60. CASE: Health Care Providers Under Quarantine

My story starts in early April, during a routine day shift in our minor care area. A previously well middle-aged man, recently returned from Hong Kong, presented with fever. Because SARS was already recognized and we’d gone through the recent experience of a crash intubation with our first case at Vancouver General, this patient was isolated at the triage area and we gowned and masked to examine him. Apart from a temperature of 37.8°C, his vital signs were normal and he looked well. He had no other symptoms, and his physical examination, CBC, urinalysis, and chest x-ray were all normal. Although the patient did not fulfill the case definition of SARS then in existence, I kept him in isolation just in case. When I went in to give him discharge instructions, I did not wear a mask and stood just inside the doorway, about two meters from him. Almost predictably, he returned with the full SARS syndrome just over 24 hours later. And wouldn’t you know it, by then, the case definition of SARS had changed!

I briefly wondered if I could pretend I was not in his room unmasked, but the thought of potentially disseminating a lethal virus persuaded me to do my civic duty and tell my boss. Two hours later Public Health phoned to inform me I was officially quarantined. Needless to say, my husband, also a physician, was incredulous and my kids were terrified. I thought it was kind of funny for the first day, like someone was playing a bad joke. Then the reality began to hit home, and I can tell you the reality was difficult to live with. This is what Public Health told me.

  • I must stay inside my house (preferably within my bedroom) 24 hours a day
  • I must not touch anyone in my family
  • I must wear an N95 mask if anyone is in the same room as me
  • I must not prepare uncooked food for my family
  • I must not sleep with my husband
  • I must use a separate bathroom
  • I must not touch anything in the house that the kids might later touch
  • I must not use the family computer or the main phone
  • I cannot have outside visitors
  • I cannot shop for groceries
  • I cannot go for a walk

The quarantine requirements were not voluntary, but were enforced by Public Health, who contacted me daily to gauge my cooperation. If I did not comply, it was clear that I would be legally compelled to do so. All this took place under the shadow of potentially transmitting SARS to my family, the people I love more than anything in the world. My nine days of quarantine were a blur of extreme boredom, some highly emotional episodes, and a re-evaluation of what I do for a living. One of our daughters moved out for the duration. Another celebrated her 16th birthday without a hug, cake or present from her housebound mother. And my son told me daily how much he wanted a snuggle. I felt guilty that my colleagues, all of whom are already overworked, had to pick up extra shifts to cover me during my enforced absence. As if all this were not enough, it slowly dawned on me that I wasn’t earning any income, and would have to put in extra shifts after my quarantine was over. I decided I never wanted to see another N95 mask again…

What did I learn from my experience? First, it is very isolating and lonely to be isolated. I hugely appreciated the calls and emails I received from my colleagues while I was off. It helped enormously to know they were thinking of me, and didn’t think this was my fault. Second, I think all emergency physicians should consider the financial implications of a sudden enforced quarantine. None of us have disability insurance that would commence quickly enough. To be under quarantine is difficult enough without the added burden of a financial penalty. Although I suffered an occupational exposure, I was not covered by Workers’ Compensation. I believe we need to negotiate with our hospitals and governments to put financial packages in place. Many hospitals are starting to compensate self-employed health care workers for income missed during quarantine. I would go further and suggest a per diem rate for days confined due to occupational exposures. Although no one can compensate me enough for nine lost days of my life, a token payment certainly wouldn’t hurt. Finally, as emergency physicians we do a far more difficult and noble job than I had ever realized. The consequences of what we do to care for our patients and protect the public are risks that put ourselves and our families in potential danger. This is something we never think about or acknowledge, but maybe we should. And maybe we should celebrate ourselves more than we do. I have huge admiration for my emergency medicine colleagues who had far worse exposures than I did in the early phase of the SARS crisis.

  • What values are involved here and for whom?
  • What ethical considerations have to be balanced in such quarantine situations? How is the most appropriate balance achieved?
  • How would you respond to this physician’s concerns? Do you feel there is any legitimacy to her complaints?

Some Values and Ethics Issues to Consider

  • Duty to provide a safe work environment
  • Duty to provide care
  • Respect for individual liberty
  • Community/ public health ethics
  • Consent
  • Disclosure of adverse events
  • Health care provider relationships
  • Risk
  • Patient safety
  • Compliance with policy
  • Disclosure of adverse events
  • Non-maleficence
  • Privacy and confidentiality
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34. CASE: To Tell or Not to Tell

The head pathologist of the regional hospital informs the head pathologist of the tertiary care centre that the post-mortem examination of a former patient, Mrs. Dempsey, has revealed that she suffered from a neurological infection called CJD (Creutzfeldt-Jakob Disease). The tertiary centre pathologist reports this to the VP of Acute Care who determines through investigation that Mrs. Dempsey had brain surgery at the tertiary care centre a year and a half ago. At that time, Mrs. Dempsey had a few symptoms consistent with CJD but this diagnostic possibility was not considered by the attending health care team. The surgical instruments used in the Mrs. Dempsey’s surgery were sterilized as per standard protocol and subsequently used in other neurological surgeries at the centre.

