55. CASE: What is My Obligation?

A family physician in a small, remote community assesses a patient, who is a local schoolteacher, as developing a post-partum psychosis. He feels he lacks adequate training or experience to manage her care.

He recommends she seek treatment at a distant large mental health centre but she refuses to travel to the centre because of the distance involved. He feels uncertain about caring for the patient when the treatment is outside his area of competency.

  • How should the physician proceed with the patient’s care? Should he treat the patient when he feels it is is outside his area of competency?
  • If the patient is unwilling to disclose her health issues to her employer, as a healthcare professional and/or a member of the community, should the physician report them to school authorities?
  • What ethics issues are at play here?
  • What resources could the physician seek to assist with this situation?

Some Values and Ethics Issues to Consider

  • Community and family relationships
  • Respect for privacy and confidentiality
  • Patient-provider relationships
  • Professional boundaries
  • Honesty, trust and truth-telling
  • Patient safety
  • Equality of access
  • Resource allocation
  • Duty to provide care
  • Intellectual honesty
  • Respect for professional integrity
  • Professional competence
  • Overlapping roles and responsibilities
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51. CASE: Confidentiality and Privacy

Joanne Baker, a nurse practitioner in a small community, prescribed a partial opiate agonist to a young man, Brian, for treatment of prescription opiate dependence. Brian is talented and plays on the same soccer team as Joanne’s son.

Three weeks later, Brian is found unresponsive after an overdose of opiates, requiring intubations and medical evacuation to a city three hours away. He recovered and didn’t want others in the community to discover that he had attempted suicide. He began to spread rumours that Joanne was incompetent and prescribed a medication that she didn’t know how to use.

Another patient brought up these rumors during his own appointment with Joanne. Joanne wishes she could set the record straight, and explain that Brian obtained opiates from a provider in a neighbouring city and had taken these in large quantities in a suicide attempt. She is unsure of how to discuss the situation without breaching Brian’s patient confidentiality.

  • How should Joanne proceed in this situation?
  • How can she clear her name/ reputation without breaching confidentiality?
  • What are the competing values in this case?
  • What role/ responsibility should Brian have in the outcome of this situation?
  • What is the specific ethics conflict or question in this case?
  • How is this ethics conflict affected by the rural context?
  • What resources are available to help Joanne address the situation?


Some Values and Ethics Issues to Consider

  • Professional boundaries
  • Community and family relationships
  • Respect for professional integrity
  • Compliance with policies and procedures
  • Respect for privacy and confidentiality
  • Overlapping roles and responsibilities
  • Patient-provider relationships
  • Professional competence
  • Transparency
  • Stigma
  • Vulnerability
  • Respect for human dignity

46. CASE: Team Work?

Judy, who had worked as a senior social worker in a mental health setting for 12 years, was hired as a team social worker in a community health care organization. Shirley, one of the team RNs, perceived Judy as hesitant and ineffective in patient care planning meetings. Other team members also found Judy to be too hesitant in making decisions, often rolling their eyes when Judy asked team members for their opinions. Despite their concerns about Judy’s hesitancy, team members also complained when Judy did not consult them before making a patient care decision. As Judy experienced these mixed messages, she became more guarded in her social work assessments.

The inter-professional team on which Judy was placed had a culture of socializing together after work. Initially, team members invited Judy to join them, but she did not have time due to the care that she was providing for her mother after work and also was uncertain about how much to socialize with her colleagues.

When the team was together after work, they discussed Judy’s behaviour, often noting that her mode of dress was out of style. Carol, the team facilitator, would occasionally join the rest of the team for a drink after work. During one of these nights, Shirley complained to Carol that Judy was not doing her job. She also mentioned that the team did not like Judy because she did not socialize with them and wouldn’t disclose information about her personal life as they all had done with each other. The nursing assistant and dietician on the team told Carol that they saw Judy as being very unfriendly. The following week, Carol spoke with Fran, the social work supervisor, stating that Judy was a problem and she wasn’t sure that Judy would work out with this team.

In her monthly supervisory meeting, Fran asked Judy how things were going with her team. As Judy’s eyes began to tear she said that she was thinking of leaving. Judy said that that she hadn’t realized how hard it would be to work with a team, and commented that the team members kept comparing her to a former team social worker who was not liked by them.

Judy told Fran that the team seemed fairly uncomfortable with mental health issues and that she was shocked when the team made derogatory comments about patients – i.e., that some were dirty and smelly or that the team couldn’t stand certain patients. And, in terms of the team, Judy wasn’t sure what to do because someone had told her that once you were on Shirley’s bad side that you were always on her bad side.

[Case modified from: P.G. Clark, C. Coot, T.J.K. Drinka, 2007, Theory and practice in interprofessional ethics: A framework for understanding ethical issues in health care teams, Journal of Interprofessional Care 21(6): 591-603.]

