice, F., Stanberry, L.R., Glismann, S., Rosenthal, S.L., Larson,  H.J. 2016. Vaccine hesitancy and healthcare providers. Vaccine, Vol 34 (52), 20 December 2016, p. 6700-6706

TEDx Talks. Tara Haelle. Why Parents Fear Vaccines. Published on May 2nd 2016. TEDxOslo. https://www.youtube.com/watch?v=ggtkzkoI3eM

 

91. Case: Franklin Isn’t Safe at Home

Franklin Pictou is a 68 year old with limited mobility receiving post-surgical follow up care in the home. He wishes to remain in his dwelling, which is not especially clean and poses hazards to him (uneven stairs, loose carpets, wood stove for heat, and mould) and to health care providers (bed bugs).

He chooses to stay at home because, as he says, “he likes it here” and he cannot find an alternative living situation that he can afford in which his large dog would be welcome.

Which factor do you think is most important in Franklin’s choice of where to live?

• Cost of alternatives
• Familiarity of home
• Comfort of home
• Having his dog with him
• Feeling in control of the situation

75. Case: Cultural Competence: Truth and Reconciliation in Action

 

Case 75: Cultural Competence: Truth and Reconciliation in Action

Alex Sylliboy has been referred to the diabetes clinic and this is his first appointment.  He identifies as Indigenous on the intake form.  Andrew Sullivan, the nurse, has read recently that the experience of residential schools has long-lasting, intergenerational effects on health, but isn’t sure if he should ask about it in the context of addressing Alex’s diabetes and is also uncertain about how to bring it up.

Discussion:

• What are the ethics concerns raised here?

• How might Andrew proceed with this encounter?

• What are some words or phrasing that Andrew might find helpful?

Resources:

• Honouring the truth, reconciling for the future, summary of the final report of the Truth and Reconciliation Commission of Canada, page 158-164. Honouring the Truth, Reconciling for the Future

• Cultural competence and cultural safety in nursing education. A framework for First Nations, Inuit and Métis Nursing. Cultural Competence and Cultural Safety in Nursing Education

 

74. Case: Compulsive Hoarding – Mary

Mary is a 72 year old woman who has been a compulsive hoarder for the last 10 years.  She can only move from room to room through pathways. She would like to move closer to her daughter and grandchildren, but she feels overwhelmed by the amount of stuff she has in her house. Despite the family’s efforts to help, her previous attempts to clean out her home have been unsuccessful. Mary has outpatient orthopedic surgery scheduled, and follow-up care will be provided in her home.  This is causing Mary anxiety and she is considering cancelling the surgery due to the shame she feels about the state of her home.*

*(Case adapted from Cermele, JA et al. (2001). “Intervention in Compulsive Hoarding: A Case Study”. Behavior Modification 25.2: 214-232.)

What are some of the important details in this case that would help you determine how to approach Mary and discuss her concerns?

What are the key ethical concerns if Mary decides to cancel the surgery?

What are the ethical concerns about follow-up care in this case?

What options do you have to address the ethical concerns about follow-up care?

_______________________________________________ 

Some values and ethics issues to consider:

Respect for Autonomy

Quality of life

Quality of care

Boundary crossing

Trust relationship

 

Resources

Gibson, Amanda K.; Jessica Rasmussen; Gail Steketee; Randy Frost; David Tolin. 2010. Ethical Considerations in the Treatment of Compulsive Hoarding. Cognitive and Behavioral Practice. Vol. 17, Issue 4:p. 426-438. http://www.sciencedirect.com/science/article/pii/S1077722910000945

Frost, Randy O.; Gail Steketee. 2014. The Oxford Handbook of Hoarding and Acquiring. Oxford University Press. 2014.

Koenig, Terry L ; Chapin, Rosemary ; Spano, Richard. 2010. Using multidisciplinary teams to address ethical dilemmas with older adults who hoard. Journal of Gerontological Social Work. February 2010; Vol. 53(2):137-147.

