89. Case: Who Has a Right to Know?

Kevin is a14-year-old admitted to hospital with persistent headache, muscle spasms, tremors, significant motor impairment, fever, cough and symptoms of liver damage.

A diagnosis of lipoid pneumonia has been made and his clinicians are very suspicious that he has been inhaling nitrite compounds. Eventually they are able to confirm this when one of the team talks with friends who are leaving after a visit with Kevin.

When the physician confronts Kevin with this information, Kevin pleads with him to not tell his parents. His parents have been regular visitors and appear to be very concerned about their son’s condition. They have repeatedly asked the doctors to explain what is happening.

Several follow-up discussions with Kevin have not changed his mind; he does not want his parents to know anything about his drug abuse history. “You are my doctor aren’t you? That means what I tell you is just between you and me, doesn’t it?”

The physicians and rest of the team are unsure how to answer him. They do not know whether they should respect Kevin’s wishes in this regard.

At the suggestion of the team, the charge nurse has requested an ethics consultation. How will you prepare for this consult? What are the key ethics issues?

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86. Case: Herbs in the Hospital

Katrina Chen is a 23 year old with a history of severe anxiety and hospitalization after particularly acute panic attacks.  She has tried a variety of psychotropic medications and of these she believes that Prozac is the best at managing her symptoms.  She is concerned, however, with its addictive nature and doesn’t like taking “chemicals”.

She has recently started working with a naturopathic doctor (ND) with the goal of getting off Prozac.  Her naturopath has compounded a herbal remedy to treat her anxiety, explaining that it contains primarily valerian as the active ingredient, and she has also begun biofeedback treatments.  Katrina feels that the valerian has been effective in reducing the severity of her symptoms and was planning on reducing her dosage of Prozac.

Katrina has been hospitalized again after a panic attack and is requesting that the hospital provide her with the valerian in addition to her Prozac prescription.  She has no family in the area and a minimal social network such that she has no other way to obtain valerian.  The fact that she does not have access to valerian seems to be increasing her agitation and anxiety.

The health care team is concerned about several aspects of this case.  They’ve come to you with the following questions:

  1. Is the hospital obligated to provide alternative therapies in response to such requests by patients?
  2. Is the team obligated to provide valerian with Prozac given a potential risk of adverse interactions between the two compounds?
  3. If there seems to be very little good evidence that valerian is effective as a treatment for anxiety, should the team actively discourage Katrina from taking it?

60. CASE: Health Care Providers Under Quarantine

My story starts in early April, during a routine day shift in our minor care area. A previously well middle-aged man, recently returned from Hong Kong, presented with fever. Because SARS was already recognized and we’d gone through the recent experience of a crash intubation with our first case at Vancouver General, this patient was isolated at the triage area and we gowned and masked to examine him. Apart from a temperature of 37.8°C, his vital signs were normal and he looked well. He had no other symptoms, and his physical examination, CBC, urinalysis, and chest x-ray were all normal. Although the patient did not fulfill the case definition of SARS then in existence, I kept him in isolation just in case. When I went in to give him discharge instructions, I did not wear a mask and stood just inside the doorway, about two meters from him. Almost predictably, he returned with the full SARS syndrome just over 24 hours later. And wouldn’t you know it, by then, the case definition of SARS had changed!

I briefly wondered if I could pretend I was not in his room unmasked, but the thought of potentially disseminating a lethal virus persuaded me to do my civic duty and tell my boss. Two hours later Public Health phoned to inform me I was officially quarantined. Needless to say, my husband, also a physician, was incredulous and my kids were terrified. I thought it was kind of funny for the first day, like someone was playing a bad joke. Then the reality began to hit home, and I can tell you the reality was difficult to live with. This is what Public Health told me.

  • I must stay inside my house (preferably within my bedroom) 24 hours a day
  • I must not touch anyone in my family
  • I must wear an N95 mask if anyone is in the same room as me
  • I must not prepare uncooked food for my family
  • I must not sleep with my husband
  • I must use a separate bathroom
  • I must not touch anything in the house that the kids might later touch
  • I must not use the family computer or the main phone
  • I cannot have outside visitors
  • I cannot shop for groceries
  • I cannot go for a walk