  • Is this a human resources issue or an ethics one?
  • How would you handle this situation?
  • Are there underlying and/or competing values that should be considered?

 

Some Values and Ethics Issues to Consider

  • Care for the vulnerable
  • Community health ethics
  • Health care provider relationships
  • Moral distress
  • Organizational culture
  • Overlapping roles and responsibilities
  • Professional competence
  • Professional boundaries
  • Respect for privacy and confidentiality
  • Respect for professional integrity
  • Staff morale

45. CASE: Un/Reasonable Expectations?

It’s one of those days that you don’t look forward to as a manager. You have two complaints about staff that need to be dealt with, and it seems that these types of issues are increasing.

The first complaint is from Ann about what was posted on another staff member’s social networking page.  Ann visited Gregor’s site (which was publicly viewable), only to read the complaints he made about his day, including quotes from “problem patients” to emphasize just what he had to deal with. While the patients weren’t identified, Ann felt that it would be possible for any staff member on the unit to know exactly who the quote was from.  And Ann felt it was inappropriate for Gregor to include this level of detail on a platform viewed regularly by his family and friends.  Ann also wondered if it would make a difference whether Gregor talked about staff members rather than patients on his page.

  • Was this social media posting appropriate?
  • Would it make a difference if Gregor talked about staff rather than patients on this webpage?
  • Is this a human resources issue or an ethics one?
  • What are the ethics issues to be addressed, if any?


The second complaint is from a patient, Greta, about the response that she received from one of your staff members about what Greta had posted on her social networking site. Greta uses her site to share regular updates about her health, as her family and friends are scattered around the world.  She finds it to be a great way to maintain her support network and values the input she receives.

Many of your staff who see Greta on a regular basis when she is in hospital are also “friends” on this site and receive these updates. Greta’s complaint is that this staff member corrected the health information Greta had posted and went on to explain some of the side effects that Greta had experienced.

  • Was this appropriate for the staff member to do?
  • Should staff be “friends” with Greta and interact online in this way?
  • What are the concerns from an ethics perspective?
  • How would you address this issue?


Some Values and Ethics Issues to Consider

  • Compliance with policies and procedures
  • Respect for privacy and confidentiality
  • Professional competence
  • Community and family relationships
  • Patient-provider relationships
  • Trust
  • Overlapping roles and responsibilities

22. CASE: Double Effect?

The following call comes in to the ethics line:

“Hi. It’s Celine from Oncology. We have a patient here who is in the end stages of lung cancer and is in a lot of pain. The patient and his family are strongly Catholic. The patient’s pain doesn’t seem to be well-controlled. But the family won’t authorize increasing his dose of hydromorphone because they are concerned, based on the physician’s description of possible side effects, that they will be artificially shortening his life. One of the family members accused the team of trying to euthanize the patient. This is causing the team a lot of stress. Can the ethics committee help us out with this?”

  • How will you respond to this request?
  • Who would you speak to in order to gather the necessary information?
  • What are the conflicting values in this situation?


Some Values and Ethics Issues to Consider

  • Spirituality/ religious beliefs
  • Capacity
  • Patient-family relationships
  • Respect for patient autonomy
  • Substitute decision-making
  • Moral distress among health care providers
  • Respect for professional integrity
  • Professional competence
  • Beneficence and non-maleficence
  • End-of-life decision-making

15. CASE: Acceptable Judgement?

Sara Thornton, an unemployed 19-year old woman, lives with her 28 year old sister, Fran, and Fran’s boyfriend, Alan. Both sisters were diagnosed with bipolar I disorder in their mid-adolescence. They are both estranged from their alcoholic mother, the only living parent.

Fran has learned to manage her illness reasonably well through lifestyle changes, participation in group psychotherapy sessions, and the regular use of mood stabilizer medications. She has a stable, functional relationship with Alan and works full-time as a paralegal at a local law firm.

Sara, on the other hand, ‘loves to party’ and has an established pattern of binge drinking to dangerous intoxication. She snorts cocaine several times a month. Despite her older sister’s advice, she often takes ‘drug holidays’ from her mood stabilizer medication in order to enjoy the up-shift phase of her mood cycle and to ‘get a lot of stuff done.’ She has a rather stormy relationship with her current clinical psychologist at the Bipolar Clinic of the local psychiatric hospital.

Fran was informed about psychiatric advance directives at her last visit with her private psychiatrist. She decides to complete one and provide the instruction that she wishes to be treated with antipsychotic medications and ECT if these treatment modalities are considered necessary by her psychiatrist in the event that she loses capacity and is hospitalized for her mental illness. She has a past history of refusing medications while in full-blown mania and this has delayed her recovery from these episodes. She names Alan as her proxy substitute decision-maker.