National Initiative for the Care of the Elderly (NICE). Compulsive Hoarding: The ethical dimensions. http://www.nicenet.ca/tools-compulsive-hoarding-the-ethical-dimensions)

Tompkins, Michael A..2014. ‘4.5 Ethical and legal considerations when helping a client with severe hoarding’. In, Clinician’s guide to severe hoarding: A harm reduction approach. Springer. November 2014.

73. Case: Compulsive Hoarding – Bessie

Bessie is 65 years old and is living with schizophrenia. She has recently been discharged from hospital, and is now receiving mental health support services at home.  For a while the team has attempted to visit Bessie twice a day. She initially refused to let the team into her apartment and has now allowed health care providers inside.

Upon entering the flat, the team observes many hazards including insects, spoiled food, and broken furniture and appliances in the apartment.  The team notices an eviction notice by the door. They are concerned with Bessie’s living situation, but not sure about what to do.*

*(Case adapted from http://www.nicenet.ca/tools-compulsive-hoarding-the-ethical-dimensions)

What are some of the important details in this case that can help the team to decide how to act?

What are the key ethical principles that apply in this case?

Is this a situation where the team can break their confidentiality with Bessie? Why/why not?

What options does the team have to address this situation?

______________________________________________________

Some values and ethics issues to consider:

Respect for Confidentiality

Respect for Autonomy

Capacity

Informed consent

Quality of life

 

Resources

Gibson, Amanda K.; Jessica Rasmussen; Gail Steketee; Randy Frost; David Tolin. 2010. Ethical Considerations in the Treatment of Compulsive Hoarding. Cognitive and Behavioral Practice. Vol. 17, Issue 4:p. 426-438. http://www.sciencedirect.com/science/article/pii/S1077722910000945

Frost, Randy O.; Gail Steketee. 2014. The Oxford Handbook of Hoarding and Acquiring. Oxford University Press. 2014.

Koenig, Terry L ; Chapin, Rosemary ; Spano, Richard. 2010. Using multidisciplinary teams to address ethical dilemmas with older adults who hoard. Journal of Gerontological Social Work. February 2010; Vol. 53(2):137-147.

National Initiative for the Care of the Elderly (NICE). Compulsive Hoarding: The ethical dimensions. http://www.nicenet.ca/tools-compulsive-hoarding-the-ethical-dimensions)

Tompkins, Michael A..2014. ‘4.5 Ethical and legal considerations when helping a client with severe hoarding’. In, Clinician’s guide to severe hoarding: A harm reduction approach. Springer. November 2014.

65. Case: Conflict in an Ethics Consultation

The next three cases are from our Advanced Clinical Consultation Workshop facilitated by Paul Hutchinson, Imagined Spaces. These cases were submitted to us from Paul.

I find it is often team conflict that can lead to an ethics consult and this will find its way into the consultation space. This can present in a couple of ways:

• Staff will become quiet and hesitant to speak and it can become difficult to deal with the real issues.

OR

• Conversation will become heated and emotion laden.

One case I remember was in dealing with a young mom whose child had been hospitalized since birth. Part of the reason for this long hospitalization was due to an error in care. This was a very young mom with two other children.  She had very few community or family resources and so proper housing and resources for care of her children were issues.

Staff had very differing views of this mom and her care of her child as well as her behaviors in hospital (she would sometimes stay out late at night with friends and on return could be quite noisy). Some staff felt she avoided caring for her child and was leaving all the responsibility to staff. There was clearly a divisiveness with some staff feeling she was simply not a good mom and would never be able to care for her child and in some cases disempowered her by taking over care. Other staff felt this mom was doing the best she could given her age, education, and socioeconomic status and were very protective of her. Staff were being directed to document and be vigilant re anything that might bring doubt on her ability as a parent and perhaps have her children taken from her.