Some relevant CJD facts:

  • The involved infectious agent is a prion
  • Prions are transmitted only by neural tissue (brain/nerves) to neural tissue exposure
  • Unlike most infectious agents, prions can survive standard sterilization procedures
  • CJD is a progressive, devastating neurological infection that leads to disabling illness and premature death
  • The usual incubation period from a person’s exposure to CJD to symptomatic infection is 12 to 28 months
  • There is no way to conclusively determine that a person has CJD prior to post-mortem autopsy
  • There is no known treatment for CJD

An ad hoc disclosure working group is struck. In the course of using their hospital’s disclosure policy’s decision-making framework, a participating infectious disease specialist, Dr. Bugg, reports on the clinical literature (evidence) related to CJD disease and its transmission. He expresses his informed opinion that, in the particular circumstances under consideration, there is a theoretical, extremely low risk of past transmission of CJD to patients who had surgery utilizing the potentially contaminated instruments for the month after Mrs. Dempsey’s surgery. Dr. Bugg also comments that, in the last twenty-five years, there have been no reported cases of CJD (world-wide) resulting from patients’ exposure to contaminated surgical instruments.

  • Using your institution’s disclosure policy decision-making framework (or that provided on NSHEN’S website under the “Ethics Resources” tab at http://www.nshen.ca/docs/nshen_adverseevents.pdf), what do you think are the key issues to be considered?

As per Step 7 in NSHEN’s framework, the working group members collaboratively develop a list of benefits and burdens for each of three identified potential disclosure options, i.e., non-disclosure, disclosure to those who have been exposed, and external-public disclosure.

  • Given the facts as presented and using the framework indicated, what decision would you support and why?

 

Some Values and Ethics Issues to Consider

  • Accountability
  • Honesty, trust and truth-telling
  • Compliance with policy
  • Medical error
  • Disclosure of adverse events
  • Patient safety
  • Transparency

32. CASE: To Report or Not

Dr. B is the epidemiologist and director of infection control for an academic health centre. The reportable disease statutes and regulations in Dr. B’s province specify that hospitals and other health care facilities throughout the province are required to track nosocomial infections (infections not present in patients prior to their admission to the hospital) and to “rapidly report outbreaks” to the local health department. What constitutes an “outbreak” is not specifically defined in the statute or in the regulations. This determination is left to the discretion of each facility’s epidemiologist.

As the hospital’s epidemiologist, Dr. B is charged with collecting data on all reportable diseases. He is responsible for determining when the threshold for an outbreak has been met. His staff provides him with data indicating that the rate of several nosocomial infections has been increasing steadily. The increases have been sustained over a period of three and a half months and are statistically significant. Although Dr. B’s data lag behind by approximately one month due to data collection limitations, all indications are that the rates will remain at their current elevated levels or may even escalate. In Dr. B’s opinion, these increases constitute a nosocomial outbreak and should be reported to the local health authorities.

The hospital is still reeling from the political fallout resulting from intense media attention on a young patient with epilepsy who was left unattended and who suffered a serious fall during a grand mal seizure. The patient is now in a persistent vegetative state. The hospital administration, risk management, and the legal counsel for the medical centre and the university are highly sensitive about the incident. The situation has upset the provincial health minister as well, who has expressed his concern about its reflection on him and his chances for re-election. He is said to have told those close to him that he will “make heads roll” in order to appear to have dealt adequately with the situation.

Dr. B’s infection control staff believes that they have identified the probable cause of the outbreak. They have found that healthcare providers are frequently not adhering to basic hand-washing regimens that are required by standard infection control procedures. Observers on the units report that only 30% of healthcare workers wash their hands between patient contacts. The situation is even worse in the ICUs where only 10% of physicians wash their hands between patient contacts. The welfare of every patient on every unit of the hospital is jeopardized by this situation. Dr. B plans an aggressive internal communications campaign to increase awareness of the current low levels of hand washing and to emphasize the importance of infection control in the care of patients.

Dr. B relays his findings to the hospital leadership and maps out his plans for an aggressive communications campaign. He receives a less than lukewarm response. He is questioned about the provincial reporting requirements. He is told that, since the parameters defining “outbreak” are not specifically defined, it is highly doubtful that the institution is experiencing an outbreak. Hospital administrators agree that the situation must be monitored closely. However, they instruct Dr. B not to report the nosocomial outbreak to the local health agency. In addition, they advise him not to disseminate data on the levels of hand washing observed on the units and instruct him to limit his campaign to a general message emphasizing the importance of hand washing in any successful infection control effort. He is told to monitor the situation closely. In response, Dr. B calls the ethics committee for assistance.

[Case modified from: Ann E. Mills, Edward M. Spencer, and Patricia H. Werhane, Developing Organization Ethics in Healthcare: A Case-Based Approach to Policy, Practice, and Compliance, Hagerstown, Maryland: University Publishing Group, 2001, Case #11 by Margaret Skelley, pp. 41-42]

  • What is your gut feeling as you read through this case?
  • What values are at play for Dr. B? For the hospital administrators?
  • Would a decision-making framework be relevant or helpful in this situation?
  • How would you approach this situation when Dr. B. called for an ethics consult?

 

Some Values and Ethics Issues to Consider

  • Accountability
  • Transparency
  • Medical error
  • Patient safety
  • Compliance with policy
  • Duty to provide care
  • Risk
  • Honesty, trust and truth-telling
  • Respect for professional integrity

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