97. Case: Surgery, Supported Decision Making and Capacity

Alex is a 27 year old resident in a supported living facility.  She has a diagnosis of developmental delay.  She is close with her younger brother, Anton.  Alex has identified Anton as someone who helps her to make decisions.  The organization that runs the facility where Alex lives has recently adopted a policy in favour of using supported decision making whenever possible.

Alex has a number of cavities and pain in her teeth is interfering with her ability to eat a wide range of foods.  She eats a soft food diet, and the staff at her facility have raised concerns about the long-term health effects of both untreated cavities and the soft food diet.

After some negative experiences in childhood with blood draws that included being held down and restrained, Alex is intensely afraid of needles and white coats.

Anton has had discussions with Alex about different options that the local dentist can provide, but Alex is adamant that she doesn’t want any dental interventions.  Alex says she will just wait until all her teeth fall out and then get dentures.  She says she’d rather deal with the long-term consequences of eating the soft food diet than face a dental appointment.  Anton observed some of Alex’s interactions with medical care when they were children, and confirms that the experiences were harrowing.

Alex and Anton’s mother is listed as Alex’s substitute decision maker, and the staff feel that Alex’s mother would be willing to authorize sedation and surgery to extract the teeth so that Alex could be fitted for dentures and return to eating a normal, varied diet (which she was happy with before her teeth started hurting).

Some staff members see this is a situation where concerns about Alex’s well-being should override the principled commitment to supported decision making.  They have identified this tension as causing some of them moral distress, and have requested support from the ethics committee.


Questions:

  • What will make this case clinically challenging?
  • What will make this case ethically challenging?
  • How might the ethics committee support the team in dealing with their moral distress?
  • What would change (if anything) if Alex hadn’t had the experience of being restrained for blood draws as a child?
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96. Case: MAiD and Depressive Disorder

An assumption for the purposes of the case – these circumstances are happening in the perhaps not-too-distant future after the Supreme Court of Canada has struck down Bill C-14’s ‘reasonably foreseeable death’ criterion.

Sally York is a 54 year-old, single, unemployed woman who has a longstanding history of treatment-resistant major depressive disorder. Her mother experienced recurrent major depressive episodes throughout her adulthood, and one of her paternal uncles was diagnosed with bipolar I disorder. Sally experienced her first major depressive episode at the age of 11½ while she was transitioning through puberty. In the last 15 years, she has experienced multiple, persistent, disabling depressive symptoms including: significant depressive dysphoria, obsessive negative rumination, intense social anxiety, heightened irritability, lack of interest in normal activities of daily living and her former hobbies, impaired concentration and focus, reduced appetite and with associated difficulty maintaining a healthy weight, prolonged, early morning waking, and suicidal ideation. Sally has been followed by numerous psychiatrists and clinical psychologists over her lifetime, and she has been trialed on a wide variety of treatment modalities including three generations of antidepressant medications and multiple augmentation agents (atypical antipsychotics, anticonvulsant medications, mood stabilizers and T3 thyroid medication). She has been actively engaged in courses of many different types of psychotherapy including supportive, insight-oriented, cognitive-behavioural, interpersonal and mindfulness-based types. She has tried and failed transcranial magnetic stimulation treatment. Although Sally has been offered trials of ECT, she has never wished to pursue this treatment intervention due to her mother’s reports of bad experiences with it in the years before her death. She was involuntarily hospitalized on four occasions in the past because of temporary formed suicidal intent.

Sally’s other active health conditions include irritable bowel syndrome, chronic mixed migraine-tension headaches, and chronic, significant shoulder girdle myofascial pain. Her chronic pain remains active despite trials of physiotherapy, massage therapy, exercise therapy, myofascial trigger-point injections, regular opioid medication, and a neuropathic pain modulator. A former attending psychiatrist believed that there was a component of somatic symptom disorder in Sally’s chronic pain presentation.

Sally’s quality of life has greatly deteriorated over the past four years due to her combined experience of persistent depression and chronic pain, although the latter has been less disabling than the former. This symptomatic worsening correlated with her financially-based decision (after leaving work for medical reasons) to move to a remote area of the Valley that is close to where her mother grew up. Without the direct support of a cognitive-behavioural therapist, Sally stopped doing her cognitive-behavioural exercises and slipped back into her former ways of looking at the world through the typical cognitive-distortions of depressed individuals, e.g., all-or-nothing thinking, mindreading, minimization of positives, etc. She spends most of her days in bed and struggles to get out of her small, government-subsidized apartment once a week to visit an elderly aunt. A friendly neighbour shops for her at the local supermarket once a week. Her medications are delivered to her by taxi through an arrangement with a pharmacy located in a nearby village. Although her medications are delivered in blister packs, she forgets to take them sometimes.

Sally has heard that MAiD is now legal in Canada but she doesn’t know much about it. She asks a cousin who lives in the nearest town, and who worked as a palliative care nurse in Halifax prior to his recent retirement, to come-by for coffee. Sally uses her enhanced knowledge from the conversation with her cousin to prepare herself for a visit to her family physician.


 

Questions

  • What is your gut reaction on a ‘first read’ of these circumstances?
  • Can legitimate distinctions be made between the experience of profound suffering arising from physical health disorders and the experience of profound suffering arising from mental health disorders?
  • How could the psychiatric symptomatology and related lived-experiences of a person with a significant mental health disorder affect her/his capacity to make a decision regarding a personal request for MAiD.
  • Are there particular mental health disorders that would preclude the making of an informed choice to request MAiD?
  • What is currently known about the capacity of individuals who suffer from treatment-resistant major depressive disorder as this pertains to their making of meaningful decisions about their health care and treatment?

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?