It was a very difficult situation, and it was ongoing when the consult occurred. It was clear values were being challenged and staff felt very strongly. Many staff felt that were being bullied and pressured by other professions and each other and this was a difficult consult to facilitate.

64. CASE: Implementing an Anti-Obesity Strategy

The local health district is in the final stages of adopting a comprehensive organizational anti-obesity policy. Its development was led by a working group of diverse stakeholders from across the district and included an extensive consultation process.

One aspect of the policy that generated a lot of discussion and debate at the working group was the suggestion that messaging should be designed to increase stigma and social pressure around obesity.  This strategy was defended recently in a leading bioethics journal and has been implemented in other jurisdictions.  Ultimately the group was convinced to include this suggestion in the policy because of the success that such messages had in decreasing smoking rates.

Prior to ratifying the new policy, senior leadership requested that the district medical advisory committee review it.  One of these reviewers is clearly upset by the policy; he sent feedback in very personal terms implying that increasing stigma and social pressure around obesity made the policy unreasonable and unethical.

• What values are relevant to the policy issues under consideration?
• Why would the reviewer deem the policy to be unethical?
• What are the conflicting values among the reviewer and the policy makers?
• Is there other information you would like to have before responding to the reviewer?
• How will you (the working committee) respond to the reviewer and why?

Some Values and Ethics Issues to Consider

• Empathy
• Respect for autonomy
• Respect for dignity
• Community health ethics
• Living at risk
• Organizational ethics
• Compliance with policy
• Social justice
• Social determinants of health
• Responsibility for health

63. CASE: Breastfeeding Concerns

Natasha is 15 years old and you, an RN, are meeting her for the first time at a prenatal visit. Her boyfriend, Josh, is 17. Natasha is planning on feeding her baby breast milk substitute as she thinks it will be easier. She has heard that it is harder to lose “baby weight” while breastfeeding, and is worried about fitting into her bikini this summer. She also tells you that she has heard that breastfeeding makes breasts saggy and is worried that Josh won’t be attracted to her anymore. Her mother, on the other hand, is pressuring her to breastfeed.

• What values are at play here and for whom?
• Are there any ethics issues in this situation?
• How would you continue the discussion with Natasha?

Some Values and Ethics Issues to Consider

• Respect for autonomy
• Patient-family relationships
• Patient-centred care
• Responsibility for health
• Stigma and blame

61. CASE: Ending the Fluoridation of Water – A Public Meeting

The local town council has received a petition signed by more than 500 residents requesting the discontinuation of fluoride in the town’s water supply. Before making a decision on the matter, the council has decided to hold a “town hall” meeting to seek more input and help to educate its members and the audience about the evidence on both sides of the debate.

As the Public Health officer for the area, you have been invited to be a member of the panel in charge of this meeting. Other panel members include the mayor, a local dentist, a family doctor, and the two residents who initiated the petition. On the night of the meeting, the local fire hall is at capacity; the mayor who is chairing the panel asks the two residents to begin the discussion by presenting their concerns with regard to water fluoridation. They make the following remarks:

Resident 1: “Everyone says fluoride in the water prevents cavities. What about looking at what causes the cavities in the first place- junk food, pop, sugary snacks and juices are all stuff that parents should be limiting. Why should we all be forced to ingest fluoride in our water because some parents aren’t doing their job? Like everything else, we are what we eat. Good health starts with what we put on the end of our forks- that is how I raised my children. In addition, a routine oral program and thorough brushing is key to any successful prevention.For those that want to provide their kids with fluoride, there are many readily available treatments and over the counter products.I am a victim of too much fluoride because I chose to eat healthy and drink lots of water. Fluoride severely damaged my thyroid and I am now forced to take pharmaceutical drugs for the remainder of my life.

