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:

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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.

61. CASE: Ending the Fluoridation of Water – A Public Meeting

The local town council has received a petition signed by more than 500 residents requesting the discontinuation of fluoride in the town’s water supply. Before making a decision on the matter, the council has decided to hold a “town hall” meeting to seek more input and help to educate its members and the audience about the evidence on both sides of the debate.

As the Public Health officer for the area, you have been invited to be a member of the panel in charge of this meeting. Other panel members include the mayor, a local dentist, a family doctor, and the two residents who initiated the petition. On the night of the meeting, the local fire hall is at capacity; the mayor who is chairing the panel asks the two residents to begin the discussion by presenting their concerns with regard to water fluoridation. They make the following remarks:

Resident 1: “Everyone says fluoride in the water prevents cavities. What about looking at what causes the cavities in the first place- junk food, pop, sugary snacks and juices are all stuff that parents should be limiting. Why should we all be forced to ingest fluoride in our water because some parents aren’t doing their job? Like everything else, we are what we eat. Good health starts with what we put on the end of our forks- that is how I raised my children. In addition, a routine oral program and thorough brushing is key to any successful prevention.For those that want to provide their kids with fluoride, there are many readily available treatments and over the counter products.I am a victim of too much fluoride because I chose to eat healthy and drink lots of water. Fluoride severely damaged my thyroid and I am now forced to take pharmaceutical drugs for the remainder of my life.

Fluoride is not only in our water (which is also absorbed through the skin), it is used as a pesticide on our food crops, and even organic food crops could be contaminated if watered with fluoridated city tap water. All beverages produced with water, reconstituted juices, contain fluoride, and for those that still receive fluoride treatments at the dentist, brush three times per day with fluoridated toothpaste and maybe even use fluoridated mouthwash, well, that is FAR MORE than any health organization (CDC, EPA or Health Canada) recommends.

I cannot remove fluoride from my water and am therefore forced to purchase distilled water to use for drinking and cooking. I am one of the lucky ones, as I am able to afford to do this. I was never asked if I wanted this industrial waste dumped into my water supply- it was a decision made for me without my consent or even any input. It was a decision made a long time ago and now it needs to undone.”

Resident 2: “I am for choice. So I would rather choose whether or not I drink a toxic chemical. I think that by giving me no choice, the city is not doing me any favours. I have done my own research, and there is very little credibility on the side that says “fluoridate the water.” Instead many experts say fluoride works best as a topical treatment. Bang on. Use it topically then, by choice, don’t force me to ingest it. I use a fluoride rinse and it has absolutely 100% made a difference in my dental health. I have not changed my diet or oral hygiene habits except for the addition of this rinse, but 4 years strong now with no new cavities. Cavities used to plague me with at least a couple new ones a year. I feel that this should be a personal choice, and if people are concerned about costs for poor communities/people then perhaps a subsidy for toothpaste or fluoride tablets is the answer (but only if those people want to purchase the items).One should also keep in mind the effect of excess fluoride on growing teeth. What if your child really likes water and ingests a lot of fluoridated water? Even dentists admit it’s only useful in the right doses. Fluoride is carcinogenic, so I would like to see statistics on cancer rates vs. fluoridation in the region. Plus, fluoride has been linked to lots of other serious conditions, but we are not told about all that – just that it prevents cavities. The jury is out on whether that is actually true. There are countries who do not add fluoride to their drinking water but their rate of cavities is as good or better than ours. So what is that about?! The town could be saving a ton of money each year by not putting fluoride in the water. It’s a smart move in my opinion.”

  • Identify the conflicting values that are relevant to this discussion and select the ones that will guide your response. What is the basis of your choice(s)?
  • As the public health officer, how will you respond to these statements?

Some Values and Ethics Issues to Consider

  • Respect for autonomy
  • Community/ public health ethics
  • Compliance with policy
  • Patient safety
  • Community relationships
  • Consent
  • Risk
  • Social justice

27. CASE: Withdrawal of Life-Sustaining Treatment

Mr. Windown, age 82, is admitted to a cardiology clinical unit with unstable angina. In addition to his coronary artery disease, Mr. Windown suffers from disabling generalized osteoarthritis, chronic and progressive obstructive lung disease, and diabetes with associated compromise of his vision and kidney function.

