93. Case: Mr. Rattan Wants to Stay

Mr. Rattan has been a resident at Ocean Wind, a retirement community offering a range of options for accommodation, for the last ten years since his partner died.  Currently he has a studio apartment in the assisted living wing, which provides assistance with ADLs.

Mr. Rattan has been diagnosed with dementia.  In the last few months his younger daughter, who typically visits on her way home from work, has become concerned that his current living situation doesn’t meet his needs and wants him to move into the locked dementia unit in a different wing of the building.  She has started to make arrangements for Mr. Rattan to move.

When his daughter talks with him about moving, Mr. Rattan seems amenable to this option.  But twice when staff have come to discuss moving with him he refuses, saying that he’s comfortable where he is and that he doesn’t want to spend the extra money.

Mr. Rattan’s elder daughter and son have both called Ocean Wind to reinforce that Mr. Rattan has told them he doesn’t want to move and that they want his wishes to be respected.  Mr. Rattan does not have an personal directive in place.

Staff have expressed some concerns about Mr. Rattan, indicating that he seems frequently to be confused and disoriented at the end of the day.  They are also considering requesting a capacity assessment, but there is disagreement about whether that is an appropriate next step.

The manager at Ocean Wind has contacted you as the chair of the ethics committee looking for support with this case.


 

Questions:

What will make this case clinically challenging?

What will make this case ethically challenging?

How might the ethics committee support Ocean Wind in addressing these challenges?

What would change (if anything) if Mr. Rattan had a personal directive identifying his son as the substitute decision maker?

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92. Case: End of Life with Dementia

Mr. Shah lives in a continuing care facility. A nurse recently commented; “My patient, Mr. Shah, has an advance directive that he wrote last year and that requests medical assistance in dying when he is no longer able to recognize his wife. His dementia has worsened quickly and recently he’s asked who his wife is after she visits, although he’s happy with her when she’s here. Are we obligated to do anything about his request for medically assisted death?”

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

78. Case: Health Care for New Canadians

 

Ahmed arrived recently in Canada as a refugee from Syria.  He was diagnosed in the refugee clinic with prostate cancer and has arrived for a follow-up visit.  The interpreter has called in sick and Ahmed speaks very little English.  Ahmed’s 13-year-old son, Bashir, has accompanied him and is acting as a translator for his father.  The health care team at the clinic would like to make some decisions today about treatment approaches, but Bashir seems uncomfortable with translating both questions and responses.

 

Discussion:

  • What are the ethical concerns raised by this case?
  • As a member of the health care team, how would you proceed?
  • What types of refugee health resources might be developed to support patients, families, and health care teams?

 

Resources:

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.

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

44. CASE: Whose Business Is It?

Brent Wathorn, 78, has been living at Halfway Lake Manor for about 6 years. His main complaint has been that he is lonely and has had difficulty connecting with the other residents. This has been a source of distress for staff at times, as they would like him to feel more ‘at home.’

Norma Carkner, 75, moved to the Manor about a month ago. She has limited cognitive abilities as the result of a stroke, but is still able to express herself reasonably well and make some choices if given enough time.

Staff members have noticed that Brent and Norma have been spending much time together and have found them kissing on occasion. While there is no evidence of a sexual relationship beyond this, some of the staff is quite concerned about the possibility.

Given his loneliness, they wonder if Brent may be putting pressure on Norma. Other staff point out how happy both Brent and Norma seem together. Much of the discussion has focused on whether and to what extent they should intervene or say something to family members.

  • What values/assumptions might be at play here for staff members?
  • What ethics concerns are you considering in this scenario?
  • Should the staff discourage this relationship?
  • Should the staff notify Brent and/or Norma’s family about the relationship?


Some Values and Ethics Issues to Consider

  • Honesty, trust and truth-telling
  • Compliance with policies and procedures
  • Respect for privacy and confidentiality
  • Respect for patient autonomy
  • Respect for dignity
  • Quality of life

41. CASE: Ethical Budgeting

This is the day you’ve been dreading as manager of the geriatric day program at your local hospital. Word has come down that your budget is going to be cut by 15% in the next fiscal year (indeed everyone’s budget at your facility faces the same cut). You have three months to determine how this money will be eliminated from your budget and must meet with your director to explain both the ways in which the money will be “saved” and what implications will follow from the “cuts.” The geriatric day program has been one of the most successful programs at this facility, based on client and family feedback. Among other activities, the geriatric day program includes rehabilitation support, general health monitoring and facilitated access to health professionals, psychosocial support and counseling, organized recreation therapy sessions, transportation to and from the health facility for those who can’t otherwise get there, and hosts a variety of speakers on topics of interest. You know that whatever change you make, the effects will be felt in the community. And, you know that some of the very vulnerable people – the clients without many social supports and multiple health issues – could potentially be affected the most.

  • Where do you start?
  • What questions should you ask?
  • What information do you need?
  • Who should you talk to?
  • What might be a good process to use for this type of decision-making?
  • Who should be involved in the process?
  • How will you know when you’ve got it right (or as right as it can be)?

 

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Distributive justice
  • Priority setting

39. CASE: Setting Priorities

In the wake of a mass casualty event, a hurricane that devastated much of Nova Scotia, blood resources within the province are extremely scarce. There is not enough blood to meet all the legitimate blood-related health needs of Nova Scotians, and the blood supply is not expected to increase significantly in the next two months. Tough choices have to be made. The following three patients have been admitted to a rural general hospital and are in need of blood transfusion:

Jim is a relatively healthy, 87-year old man who requires a colectomy for a benign hemorrhagic bowel disorder. He is scheduled for surgery along with many urgent others, and it is anticipated that he will not rise to the top of the waiting list for at least two months. To bridge the gap between now and then, he requires regular (e.g., q 3 weeks) transfusions. Jim lives independently in the community and is very engaged with two of his children and six grandchildren who live in the local area.

Sue is a 42-year old woman admitted to the palliative care service whose progressive leukemia is causing her to be significantly fatigued and short of breath. The attending hematologist estimates that regular blood transfusions would allow her to remain functional at home for about another eight months. She has three children ages 4, 7 and 11. The family is dependent on the single income of her husband who is a plumber.

Kevin is a six-year old boy with a poor prognosis cancer diagnosis. His present quality of life is poor – he is confined to bed and spends most of his time asleep. He is not experiencing any pain. Kevin is able to communicate with his parents for an hour or two a day. His medical oncologist estimates that regular blood transfusions would extend his life for about another five months. It is anticipated that Kevin’s quality of life will remain essentially unchanged during this period of time. Kevin’s parents are demanding that their son receive these blood transfusions.

Dr. Fairchance, as the hematologist on-call, is asked to make a decision about which of these three patients should be started on blood transfusions. She recognizes that there is currently enough available blood to meet the needs of only one of these patients. Dr. Fairchance is also asked to prioritize the other two patients in the unlikely event that more blood becomes available in the next week or two. As the medical resident on-call, you have been requested to assess Jim, Sue and Kevin and to report back to Dr. Fairchance regarding their present health status. She would also like you to assist her with the rationing decision.

  • What factors should be considered in micro-allocation decisions? How do you prioritize them?
  • What principles and values would inform your decision-making?
  • What decision-making process would you use to work through this decision?
  • Is there a better way than ‘bedside rationing’ to allocate scarce health resources?
  • What are the implications – organizational or otherwise – of your decision?

 

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Distributive justice
  • Priority setting