66. Case: Blood Transfusions

Joyce Skinner is a 38 year old woman with non-curative leukemia. She is the single mother of two children, ages 11 and 8, and her ex-husband is ‘out of the (parental) picture’. Since her leukemia diagnosis, Joyce has approached her progressive hematological cancer in an assertive manner, seeing it as her responsibility to fight to stay alive and look after her children for as long as possible. Over the past few years, her attending hemato-oncologist, Dr. Jones, has arranged for her to be a research participant in a variety of experimental chemotherapy trials, which have extended her life beyond what was initially anticipated. However, about 6 months ago, Joyce’s leukemia moved into a treatment-resistant phase and her medical regime is currently palliative in nature and intent. Joyce is now residing in a hematology clinical unit of a tertiary care hospital where she is followed regularly by a palliative care consultant, Dr. Miller. In the last 3 weeks, the frequency of blood transfusions required to keep Joyce’s hemoglobin at a low functional level has progressively increased such that she is now receiving transfusions every second day. Joyce is not eligible for transfer to the hospital’s Palliative Care Unit while blood transfusions are a component of her care plan. She is very weak and is confined to her hospital bed. Her children visit her regularly with their aunt, Cathy, who has assumed parental responsibility for them. They have missed a considerable amount of school time in the last few months.

Despite the honest information provided by Dr. Jones, Joyce is in some denial about her grim prognosis and strongly believes that she can continue to ‘beat the odds’. She remains reasonably clear-headed and is capable of making health care and treatment decisions on her own. She insists that Dr. Jones continue the blood transfusions indefinitely. Her sister and Drs. Jones and Miller are of the shared opinion that the transfusions should be discontinued and that Joyce should be transferred to the Palliative Care Unit.

Dr. Jones, who sits on the provincial blood management committee, is aware that there has been an exceptional demand on existing provincial blood resources in the last few weeks due to a number of major highway accidents. The hospital is chronically under-resourced. There are typically one or more patients waiting in the emergency department for admission to the hematology clinical unit.

 

 

  1. What do you think is important to Joyce (in terms of her personal values)? What do you suspect about her personality structure?

 

  1. On what basis, if any, could Joyce claim a right to continue receiving blood transfusions? What other ethics principles and values are at play in these circumstances?

 

  1. What weight in the decision making should be given to the clinical judgments of Drs. Jones and Miller?

 

  1. Should Cathy (as an engaged family member) participate and have some authority in the decision making? Would the nature of this authority change if Joyce loses capacity?

 

  1. Is ‘bedside rationing’ of limited health resources an appropriate form of health resource allocation?

 

  1. With their mandates to manage limited health resources prudently, should the Nova Scotia Health Authority and/or the provincial Department of Health & Wellness have a role(s) in such end-of-life decision making?

 

  1. Under what circumstances, if any, would it be ethical to deny Joyce’s request for further blood transfusions?

 

 

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59. CASE: HPV Vaccine for Boys

PEI is expanding its human papilloma virus (HPV) vaccination program to include grade six boys. Girls have been receiving the HPV vaccine since 2007. HPV is the most common sexually-transmitted infection among young adults. It can lead to genital warts and, in girls, cervical cancer. For boys it can also lead to cancers of the mouth, throat and genital area.

Deputy chief public health officer, Dr. Lamont Sweet, said vaccinating the boys will not only protect them, it will also lead to fewer women dying from cervical cancer. “Boys can be the source of the virus for their female partners,” said Sweet. “By preventing boys from carrying the virus, you in turn will help prevent girls from getting the virus which causes cervical cancer.” The new program won’t cost more than the original vaccination program, he said, because the price of the vaccine is half what it used to be. The cost of vaccinations for girls in PEI has been $280,000 a year, with about 85 per cent of girls vaccinated. Health Minister Doug Currie said PEI is the first province to offer the vaccine to boys. Nancy Bickford, public affairs for the Society of Obstetricians and Gynecologists of Canada, was pleased by the news. “The SOGC welcomes this move and in fact will be contacting other provincial and territorial ministers of health to follow PEI’s lead,” Bickford said.