The coronary angiography reveals significant blockages of Mr. Windown’s coronary arteries. His attending cardiologist recommends that he undergo urgent four-vessel cardiac bypass grafting (to shunt blood around the blockages). The consultant cardiovascular surgeon, Dr. Paterna, gets Mr. Windown to sign a consent form for the procedure and mentions that it is anticipated that Mr. Windown will need to spend two days in the Cardiovascular ICU after the surgery.

In the past year, Mr. Windown’s health status has deteriorated to the extent that he can no longer perform any physical chores on his hobby farm. Prior to developing unstable angina, he was limited to walking around the first floor of his farmhouse and watching TV. After giving considerable thought to his future health care and treatment, Mr. Windown named his daughter, Elle, as his delegate in a personal directive, which does not provide any specific instructions. In a general, frank discussion about his health, Mr. Windown clearly expressed to his wife and Elle that he did not wish to be maintained on life support for a prolonged period of time.

Unfortunately, Mr. Windown experiences a significant complication from his cardiac bypass surgery – he suffers an intra-operative stroke, which renders him incapable of making health care decisions on his own.

Two and a half weeks after the surgery, Elle speaks to Dr. Paterna (who is now her father’s attending ICU physician) and requests that her father’s life sustaining treatment (including mechanical ventilation and renal dialysis) be withdrawn. Dr. Paterna gets annoyed with Elle, describes Mr. Windown’s health status in highly technical terms, and emphatically informs her that, in his opinion, her father has a reasonable chance of recovery to a functional status similar to the one he has experienced for the past year. Dr. Paterna tells Elle that this recovery will require another two to four weeks in the ICU and that he is uncomfortable with withdrawing Mr. Windown’s life sustaining treatment at this time.

When Elle insists that her father’s prior, verbally-expressed wishes be respected, Dr. Paterna manages to put her off for a few days by not responding to her request for a family meeting. He complains bitterly in the staff room that Mr. Windown’s family is being “difficult”. With the encouragement of the ICU’s assertive social worker, Dr. Paterna reluctantly agrees to consult ethics.

  • How would you proceed with this consult?
  • Is this a communication and/or professional practice issue or an ethics one?
  • Identify any underlying ethical tensions in this situation?
  • Is Dr. Paterna right to push back on Elle’s request?



Some Values and Ethics Issues to Consider

  • Advance care planning and personal directives
  • Substitute decision-making
  • Respect for professional integrity
  • Respect for patient autonomy
  • Respect for human dignity
  • Patient-provider relationships
  • Patient-family relationships
  • Quality of life
  • Consent

26. CASE: Withdrawal of Life-sustaining Treatment, or Euthanasia?

An ethics request came from nursing staff caring for a patient dying with end-stage throat cancer on acute surgical service. The patient has requested a removal of her tracheotomy and a chance to die as she chooses. She had agreed to try the trach for a while, but is finding it negatively impacts her quality of life too greatly. Her spouse (in his 80s and not physically well) is present and her whole family is agreeable to her request.

The conversation with the patient continued for several days to give her ample time to consider the implications of her decision and allow her to change her mind if she wanted. She remains adamant, has capacity, is well-informed, and has made her decision voluntarily.

Difficulty has arisen because a few staff members on her team see this course as “assisting suicide” and have refused to continue to care for her. Other staff members are uncomfortable and concerned about possible legal repercussions.

When the trach is finally removed, an unexpected crisis develops. The sedation given during the procedure wears off several hours later, such that the patient becomes very short of breath and agitated, which distresses the family and the staff caring for her. Staff felt they were not adequately prepared to handle this sort of crisis and did not have ready/ timely access to palliative care or ENT physician support to deal with it.

The nursing unit manager thinks it would be helpful to have an ethics-focused discussion facilitated by people not connected to this inpatient unit.

  • In this scenario there are a number of different ethics concerns affecting the patient and family as well as staff members. What issues would you consider important to include in the discussion with staff who attend the meeting?
  • What values may be stake for the various participants in this scenario?
  • What steps would you take to prepare for this meeting?
  • Does this case have policy implications? If so, what are they?