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?

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.

58. CASE: Harm Reduction

Medical Officers of Health from British Colombia, Nova Scotia, and Saskatchewan have written to advocate for emphasizing harm reduction in the approach to cannabis and other illegal drugs (including possible legalization).

“Evidence-based drug treatment programs are cost effective, and significant benefits should be derived, at both individual and societal levels, through an increase in scale. Consistent with the recent recommendations of the House of Commons Standing Committee on Public Safety and National Security, this would include expanding access to existing evidence-based models of care such as medical and non-medical withdrawal programs, programs to manage concurrent mental health problems and addictions, ambulatory and residential treatment programs, and opioid substitution therapies. Similarly, given the substantial health (e.g. infectious disease, overdose death) and social (e.g. crime) concerns caused by heroin addiction in urban areas and the potential for heroin by prescription to reduce these harms among those for whom conventional treatments fail, the prescription of heroin could be considered for selected patients with opioid addiction that is refractory to all other treatment modalities.

Various harm reduction strategies, such as needle exchange programs and methadone maintenance therapy, have also proven effective in reducing drug-related harm and have not been associated with unintended consequences. The joint recommendations recently released by several United Nations agencies, including the World Health Organization, provide a strong scientific basis for expanding harm reduction efforts. Beyond these recommendations, the recent consensus statement from Canada’s National Specialty Society for Community Medicine, which endorses the scale-up of supervised consumption facilities, reflects the compelling national and international evidence to support the controlled expansion of these programs in urban areas with high concentrations of public drug use and related harms.”

  • What values are being prioritized in this argument?
  • What other values, if any, might be important/relevant to consider?
  • What would you suggest if you were asked to be part of a group looking to help local government develop and prioritize approaches to similar issues?

Some Values and Ethics Issues to Consider

  • Duty to provide care
  • Empathy
  • Respect for autonomy
  • Respect for dignity
  • Vulnerability
  • Community/ public health ethics
  • Community relationships
  • Living at risk
  • Patient-centred care
  • Patient safety
  • Quality of life
  • Resource allocation

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

53. CASE: Disease Stigma

A patient has been followed by you, his family doctor, for several medical issues and is being seen for a minor work-related injury. He is very negative and tearful but will not acknowledge his symptoms when asked.

You believe he is depressed and you know you can provide treatment for his depression. However, the patient is uncomfortable seeking treatment or having you document your findings in his record because of the stigmatizing effect of having a mental health disorder known in a remote community.

  • What steps should you take to address his depression?
  • What factors external to your family practice must be considered?
  • Do you think that it is likely or unlikely that the patient’s concerns about confidentiality are valid?
  • What policies and procedures should be in place to maintain privacy and confidentiality in rural communities. How should these be enforced?


Some Values and Ethics Issues to Consider

  • Respect for privacy and confidentiality
  • Respect for patient autonomy
  • Community and family relationships
  • Respect for human dignity
  • Honesty, trust and truth-telling
  • Patient-provider relationships
  • Patient safety
  • Stigma
  • Vulnerability
  • Equality of access

46. CASE: Team Work?

Judy, who had worked as a senior social worker in a mental health setting for 12 years, was hired as a team social worker in a community health care organization. Shirley, one of the team RNs, perceived Judy as hesitant and ineffective in patient care planning meetings. Other team members also found Judy to be too hesitant in making decisions, often rolling their eyes when Judy asked team members for their opinions. Despite their concerns about Judy’s hesitancy, team members also complained when Judy did not consult them before making a patient care decision. As Judy experienced these mixed messages, she became more guarded in her social work assessments.

The inter-professional team on which Judy was placed had a culture of socializing together after work. Initially, team members invited Judy to join them, but she did not have time due to the care that she was providing for her mother after work and also was uncertain about how much to socialize with her colleagues.

When the team was together after work, they discussed Judy’s behaviour, often noting that her mode of dress was out of style. Carol, the team facilitator, would occasionally join the rest of the team for a drink after work. During one of these nights, Shirley complained to Carol that Judy was not doing her job. She also mentioned that the team did not like Judy because she did not socialize with them and wouldn’t disclose information about her personal life as they all had done with each other. The nursing assistant and dietician on the team told Carol that they saw Judy as being very unfriendly. The following week, Carol spoke with Fran, the social work supervisor, stating that Judy was a problem and she wasn’t sure that Judy would work out with this team.

In her monthly supervisory meeting, Fran asked Judy how things were going with her team. As Judy’s eyes began to tear she said that she was thinking of leaving. Judy said that that she hadn’t realized how hard it would be to work with a team, and commented that the team members kept comparing her to a former team social worker who was not liked by them.

Judy told Fran that the team seemed fairly uncomfortable with mental health issues and that she was shocked when the team made derogatory comments about patients – i.e., that some were dirty and smelly or that the team couldn’t stand certain patients. And, in terms of the team, Judy wasn’t sure what to do because someone had told her that once you were on Shirley’s bad side that you were always on her bad side.

[Case modified from: P.G. Clark, C. Coot, T.J.K. Drinka, 2007, Theory and practice in interprofessional ethics: A framework for understanding ethical issues in health care teams, Journal of Interprofessional Care 21(6): 591-603.]

  • Is this a human resources issue or an ethics one?
  • How would you handle this situation?
  • Are there underlying and/or competing values that should be considered?

 

Some Values and Ethics Issues to Consider

  • Care for the vulnerable
  • Community health ethics
  • Health care provider relationships
  • Moral distress
  • Organizational culture
  • Overlapping roles and responsibilities
  • Professional competence
  • Professional boundaries
  • Respect for privacy and confidentiality
  • Respect for professional integrity
  • Staff morale