101. Case: Chatting About Hopes and Goals

You are a social worker who is part of a rehab team.  During lunch, the conversation turns to one of the patients that you and your team is working with. The patient was in a scooter accident and suffered multiple fractures. They are struggling to regain their ability to walk and can often be heard expressing their frustration. Some around the table are concerned that the patient is giving up and that they seem to have “no hope for the future” – despite the expectation that they should be able to walk again. One of your team members turns to you and says, “You seem to have a good rapport with this patient, why don’t you talk to them about this?”  This is not the first time you’ve received such a request, and you appreciate that your colleagues have recognized your skill at building rapport. But there is no extra time, or any other resources provided to you to acknowledge the contribution you are making.  How will you respond to this request?  And how might you raise this at the next team meeting?


You are 23 years old and you were in a collision while riding your scooter and are now in rehab recovering after multiple serious fractures. Rehab is a lot of effort and you aren’t experiencing the improvements you expected.  Your friends have stopped coming by to visit and you feel lonely and isolated in the hospital.  You know that the health care providers are trying their best, but you find it hard not to take your frustration out on them when they’re the only people you see most days. How will you respond the next time a team member encourages you to keep trying?


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 values that might be in tension for the social worker in thinking through the situation?
  • What types of support might make it easier for the social worker to take on the work of having difficult conversations?
  • How do health care providers build the skills that help difficult conversations go well?

References:

Canadian Physiotherapy Association. Ethics and professionalism toolkit. https://physiotherapy.ca/ethics-and-professionalism-toolkit

Forbes Coaches Council. 14 Ways To Approach Conflict And Difficult Conversations At Work https://www.forbes.com/sites/forbescoachescouncil/2017/07/17/14-ways-to-approach-conflict-and-difficult-conversations-at-work/#698346ac3cfd

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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92. 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

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.

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

12. CASE: Should Steve Go Home?

Throughout his life, Steve was the athlete that everyone admired. He played all sports well, especially excelling at basketball. While being quite competitive, Steve was a team player who enjoyed being a part of the team experience.

Unfortunately, while ‘horsing around’ with his friends last summer, Steve dove off a dock into water that was too shallow. His head cracked on the bottom resulting in a spinal cord injury. He is no longer able to walk and has slowly been regaining some control over a few of his fingers.

At 17, Steve felt that his life was over and has had difficulties participating in his rehabilitation program, saying things like, “What’s the point if I’m never going to walk again?” and, “I can’t even go to the bathroom by myself!”

Steve’s family, friends, and health care team rallied around him providing lots of support and encouragement. Over the past month-and-a-half, the health care team noticed some positive changes in Steve’s involvement in his rehabilitation program. He is participating more and talking about wanting to get out of the rehab facility. Accordingly, the health care team was working with Steve on a discharge plan in three weeks, if his progress continued. All of this seemed to indicate that Steve was beginning to see a new life for himself – until one of the Recreation Therapists came to the team meeting three days ago.

Steve and Andrea, the Rec Therapist, developed a close working relationship over his time at the rehab facility. Steve often shared with Andrea what he was really thinking and this has been helpful for the health care team to identify what interventions and supports may be needed. Steve confided to Andrea (three days ago) that the only reason that he was working so hard at learning to use his motorized wheelchair was so that he could control the joystick well enough to ensure that he could kill himself by driving off the same dock where his injury occurred.

A consult with a psychiatrist who specializes in persons with spinal cord injuries reports that Steve is not depressed and does not seem to have the intent to follow through with his plan of suicide. He said that this expression may have been primarily an indication of Steve’s ongoing frustration and adjustment to his spinal cord injury.

Even with this information, the team is conflicted about what to do. Their own hopes that they were making progress with Steve have been challenged too. The team agrees to consult the ethics support service.

  • How would you handle this request?
  • What values appear to be shaping the dynamic for team members? For Steve?
  • What are the ethics concerns?
  • How should the health care team reconcile the difference in opinion between the psychiatrist and those who believe Steve’s plan to commit suicide?

 

Some Values and Ethics Issues to Consider

  • Capacity
  • Respect for patient autonomy
  • Moral distress of health care providers
  • Respect for professional integrity
  • Honesty, trust and truth-telling
  • Patient-provider relationships
  • Compliance with policy

10. CASE: At a Crossroads…

Sandra Livingstone, age 45, was admitted to the hospital with diffuse ischemic encephalopathy – a very significant, global brain injury – secondary to sustaining a massive stroke at home. It is now ten months after her admission. Ms. Livingstone is on an acute internal medicine unit where she has been living since her discharge from the intensive care unit.