You are asked to respond to media questions about this issue – should Nova Scotia follow PEI’s lead and vaccinate grade six boys?

  • Identify the values that are relevant to this discussion and select the ones that will guide your response.
  • How would you justify this response?

Some Values and Ethics Issues to Consider

  • Duty to provide care
  • Fairness
  • Community/ public health ethics
  • Priority setting
  • Resource allocation
  • Risk

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

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

40. CASE: All Things Being Equal…

As a member of your health region Foundation Board, you know that there is going to be a rather intense, lengthy, and difficult discussion tonight. A high profile community member recently passed away and left $500,000 in her will to the Foundation. This was an unexpected donation and means that the Foundation is in a position to put the money towards an important project for the health region in addition to what was already planned. Many suggestions for the use of this money have been made, and in conversation with senior leadership, the Foundation Board has narrowed these options down to three for consideration:

  • The accreditation report from a few years ago strongly recommended equipment upgrades for both the Emergency Department and the Intensive Care Unit. While some upgrades have been made, there are still a number of important ones left to do. Knowing that accreditation is coming up again soon, there is increasing pressure to find the resources to complete these upgrades.
  • The health care teams on several inpatient units recently highlighted the need for equipment to accommodate persons who are obese. This equipment includes specialized beds, lifts, chairs, etc. and will require some renovation of doorways for the new equipment. Issues of patient and staff safety, as well as good patient care, have been identified as motivating this request. Given some local press on the difficulties experienced and the associated shame expressed by patients who are morbidly obese in the health region, a number of people have indicated that this is an issue that requires immediate attention.
  • A pledge to expand community palliative care services was made last year by the health region. With the aging population and difficulty for many in accessing hospital-based palliative care, this pledge was received with much anticipation. To date, however, it has been difficult to attract the needed staff. Additional funds could go towards incentive packages as well as to greatly improve the infrastructure for this type of service.
  • How would you advise your board to make such a decision?
  • What further information do you need to move ahead with the discussion?
  • What underlying values should be considered?
  • How will you justify and communicate the decision that you made?

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Distributive justice
  • Priority setting

39. CASE: Setting Priorities

In the wake of a mass casualty event, a hurricane that devastated much of Nova Scotia, blood resources within the province are extremely scarce. There is not enough blood to meet all the legitimate blood-related health needs of Nova Scotians, and the blood supply is not expected to increase significantly in the next two months. Tough choices have to be made. The following three patients have been admitted to a rural general hospital and are in need of blood transfusion:

Jim is a relatively healthy, 87-year old man who requires a colectomy for a benign hemorrhagic bowel disorder. He is scheduled for surgery along with many urgent others, and it is anticipated that he will not rise to the top of the waiting list for at least two months. To bridge the gap between now and then, he requires regular (e.g., q 3 weeks) transfusions. Jim lives independently in the community and is very engaged with two of his children and six grandchildren who live in the local area.

Sue is a 42-year old woman admitted to the palliative care service whose progressive leukemia is causing her to be significantly fatigued and short of breath. The attending hematologist estimates that regular blood transfusions would allow her to remain functional at home for about another eight months. She has three children ages 4, 7 and 11. The family is dependent on the single income of her husband who is a plumber.

Kevin is a six-year old boy with a poor prognosis cancer diagnosis. His present quality of life is poor – he is confined to bed and spends most of his time asleep. He is not experiencing any pain. Kevin is able to communicate with his parents for an hour or two a day. His medical oncologist estimates that regular blood transfusions would extend his life for about another five months. It is anticipated that Kevin’s quality of life will remain essentially unchanged during this period of time. Kevin’s parents are demanding that their son receive these blood transfusions.