The quarantine requirements were not voluntary, but were enforced by Public Health, who contacted me daily to gauge my cooperation. If I did not comply, it was clear that I would be legally compelled to do so. All this took place under the shadow of potentially transmitting SARS to my family, the people I love more than anything in the world. My nine days of quarantine were a blur of extreme boredom, some highly emotional episodes, and a re-evaluation of what I do for a living. One of our daughters moved out for the duration. Another celebrated her 16th birthday without a hug, cake or present from her housebound mother. And my son told me daily how much he wanted a snuggle. I felt guilty that my colleagues, all of whom are already overworked, had to pick up extra shifts to cover me during my enforced absence. As if all this were not enough, it slowly dawned on me that I wasn’t earning any income, and would have to put in extra shifts after my quarantine was over. I decided I never wanted to see another N95 mask again…

What did I learn from my experience? First, it is very isolating and lonely to be isolated. I hugely appreciated the calls and emails I received from my colleagues while I was off. It helped enormously to know they were thinking of me, and didn’t think this was my fault. Second, I think all emergency physicians should consider the financial implications of a sudden enforced quarantine. None of us have disability insurance that would commence quickly enough. To be under quarantine is difficult enough without the added burden of a financial penalty. Although I suffered an occupational exposure, I was not covered by Workers’ Compensation. I believe we need to negotiate with our hospitals and governments to put financial packages in place. Many hospitals are starting to compensate self-employed health care workers for income missed during quarantine. I would go further and suggest a per diem rate for days confined due to occupational exposures. Although no one can compensate me enough for nine lost days of my life, a token payment certainly wouldn’t hurt. Finally, as emergency physicians we do a far more difficult and noble job than I had ever realized. The consequences of what we do to care for our patients and protect the public are risks that put ourselves and our families in potential danger. This is something we never think about or acknowledge, but maybe we should. And maybe we should celebrate ourselves more than we do. I have huge admiration for my emergency medicine colleagues who had far worse exposures than I did in the early phase of the SARS crisis.

  • What values are involved here and for whom?
  • What ethical considerations have to be balanced in such quarantine situations? How is the most appropriate balance achieved?
  • How would you respond to this physician’s concerns? Do you feel there is any legitimacy to her complaints?

Some Values and Ethics Issues to Consider

  • Duty to provide a safe work environment
  • Duty to provide care
  • Respect for individual liberty
  • Community/ public health ethics
  • Consent
  • Disclosure of adverse events
  • Health care provider relationships
  • Risk
  • Patient safety
  • Compliance with policy
  • Disclosure of adverse events
  • Non-maleficence
  • Privacy and confidentiality

33. CASE: Ethical Advertising?

A hospital has placed billboards throughout the region with the following statement:  “Are You a Victim of Sexual or Domestic Assault?  Come to Warman Center Where We Will Treat You Immediately. Our Staff of Counsellors and Providers Have Received Special Sensitivity Training in This Area. You Are Our Main Concern.”

A twenty-five-year-old college student presents to the Warman Center’s emergency department stating, “My boyfriend assaulted and raped me and I need help.”  The registration clerk notices that there are fresh bruises and bleeding on her face, neck, and arms.  The student fills out registration information and is asked to sit in the waiting room.

Several hours pass. The young woman approaches the registration clerk and states, “I am really scared.  I have pain. I am terribly upset about what has happened to me, and I just can’t sit here any longer.”

The registration clerk responds, “Haven’t you seen all the ambulances come in?  We have patients with critical injuries like pneumothorax here.  You will have to wait your turn.”

Three and a half hours later, when a nurse calls out the student’s name to be seen, she is no longer in the waiting room.

(Case adapted from: Ann E. Mills, Edward M. Spencer, and Patricia H. Werhane (eds), Developing Organization Ethics in Healthcare: A Case-Based Approach to Policy, Practice, and Compliance, Maryland: University Publishing Group, 2001, p. 55)

  • What do you see as the organizational ethics issues?
  • How should these issues be addressed?
  • What values should be considered in this discussion?


Some Values and Ethics Issues to Consider

  • Accountability
  • Duty to provide care
  • Honesty, trust and truth-telling
  • Compliance with policy
  • Priority-setting

20. CASE: To Treat or Not to Treat

Stan Miller, a retired widower, sustains severe burns covering 80% of his body surface in a house fire secondary to a propane gas leak. He is initially assessed in the ED of the local hospital where he is sedated and intubated without any pre-resuscitation discussion about the seriousness of his thermal injuries and his care preferences. He is transferred by air ambulance to the ED of the provincial tertiary care centre where he is assessed by an on-call, senior plastic surgery resident. The brief transfer documentation indicates that Mr. Miller has a variety of pre-morbid health conditions including type II diabetes, essential hypertension, coronary artery disease and moderate COPD. He is admitted to the Burn Unit from the ED.