She is unable to communicate with others and appears to be in profound distress, spending much of her time screaming and obstructing the attempts of nurses to care for her. She is unable to eat and drink due to neurological damage to her swallowing mechanism. She has just managed to remove her J-tube for the fourth time despite being in arm restraints and having her hands padded on a twenty-four hour basis. Trials of various medications to target her intense agitation have been unsuccessful.

The consultant neurologist, Dr. Bailey, recently reassessed Ms. Livingstone. In his opinion, her neurological status is now stable and the prognosis for further neurological recovery is extremely low. He comments that “this is the way she will always be”.

Ms. Livingstone had not made a personal/ advance directive prior to her stroke. Her statutory decision-maker is her father, Mr. Livingstone, a person of strong religious faith. He believes that his daughter is “still in there” and that she will eventually recover sufficiently to allow him to take her home. He refuses to discuss the possibility of withdrawing life-sustaining treatment, i.e., her J-tube.

The clinical unit’s social worker, Mr. Roberts, has been exploring alternative residency options for Ms. Livingston. Given her current health status and long term, significant care requirements, Ms. Livingstone cannot be formally classified for placement in a continuing care facility. Her local rural hospital has declined to accept her for care through a transfer from the tertiary care centre.

A health lawyer from Legal Services and a clinical ethics consultant are asked to participate in a health care team conference to explore potential ways forward.

  • What issues should be discussed at this meeting?
  • Which of these issues are ethics issues?
  • What decisions need to be made?
  • How should the decision-making be prioritized?
  • What resource allocation and policy issues in this case have ethical implications?

Some Values and Ethics Issues to Consider

  • Substitute decision-makers
  • Capacity
  • Compliance with policy
  • Spirituality/ religious beliefs
  • Patient-family relationships
  • Respect for human dignity
  • Quality of life
  • Resource allocation

6. CASE: To Feed or Not to Feed?

You receive a call on the ethics line about a patient’s relative (next-of-kin and legal decision-maker) force-feeding her sister who is a patient on the unit (pushing food into the patient’s mouth and then holding her mouth closed, pinching her nose, etc. until she swallows). Apparently, this was not an uncommon approach to getting her to eat in the group home where she had lived very happily for 10 years prior to admission (she is 58 years old). The charge nurse feels this is abusive and dangerous behaviour, not acceptable in the hospital setting, and has told the relative this. The patient currently receiving TPN-GI does not feel she is a candidate for a peg-tube. The psychiatrist has assessed the patient as depressed and medication has been started- it takes several weeks to reach full effect, so the team is waiting to see how this will go. The option of ECT has been looked into also, but the anaesthetist feels the patient is too fragile to receive the sort of sedation needed for this procedure. The team does not feel the patient is appropriate for the acute care orthopedics unit (she is unlikely to walk again, is incontinent, immobile, dependent for ADLs with little sign that this will ever change, so not likely to get back to a group home situation in the community). The team’s concern appears to be “we need our beds for patients we can operate on and fix”, although they have not voiced this opinion explicitly. The charge nurse has learned the patient’s relative is angry with the team because she feels the patient is being discriminated against on the basis of her cognitive and physical disabilities so that PT and OT are not working hard enough with her. Staff says this is not the case- the patient is refusing to participate (originally she was told that if she walked and ate she could get back to her group home- this has not happened and the nurse feels she has given up, and is exerting the only sort of protest she can by not eating or cooperating with staff efforts any longer). Finally, there is concern about the possibility of a feeding tube down the road – should the patient get one if she continues to refuse to eat, even after the depression is adequately treated? Is this a decision the relative can make? There are also questions about the possibility of modifying the patient’s diet to be more palatable to her, realizing that this is also more dangerous given her high risk of aspiration.

  • How would you work through this case?
  • Which issues are ethics issues and which are medical decisions?
  • Who needs to be involved in making necessary decisions to move forward?

Some Values and Ethics Issues to Consider

  • Patient-family relationships
  • Respect for professional integrity
  • Moral distress of health care providers
  • Resource allocation
  • Substitute decision-makers
  • Respect for dignity
  • Staff morale
  • Quality of life
  • Duty to provide care

1. CASE: Sensitive Information

John is a young man with a traumatic spinal cord injury that has resulted in paraplegia. He is leaving the rehab hospital on a weekend pass and has confided to his chaplain that he intends to kill himself. The chaplain calls the ethics service for assistance.

  • Should the hospital issue the pass?
  • What are the ethics issues involved?
  • What information do you need to find out to move forward?
  • Who would you invite to a discussion about this issue?

Some Values and Ethics Issues to Consider 

  • Respect for autonomy
  • Beneficence
  • Non-maleficence
  • Duty to provide care
  • Living at risk
  • Moral distress
  • Compliance with policy
  • Respect for privacy and confidentiality