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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90. Case: End the 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.

Questions for Collective Consideration

  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?

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?

 

 

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

57. CASE: Caregiver Stress

Dr. Morrison has been the only physician in his small community of 1,500 people for about 15 years and is known as the “Town Doc.” When he first moved to town, he quickly became friends with many people and involved in the community. However, the longer he practiced, the more awkward his social life became.

He helped coach the baseball team for several years. But then he treated one of the boys on the team for chlamydia and the boy stopped coming to practice. Dr. Morrison didn’t sign up to coach the following year. He began to turn down social invitations, as more friends became patients. Eventually he began to feel burdened and overworked but unable to decrease his workload. He attended to numerous horrific farm and motor vehicle accidents, often as the only provider for multiple patients, resulting in increasing mental trauma and distress.

He felt indebted to the community but also began to feel resentful. Where he once took pride in the fact that people looked to him for support, he began to feel overwhelmed and useless. He recognized that he was depressed but had no idea where to turn for help. His patients began to notice that he seemed tired and irritable. At the nearby critical access hospital, where Dr. Morrison is affiliated, the administrators were increasingly concerned about his ability to practice and feared he might even resign.

[From Rural Health Ethics: A Manual for Trainers. William Nelson & Karen Schifferdecker. https://geiselmed.dartmouth.edu/cfm/resources/ethics/%5D

  • What, if anything, should the administrators say or do?
  • What steps can rural health care providers take to avoid isolation and burnout?
  • What steps can rural health administrators and community leaders take to avoid isolation and burnout among their health care providers?
  • What resources could Dr. Morrison access to assist in this situation?


Some Values and Ethics Issues to Consider

  • Community and family relationships
  • Respect for privacy and confidentiality
  • Resource allocation
  • Patient-provider relationships
  • Professional boundaries
  • Honesty, trust and truth-telling
  • Duty to provide care
  • Moral distress among health care providers
  • Overlapping roles and responsibilities

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

49. CASE: Reality Check?

A clerk and resident are frustrated after a morning of taking histories from and doing physical examinations of patients referred to the GI Clinic. As you (the attending clinic gastroenterologist) are going over the morning’s work with them, the clerk and resident complain that most of the patients seem to have less clinically significant symptoms and physical findings than were described by their attending family physicians in the referral notes to the clinic.

They start an argument (which looks to you like it’s on its third round) about whether it’s the patients or the referring physicians who are responsible. Adding to their frustration, the Department Head interrupted them just as the clerk was beginning with one patient – who she was already thinking might be the healthiest person she’d seen in her entire rotation – and insisted on doing the history and physical himself. The resident, who recently arrived from out of province, gets some local information from the clerk, who tells him the significance of that particular patient’s family name (major regular contributor to the Hospital Foundation).

The clerk thinks several of the morning’s problematic referrals came from the same family physician, and that there should be repercussions for that physician, e.g., putting his patients at the bottom of the waiting list, or calling him up to complain. The resident defends the referring physician and speculates that it’s the patients who are causing the problem.

You’re wondering how to get them to focus on something more productive and professional.

  • Should you communicate to them that practice in the real world is like this, and that they should get on to the next patient? Or is this a teachable moment in some way?
  • Is this a clinical practice issue or an ethics issue? 

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Compliance with policies and procedures
  • Respect for professional integrity
  • Patient-provider relationships
  • Health care provider relationships
  • Honesty, trust and truth-telling
  • Professional boundaries

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