Mr. Miller has three adult children, two of whom arrive on the scene shortly after their father’s admission to the Burn Unit. The children, David and Sarah, describe their father as a “go-getter” who approaches his retired life with enthusiasm despite his chronic health problems. They mention that he has been living with a partner, Cathy, who was away on a visit to Ontario to see her family when the fire occurred.

Mr. Miller’s three children had an informal discussion with their father a couple of years ago at Christmas time about what he would wish to have done if he ended up in an ICU Unit and could not make treatment decisions on his own. Mr. Miller essentially told them that his care preference would be to fight to stay alive.

A family meeting held on the Burn Unit is held in order to decide the course of treatment. It is attended by Sarah, David, the attending plastic surgeon on rotation, two residents and a nurse who provides direct care to Mr. Miller.

  • What issues would be important to discuss during this meeting?

Now Consider:

What if the above scenario is the same except that Sarah’s 17 -year old son Mike (Mr. Miller’s grandson) was staying over for the weekend when the fire happened and he too sustains severe burns- in his case, covering 90% of his body. He arrives with his grandfather by air ambulance after being sedated and intubated in the local hospital ED. In discussion with members of the health care team, Sarah comments that her son recently received an athletic scholarship to attend Acadia University next fall. She reports that he loves the outdoors and has always been in excellent health. The same plastic surgeon and residents and a nurse who directly attends Mike participate in a family meeting with Sarah and her husband in order to decide the course of treatment.

  • What issues would be important to discuss during this meeting?
  • Does the age and relative health of the patient in this scenario change the issues at hand compared to the first scenario?

Some Values and Ethics Issues to Consider

  • Substitute decision-making
  • Advance care planning
  • Pediatric ethics
  • Resource allocation
  • Patient-family relationships
  • Quality of life

13. CASE: Mind Over Matter?

Essie Marshall is well-known in the community for her many years of dedicated volunteer work and leadership. She is also well-known in the emergency department for her frequent visits. As one of the doctors describes her, “She’s a challenging patient, but not in the medical sense.”

Today Essie is back in the emergency department, saying she is terribly fatigued and has some “pretty bad stomach gas pain” at night. “I just can’t seem to get out of bed these days,” she tells the attending doctor. “You’ve got to give me something to boost my energy!” Dr. Gibson performs a careful physical examination, including a complete abdominal exam, the results of which are unremarkable. He suspects, based on further discussion, that her gas pains are due to gastroesophageal reflux disease (GERD) and tells her that he will prescribe an anti-reflux medication. He also spends some time explaining measures she can take to minimize her reflux symptoms. “But what about my fatigue?” she complains. “You haven’t given me anything for that and it’s worse than the stomach thing!”

Dr. Gibson isn’t sure what to do. With Essie’s history, any attempts at referring her for a psychiatric consult or to social work have been repeatedly refused. No previous tests or exams have revealed any direct cause for her fatigue. Many in the emergency department believe that Essie is lonely and not sleeping well since the death of her husband three years ago. Because they know her, they have a hard time trying to “get her out the door quickly,” even though they know Essie is taking up time and resources that could be used to reduce wait times.

In talking it over with the nurses on duty, the decision is made to give Essie a “prescription” for some vitamins and to give her a shot of vitamin B-12. This could help with her fatigue, but all are a little uncertain about how far to indulge Essie’s complaints. This will deal with her today, but what about tomorrow? Together the nurses and Dr. Gibson decide to call for an ethics consultation to talk about this case and the questions it raises.

[Case substantially modified from: Prescribing Placebos, Virtual Mentor 8(6): 377-380, June 2006 – see virtualmentor.ama-assn.org]

  • What underlying values should the staff involved in this case consider?
  • What ethics questions are raised in this case?
  • Is the prescribed treatment the same as giving her a placebo? Is this ok?
  • Is this the right way to handle “frequent flyers” such as Essie?


Some Values and Ethics Issues to Consider

  • Capacity
  • Patient-provider relationships
  • Resource allocation
  • Honesty, trust and truth-telling
  • Respect for professional integrity
  • Patient-centered care
  • Empathy

7. CASE: Unknown Risks

A person who was a first responder at an accident comes into the Emergency Room with blood/body fluid on himself. The patient who was involved in the accident was immediately sent to Halifax where he later passed away. His family had refused to allow his blood to be drawn for testing. The first responder is concerned about disease transmission and wants this brought to ethics. The request came via the Patient Care Manager in the Emergency Department.

  • What are the ethics issues in this case?
  • Who has decision-making authority in this case?
  • How will you proceed with the request?

Some Values and Ethics Issues to Consider

  • Respect for privacy and confidentiality
  • Respect for patient autonomy
  • Duty to provide care
  • Patient-family relationships