Fluoride is not only in our water (which is also absorbed through the skin), it is used as a pesticide on our food crops, and even organic food crops could be contaminated if watered with fluoridated city tap water. All beverages produced with water, reconstituted juices, contain fluoride, and for those that still receive fluoride treatments at the dentist, brush three times per day with fluoridated toothpaste and maybe even use fluoridated mouthwash, well, that is FAR MORE than any health organization (CDC, EPA or Health Canada) recommends.

I cannot remove fluoride from my water and am therefore forced to purchase distilled water to use for drinking and cooking. I am one of the lucky ones, as I am able to afford to do this. I was never asked if I wanted this industrial waste dumped into my water supply- it was a decision made for me without my consent or even any input. It was a decision made a long time ago and now it needs to undone.”

Resident 2: “I am for choice. So I would rather choose whether or not I drink a toxic chemical. I think that by giving me no choice, the city is not doing me any favours. I have done my own research, and there is very little credibility on the side that says “fluoridate the water.” Instead many experts say fluoride works best as a topical treatment. Bang on. Use it topically then, by choice, don’t force me to ingest it. I use a fluoride rinse and it has absolutely 100% made a difference in my dental health. I have not changed my diet or oral hygiene habits except for the addition of this rinse, but 4 years strong now with no new cavities. Cavities used to plague me with at least a couple new ones a year. I feel that this should be a personal choice, and if people are concerned about costs for poor communities/people then perhaps a subsidy for toothpaste or fluoride tablets is the answer (but only if those people want to purchase the items).One should also keep in mind the effect of excess fluoride on growing teeth. What if your child really likes water and ingests a lot of fluoridated water? Even dentists admit it’s only useful in the right doses. Fluoride is carcinogenic, so I would like to see statistics on cancer rates vs. fluoridation in the region. Plus, fluoride has been linked to lots of other serious conditions, but we are not told about all that – just that it prevents cavities. The jury is out on whether that is actually true. There are countries who do not add fluoride to their drinking water but their rate of cavities is as good or better than ours. So what is that about?! The town could be saving a ton of money each year by not putting fluoride in the water. It’s a smart move in my opinion.”

• Identify the conflicting values that are relevant to this discussion and select the ones that will guide your response. What is the basis of your choice(s)?
• As the public health officer, how will you respond to these statements?

Some Values and Ethics Issues to Consider

• Respect for autonomy
• Community/ public health ethics
• Compliance with policy
• Patient safety
• Community relationships
• Consent
• Risk
• Social justice

59. CASE: HPV Vaccine for Boys

PEI is expanding its human papilloma virus (HPV) vaccination program to include grade six boys. Girls have been receiving the HPV vaccine since 2007. HPV is the most common sexually-transmitted infection among young adults. It can lead to genital warts and, in girls, cervical cancer. For boys it can also lead to cancers of the mouth, throat and genital area.

Deputy chief public health officer, Dr. Lamont Sweet, said vaccinating the boys will not only protect them, it will also lead to fewer women dying from cervical cancer. “Boys can be the source of the virus for their female partners,” said Sweet. “By preventing boys from carrying the virus, you in turn will help prevent girls from getting the virus which causes cervical cancer.” The new program won’t cost more than the original vaccination program, he said, because the price of the vaccine is half what it used to be. The cost of vaccinations for girls in PEI has been $280,000 a year, with about 85 per cent of girls vaccinated. Health Minister Doug Currie said PEI is the first province to offer the vaccine to boys. Nancy Bickford, public affairs for the Society of Obstetricians and Gynecologists of Canada, was pleased by the news. “The SOGC welcomes this move and in fact will be contacting other provincial and territorial ministers of health to follow PEI’s lead,” Bickford said.

You are asked to respond to media questions about this issue – should Nova Scotia follow PEI’s lead and vaccinate grade six boys?

• Identify the values that are relevant to this discussion and select the ones that will guide your response.
• How would you justify this response?

Some Values and Ethics Issues to Consider

• Duty to provide care
• Fairness
• Community/ public health ethics
• Priority setting
• Resource allocation
• Risk