102. Case: A Question from Family About Outcomes

You are caring for a patient following a severe stroke. The attending physician has been very clear with the family that it is unlikely that the patient will survive and that, if he does, it will be with very significant impairments. Still, the family takes any movement or facial change as an indication that he is improving. They are praying for his full recovery and today, at the end of your shift, the eldest child asks you when you think her father will be ready to go home.  How will you respond to the question?


Your family has strong faith convictions and a firm belief that “where there is breath, there is hope”.  Your father had a stroke unexpectedly and you found him slumped over when you came home from class.  You feel guilty because you stopped on the way home to get coffee with a friend.  The doctor said that your father’s “prognosis is poor”, but you’ve heard lots of stories about doctors being wrong. You also feel strongly that if you believe that your father will recover this will help to bring it about and that the converse is true, that if you allow yourself to think or talk about your father’s death it could cause it to happen.  So, you ask the doctor when they think your father will be able to come home. How would you respond if the physician says, “I don’t think your father will be able to go home…”?


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 might be some of the undercurrents that influence the direction the conversation takes?
  • What makes this a difficult conversation for each participant?
  • Who else might be involved in having subsequent conversations with the family about care decisions?

References:

Barley, S. 2010. Having the difficult conversations about the end of life. The BMJ 2010; 341, published 16 September 2016 https://www.bmj.com/content/341/bmj.c4862

Lippe, M. 2018. Drawing the line between hope and false expectations. Blogpost, Reflections on Nursing Leadership. Published online 09/19/2018 https://www.reflectionsonnursingleadership.org/features/more-features/Drawing-the-line-between-hope-and-false-expectations

NSHA Library Services: Conversations about serious illness: https://library.nshealth.ca/SeriousIllness/GOC

Welsh, A. 2016. At end of life, doctors and families often differ in expectations. CBC news, published May 17, 2016. https://www.cbsnews.com/news/better-doctor-family-communication-needed-at-end-of-life-study/

Woelk, C.J. 2008. Management of Hope. Can Fam Physician; 2008 Sep. 54(9): 1243-1245 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2553443/

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98. 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?


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?


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

 

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.

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

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

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