 

Some Values and Ethics Issues to Consider

  • Capacity
  • Respect for patient autonomy
  • Informed consent
  • Respect for human dignity
  • Patient-centered care
  • Patient-family relationships
  • Moral distress among health care providers
  • Medical error
  • End-of-life decision-making

25. CASE: A Difference of Opinion?

Mary is a 90-year old woman who has been in hospital several weeks. She has a COPD exacerbation, increasing difficulty swallowing, and pneumonia. She has said repeatedly she is tired of being in hospital and tired of fighting to breathe. She doesn’t want a feeding tube or her IV but wants to be allowed to die comfortably.

Mary’s daughters who have been regular, frequent visitors, say she has always been a fighter and would never want to give up. They believe she is just discouraged and are requesting everything be done to keep her alive including a feeding tube, IV hydration, and mechanical ventilation if it becomes necessary.

The resident in charge of Mary’s care calls the ethics request line.

  • What are the ethics issues in this situation?
  • What underlying values are at stake?
  • Should Mary or her daughter’s have decision-making authority?
  • How would you respond to this call for ethics support?
  • Who should be involved in the discussion?

 

Some Values and Ethics Issues to Consider

  • Informed consent
  • Capacity
  • Substitute decision-making
  • Advance care planning and personal directives
  • Quality of life
  • Respect for human dignity
  • Respect for patient autonomy
  • Patient-family relationships
  • End-of-life decision-making

23. CASE: Reaching the Limits

Mr. Stanley, a divorced 55-year old journalist with a history of epilepsy, was admitted to the medical ICU after an unwitnessed (presumably prolonged) episode of status epilepticus at home. Investigations, including an MRI study, revealed that he had sustained watershed cortical infarcts and a diagnosis of severe anoxic encephalopathy was made.

Mr. Stanley did not regain consciousness during the first three weeks of his ICU admission. Although formal criteria for brain death were not met, the attending critical care specialist, Dr. Hamilton, was of the opinion that Mr. Stanley would not regain sufficient functional status to allow him to meaningfully communicate with others and to live outside of an extended care facility. A consultant neurologist agreed with Dr. Hamilton’s opinion. The unit’s transplant coordinator was aware of Mr. Stanley’s clinical circumstances and had a brief hallway chat with Dr. Hamilton.

After a long discussion with Dr. Hamilton, two of Mr. Stanley’s three adult sons, both of whom were living in the area, made the difficult decision to withdraw their father’s life support. The youngest brother, who was angry with his father about his parents’ divorce, was living in the UK and had not been in contact with Mr. Stanley during the past two years. Speaking to his brothers over the telephone, he strongly objected to the withdrawal of his father’s life-sustaining treatment. He informed them that he had heard of miraculous recoveries in similar circumstances.

A telephone call to the provincial organ donation registry revealed that Mr. Stanley had not indicated “yes” on his MSI card donor certificate. However, one of his Halifax-based sons recalled a brief discussion in which his father had stated that he wished to donate his organs after death.

The transplant coordinator had a prolonged, sit-down discussion with the two locally-based sons. They decided to provide consent for DCD – organ donation after cardiac death. In the day and a half prior to the scheduled discontinuation of mechanical ventilation, several tests were performed to assess the viability of Mr. Stanley’s organs. In addition, two intravenous medications were administered to ensure the continued viability of his organs until the organ donation/ transplantation procedure could take place.

Mr. Stanley’s youngest son arrived on the scene and witnessed the performance of these tests and interventions. He asked Dr. Hamilton to explain why these were being performed and requested a detailed description of the DCD process. He became very upset and left the unit to seek the advice of a lawyer.

The next morning, Mr. Stanley was removed from life support in the ICU with the two locally-based sons present. His heart stopped thirty-five minutes later. Five minutes after this, he was quickly transferred to a nearby surgical unit where his organs were surgically procured for transplantation to a number of waiting hospital patients in end-organ failure.

  • How would you feel about these circumstances as a health care provider assigned to Mr. Stanley’s care?
  • What are some of the relevant ethics issues?
  • Does the practice of DCD challenge our usual understandings of death and/or informed consent/ choice?
  • Do you think the right decision was made?

 

Some Values and Ethics Issues to Consider

  • Informed consent
  • Personal directives and advance care planning
  • Patient-family relationships
  • Respect for patient autonomy
  • Substitute decision-making
  • Moral distress among health care providers
  • End-of-life decision-making