Dr. Fairchance, as the hematologist on-call, is asked to make a decision about which of these three patients should be started on blood transfusions. She recognizes that there is currently enough available blood to meet the needs of only one of these patients. Dr. Fairchance is also asked to prioritize the other two patients in the unlikely event that more blood becomes available in the next week or two. As the medical resident on-call, you have been requested to assess Jim, Sue and Kevin and to report back to Dr. Fairchance regarding their present health status. She would also like you to assist her with the rationing decision.

  • What factors should be considered in micro-allocation decisions? How do you prioritize them?
  • What principles and values would inform your decision-making?
  • What decision-making process would you use to work through this decision?
  • Is there a better way than ‘bedside rationing’ to allocate scarce health resources?
  • What are the implications – organizational or otherwise – of your decision?

 

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Distributive justice
  • Priority setting

38. CASE: Managing Human Resources

The Bluenose Villa is a long-term care facility licensed under the Nova Scotia Homes for Special Care Act. It is owned and operated by a rural, non-profit health organization. At a recent meeting of the senior management team and Board of Directors to establish next year’s annual budget, the CEO, Ms. Seahead, shares her concerns about the long term, sustainability of the Villa to recruit and retain qualified, motivated employees. She cites the relevant shifting demographics including an urbanization trend, an aging population and workforce, the upcoming retirement of large cohorts of ‘baby boomer’ workers, and the likelihood of intensified recruitment of personal care workers by acute care hospitals that are able to offer higher salaries.

The Villa devotes as many of its resources as possible to the delivery of a broad range of programs and services for its residents including comprehensive recreational/ social programs and the offering of high quality and varied food choices. The non-profit organization needs to invest on a regular basis in the maintenance and improvement of its aging physical facilities. While the CEO believes that the Villa has been fair in the terms and conditions of employment of its staff, she is worried that the Villa is falling behind other health employers in the District in its ability to attract and retain good staff.

Most of the Villa’s residential placements are government subsidized and the CEO has just been informed that the per diem care rate paid by the Department of Health will remain unchanged for the next year.

The decision-making group, consisting of the senior management team and Board, decide to use the health priority-setting decision-making framework developed by the Nova Scotia Health Ethics Network to assist them in their annual budgeting process.

  • Using A Decision-Making Framework for Health Priority Setting found on NSHEN’s website (http://www.nshen.ca/docs/nshen_healthpriority.pdf) to work through this case, what key budget-related concerns do you identify?
  • What are your fiscal priorities?
  • How do your priorities relate to your employee-retention plan?
  • How will you justify the priorities you determine after using the decision-making framework?

33. CASE: Ethical Advertising?

A hospital has placed billboards throughout the region with the following statement:  “Are You a Victim of Sexual or Domestic Assault?  Come to Warman Center Where We Will Treat You Immediately. Our Staff of Counsellors and Providers Have Received Special Sensitivity Training in This Area. You Are Our Main Concern.”

A twenty-five-year-old college student presents to the Warman Center’s emergency department stating, “My boyfriend assaulted and raped me and I need help.”  The registration clerk notices that there are fresh bruises and bleeding on her face, neck, and arms.  The student fills out registration information and is asked to sit in the waiting room.

Several hours pass. The young woman approaches the registration clerk and states, “I am really scared.  I have pain. I am terribly upset about what has happened to me, and I just can’t sit here any longer.”

The registration clerk responds, “Haven’t you seen all the ambulances come in?  We have patients with critical injuries like pneumothorax here.  You will have to wait your turn.”

Three and a half hours later, when a nurse calls out the student’s name to be seen, she is no longer in the waiting room.

(Case adapted from: Ann E. Mills, Edward M. Spencer, and Patricia H. Werhane (eds), Developing Organization Ethics in Healthcare: A Case-Based Approach to Policy, Practice, and Compliance, Maryland: University Publishing Group, 2001, p. 55)

  • What do you see as the organizational ethics issues?
  • How should these issues be addressed?
  • What values should be considered in this discussion?


Some Values and Ethics Issues to Consider

  • Accountability
  • Duty to provide care
  • Honesty, trust and truth-telling
  • Compliance with policy
  • Priority-setting