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?
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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

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?

85. Case: Adam’s Story

Adam Snowdon, a 16 year-old Sydney boy, was diagnosed with ALS (Amyotrophic Lateral Sclerosis) 18 months ago.  The disease has progressed rapidly over the past three months and over this period Adam has quickly begun losing the ability to use his right arm to the point now where it is no longer effectively functional.  He is also beginning to have difficulty standing and walking and is showing early signs of respiratory, swallowing and speech problems.  His doctors speculate that Adam will die within a year and that in the months prior to that he will likely become “locked in” and unable to communicate at all.

Adam has always been a rambunctious boy.  He has had numerous behavioral issues throughout his childhood, proving to be quite a handful for his parents.  He has run away from home several times, has been suspended various times and expelled from two schools. Adam has also been detained by the police on four occasions for possession of alcohol and marijuana.

Adam is currently living at home in Sydney with his mother Nancy Snowdon and older brother David who just turned 17.  Nancy works part time as a school librarian.  She has full-time custody of her two sons.  Nancy has been suffering from clinical depression for several months now.  She has been under emotional strain since Adam became ill.  She is currently taking antidepressant medication and is receiving counseling from a chartered psychologist.  Through this treatment appears to be helping Nancy, she is still struggling to cope.  On a few occasions she has missed appointments with Adam’s doctor, simply feeling unable to face the situation on her “bad days”.  On those occasions Adam missed his appointments altogether as he shows no initiative in attending his medical appointments on his own.

Adam’s health care providers have not been able to establish a trusting relationship with him.  They find it generally difficult to engage him in conversation, and he is especially uncomfortable discussing the ALS.  He refuses to discuss the details of how his disease will progress or his preferences regarding options such as ventilators etc.  He has, however, stated emphatically that he has no intention of allowing them to “put him in the hospital do die”.

Adam’s father, Ted Snowdon, is an engineer in Alberta.  He and Nancy divorced relatively amicably when Adam and David were nine and ten respectively.  Mr. Snowdon has not played much of a role in the lives of both of his sons after the divorce but he visits every summer and they all go camping.  He has remarried to Clarice Snowdon who has shown little interest in the boys.  Since Adam’s diagnosis, Mr. Snowdon has been flying out to Sydney regularly to be involved with decisions around organizing care for Adam. Mr. Snowdon feels strongly that decisions about Adam’s future care need to be made immediately.

Dr. Kerrigan is Adam’s family physician.  She is concerned that Adam’s condition is getting worse very rapidly and is anxious about the decisions that will have to be made about Adam’s care.  In particular, Dr. Kerrigan is worried about the relationships within the family.  She knows that Mr. Snowdon feels strongly that his son should be hospitalized and eventually ventilated.  He has stated that Adam is “too young” to know what he wants and is worried that Nancy is not able to handle keeping Adam at home, even with home care support.  Dr. Kerrigan is concerned that Mr. Snowdon will dominate the decision-making process at the critical time and that Adam’s and his mother’s wishes may be overridden or altogether neglected.  Beyond her concerns about the family dynamics, she is uncertain as to Adam’s decision-making capacity – and Mrs. Snowdon’s for that matter – and is also unclear on the more basic question of who ought to be making decisions about Adam’s care.

Since Adam became ill he has been seeing a neurologist at the local hospital, Dr. Watson, and Dr. Kerrigan are in touch frequently regarding Adam’s care and have discussed Dr. Kerrigan’s concerns around the family dynamics and the decision making that will need to occur in providing end of life care for Adam.  Dr. Watson has requested a consult from the hospital ethics committee.  Mr. Snowdon and his wife have flown in from Calgary just for this meeting.  Adam was asked to participate in the meeting but he flatly refused, saying he wanted to spend time with some of his friends instead.

Participants’ Roles:

Ethics consultant #1 (facilitator)

Ethics consultant #2 (ethics facilitator)

Ethics consultant #3 (recorder)


Nancy Snowdon (Adam’s mother):  Very concerned about her son’s welfare.  Feeling overwhelmed, isn’t sure what to do.

Mr. Ted Snowdon (Adam’s father):  Skeptical of Adam’s decision making capacity and can’t understand why Adam is acting the way he is.

David Snowdon (Adam’s 17 year old brother):  David is scared, angry with both parents, worried about Adam, and worried about his own life. Most of all, he wants peace for Adam.

Dr. Watson (neurologist):  wary of the complex relational issues at stake, as well as the challenges of making decisions for young ALS patients like Adam.  Wants to make decisions as soon as possible before Adam is no longer able to express his own views.  Feels in over his/her head, wants the committee to get this sorted out as much as possible.  Dr. Watson has been developing an interest in bioethics and is considering becoming a member of the ethics committee.

Dr. Kerrigan (family physician):  Concerned about the toll this is taking on Nancy, Adam and David.  Worried that Mr. Snowdon is driving discussions around care.

Jamie Lee (patient services coordinator):  Has been taking a bioethics course and is eager to apply her/his newly developed skills.

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.

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.

64. CASE: Implementing an Anti-Obesity Strategy

The local health district is in the final stages of adopting a comprehensive organizational anti-obesity policy. Its development was led by a working group of diverse stakeholders from across the district and included an extensive consultation process.

One aspect of the policy that generated a lot of discussion and debate at the working group was the suggestion that messaging should be designed to increase stigma and social pressure around obesity.  This strategy was defended recently in a leading bioethics journal and has been implemented in other jurisdictions.  Ultimately the group was convinced to include this suggestion in the policy because of the success that such messages had in decreasing smoking rates.

Prior to ratifying the new policy, senior leadership requested that the district medical advisory committee review it.  One of these reviewers is clearly upset by the policy; he sent feedback in very personal terms implying that increasing stigma and social pressure around obesity made the policy unreasonable and unethical.

  • What values are relevant to the policy issues under consideration?
  • Why would the reviewer deem the policy to be unethical?
  • What are the conflicting values among the reviewer and the policy makers?
  • Is there other information you would like to have before responding to the reviewer?
  • How will you (the working committee) respond to the reviewer and why?

Some Values and Ethics Issues to Consider

  • Empathy
  • Respect for autonomy
  • Respect for dignity
  • Community health ethics
  • Living at risk
  • Organizational ethics
  • Compliance with policy
  • Social justice
  • Social determinants of health
  • Responsibility for health

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

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

21. CASE: Balancing Concerns

“Where’s the door to my bathroom? Can’t a man get some privacy?”

“Uh oh, that’s Elias again. We’d better make sure he’s alright.”

“How many times are we going to have to go through this with him? Maybe we should just put the bathroom door on again.”

“The only problem is that on his ‘bad’ days, he often gets confused and trapped in the bathroom. Don’t you remember how long it took us to calm him down after that happened about five weeks ago? He was so worked up! Elias and his family agreed to taking the door off at the meeting about this a couple of weeks ago. It seemed the safer way to go. The problem is that Elias can’t always remember that this is something he said he wanted.”

“Well, that must have been on one of his ‘good’ days. We don’t seem to be having so many of them now. I’m finding it hard to have this conversation with him every shift!”

  • What are the ethics issues here?
  • Are there other options that could be considered in this case?
  • How would you suggest the health care team work through this issue?
  • Should Elias’ safety take precedence over his dignity?

Some Values and Ethics Issues to Consider

  • Capacity
  • Respect for human dignity
  • Quality of life
  • Living at risk
  • Patient safety
  • Beneficence and non-maleficence
  • Substitute decision-making
  • Organizational policy