Fran encourages Sara to write a psychiatric advance directive (PAD) as well. Sara decides to name a friend of hers, who is also a person with mental illness, to be her substitute decision-maker. Because she had a bad side-effect experience with the use of an atypical antipsychotic medication during one of her manic episodes, Sara indicates in her PAD that she does not wish to receive antipsychotic medication if and when she loses the capacity to make her own health care decisions during a manic episode. Following hospital policy, Sara’s social worker forwards her completed PAD to her electronic health record.

Three months later Sara presents to the psychiatric hospital ED in full-blown, acute mania. She is threatening to kill her new boyfriend. She is admitted to hospital on an involuntary basis. The psychiatrist on her clinical unit, Dr. Control, knows both sisters from previous hospitalizations and calls Fran about her sister’s emergency admission. With support from Fran, Dr. Control challenges the validity of Sara’s PAD claiming that, in all likelihood, Sara lacked capacity when she made it. He orders intramuscular antipsychotic medication for management of Sara’s acute mania. The nurse preparing this medication for injection notices that Sara’s PAD was witnessed by her family doctor. She calls the ethics support line.

  • How would you handle this request?
  • What issues need to be considered?
  • Who should be making care decisions in this case?
  • Who should determine the validity of a personal directive?

 

Some Values and Ethics Issues to Consider

  • Capacity
  • Substitute decision-making
  • Respect for professional integrity
  • Respect for patient autonomy
  • Professional competence
  • Care for the vulnerable
  • Beneficence and non-maleficence
  • Advance care planning

8. CASE: Who Should Decide?

This case concerns a 35-year-old developmentally delayed female patient (functional age about 5 years old); her mother is her legal guardian. The patient tested positive for a BRCA gene mutation. Her mother is concerned that her daughter may develop ovarian cancer and wants her to have preventive surgery.

Her physician does not believe this is in the patient’s best interests for the following reasons:

  1. There is only a 15-30% chance she may develop the disease
  2. The procedure does not offer a guarantee against developing cancer
  3. The patient has high risk co-morbid conditions including pulmonary stenosis
  4. The patient is highly averse to medical procedures (becomes extremely anxious and agitated).

Her physician is questioning the mother’s decision and if the surgery should even be offered. He feels surveillance/ screening for the purposes of early detection and treatment is the best option.

  • How do you approach this case?
  • What ethics issues must be considered?
  • Where do the value tensions lie in this situation?
  • Should the mother’s request for surgery be granted despite the physician’s expert opinion?
  • Should the daughter’s aversion to medical procedures be considered?
  • Who should make this decision?


Some Values and Ethics Issues to Consider

  • Capacity
  • Respect for patient autonomy
  • Respect for professional integrity
  • Substitute decision-makers
  • Resource allocation
  • Quality of life
  • Risk

6. CASE: To Feed or Not to Feed?

You receive a call on the ethics line about a patient’s relative (next-of-kin and legal decision-maker) force-feeding her sister who is a patient on the unit (pushing food into the patient’s mouth and then holding her mouth closed, pinching her nose, etc. until she swallows). Apparently, this was not an uncommon approach to getting her to eat in the group home where she had lived very happily for 10 years prior to admission (she is 58 years old). The charge nurse feels this is abusive and dangerous behaviour, not acceptable in the hospital setting, and has told the relative this. The patient currently receiving TPN-GI does not feel she is a candidate for a peg-tube. The psychiatrist has assessed the patient as depressed and medication has been started- it takes several weeks to reach full effect, so the team is waiting to see how this will go. The option of ECT has been looked into also, but the anaesthetist feels the patient is too fragile to receive the sort of sedation needed for this procedure. The team does not feel the patient is appropriate for the acute care orthopedics unit (she is unlikely to walk again, is incontinent, immobile, dependent for ADLs with little sign that this will ever change, so not likely to get back to a group home situation in the community). The team’s concern appears to be “we need our beds for patients we can operate on and fix”, although they have not voiced this opinion explicitly. The charge nurse has learned the patient’s relative is angry with the team because she feels the patient is being discriminated against on the basis of her cognitive and physical disabilities so that PT and OT are not working hard enough with her. Staff says this is not the case- the patient is refusing to participate (originally she was told that if she walked and ate she could get back to her group home- this has not happened and the nurse feels she has given up, and is exerting the only sort of protest she can by not eating or cooperating with staff efforts any longer). Finally, there is concern about the possibility of a feeding tube down the road – should the patient get one if she continues to refuse to eat, even after the depression is adequately treated? Is this a decision the relative can make? There are also questions about the possibility of modifying the patient’s diet to be more palatable to her, realizing that this is also more dangerous given her high risk of aspiration.

  • How would you work through this case?
  • Which issues are ethics issues and which are medical decisions?
  • Who needs to be involved in making necessary decisions to move forward?

Some Values and Ethics Issues to Consider

  • Patient-family relationships
  • Respect for professional integrity
  • Moral distress of health care providers
  • Resource allocation
  • Substitute decision-makers
  • Respect for dignity
  • Staff morale
  • Quality of life
  • Duty to provide care