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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98. Case: A Conversation About Vaccination with a New Parent

You are a nurse practitioner working in a family practice.  A first-time parent brings their child in for a 2-month checkup.  The parent seems nervous when vaccines are mentioned as a routine part of the appointment.  You ask the parent specifically about vaccination, and the parent is hesitant.  They say that they “can’t get idea of something bad happening to the baby because of the vaccination out of [their] head”.  You have a strong commitment to vaccination as a part of good health care practice and to adhering to the standard public health vaccination schedule.  How do you proceed with this conversation?


You are a first-time parent taking your 2-month-old baby into your doctor’s office for a checkup.  You are told when you arrive that the nurse practitioner, whom you’ve met before and liked, will be seeing you today.  You don’t have any concerns about your baby’s growth and development and are excited to see how much weight they’ve gained since their last appointment.   You are surprised when the nurse mentions vaccination; you had thought that you didn’t have to worry about that until the next appointment.  Since your baby was born you’ve been very aware of all the ways that they could be harmed, and you’ve been intent on avoiding all the risks you can; you have even stopped driving with your baby in the car unless absolutely necessary.  You know that the risks associated with vaccination are low but wonder if they could nonetheless be reduced or avoided somehow.  You experience the nurse’s questions about vaccination as a type of threat and feel defensive, although you also recognize that’s not the nurse’s intent.  How will you respond to the nurse practitioner?


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 other values and principles that are relevant when considering how to proceed in cases like this?
  • Which factors contribute to making this a difficult conversation?
  • What would the best possible outcome in this case look or sound like?

References:

Halperin, S.A.  2000. How to Manage Parents Unsure About Immunization. CME. January 2000; 62-75. https://www.ucalgary.ca/paed/files/paed/4-halperin-article3.pdf

Zimlich, R. 2018. 4 Tools to Frame Conversations about Vacccines. Contemporary Pediatrics, November 13, 2018.   https://www.contemporarypediatrics.com/pediatric-immunization/4-tools-frame-conversations-about-vaccination

Centers for Disease Control and Prevention. Talking with Parents about Vaccines for Infants. Provider Resources for Vaccine Conversations with Parents. [Accessed March 12, 2019]  https://www.cdc.gov/vaccines/hcp/conversations/talking-with-parents.html

Paterson, P., Meurice, F., Stanberry, L.R., Glismann, S., Rosenthal, S.L., Larson,  H.J. 2016. Vaccine hesitancy and healthcare providers. Vaccine, Vol 34 (52), 20 December 2016, p. 6700-6706

TEDx Talks. Tara Haelle. Why Parents Fear Vaccines. Published on May 2nd 2016. TEDxOslo. https://www.youtube.com/watch?v=ggtkzkoI3eM

 

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?

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?

95. Case: Conventional vs Chinese Medicine

Lisa Chun is a 12 year old recently diagnosed with Crohn’s disease.  She arrived as a refugee from China five years ago with her parents and her younger brother.  She has integrated well into the community and is successful in school.  She often acts as an interpreter for her parents.

Lisa is prescribed corticosteroids and biologic therapies, but she states that she would prefer to pursue treatment with traditional Chinese medicine (TCM), consisting of acupuncture and herbs.  Her parents indicate that they support her in this choice. Lisa’s parents have previously expressed discomfort about the diagnostic tests that Lisa underwent and Lisa and her family have missed a few appointments, which have had to be rescheduled.

The team is concerned about the long-term effects of not treating with conventional therapies, given that Lisa is very small for her age and is not displaying signs of puberty.

Some members of the team who have worked closely with Lisa feel that she has capacity to make this decision.  They believe that her reasoning, based on belief that TCM treatment is better able to respond to the way that Crohn’s has manifested in her body, is appropriate.  Other members of the team feel very uncomfortable with allowing her to refuse conventional therapy altogether, although they say they are willing to explore integrating TCM with conventional approaches.

Finally, certain team members are concerned that they will “lose” Lisa and her family and worry that requiring a capacity assessment for Lisa (or her parents) will irrevocably damage the relationship.

Concerns have also been raised about whether there’s an obligation to contact Child Welfare if Lisa and her parents continue to refuse conventional therapy.

The team has requested support from the ethics committee to help them work out how to approach this situation.


Questions:

What will make this case clinically challenging?

What will make this case ethically challenging?

How might the ethics committee support the team in addressing these challenges?

What would change (if anything) if Lisa and her parents came from Estonia instead of China?

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?

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?

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.

77. Case: Accommodating Requests: Which Differences Make a Difference?

 

Michelle Yoder is 8 months pregnant and a member of the Amish community.  She requests that only female health care providers and staff be involved in providing her care during labour and delivery.

Michelle Federov is 8 months pregnant.  She requests that only white health care providers and staff be involved in providing her care during labour and delivery.

 

Discussion:

  • What are the ethical concerns raised by these cases?
  • How are your responses different to these two scenarios?
  • How do you think health care organizations should respond to requests like these?

Resources: