99. Case: Talking About an Adverse Event

You are a respiratory therapist working in a large hospital seeing a range of patients, but primarily working with the teams in the Emergency Department and ICU.  With one complex patient in ICU there was a miscommunication that resulted in improper settings being used for ventilation and this resulted in the patient having a longer-than-expected ICU stay.  You feel responsible for this and as part of the adverse event disclosure process you are going to talk to the family about it.  How will you prepare for the conversation?


Your loved one, who has dementia and COPD, is in ICU and you know that there was a mistake with their ventilator because you overheard some of the nurses talking about it.  You feel that the ICU environment is making your loved one’s dementia worse, and you’re angry that someone’s carelessness has resulted in harm to your loved one.  The nurses let you know that the respiratory therapist wants to talk to you about the incident.  You’re willing to have the conversation, but you’re tired from looking after your loved one and frustrated by your whole experience in the hospital.  What is most on your mind when you go into this conversation?


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?
  • Why is it important to have this conversation from each person’s perspective?
  • Which values and principles are reflected in the commitment to ensuring that the conversation happens?
  • What can be done to help ensure that this is a “good” difficult conversation?

References:

Alberta Health Services. Disclosure Done Well – Early Disclosure: Unsure If Care Is Reasonable. Published March 16, 2018. https://www.youtube.com/watch?v=i2uEHmElX5M

Bonney, W. (2014). Medical errors: moral and ethical considerations. Journal of Hospital Administration. 3(2): 80-88. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=2ahUKEwjjwa2Z7PzgAhUV854KHa5sCPkQFjABegQIBBAC&url=http%3A%2F%2Fwww.sciedu.ca%2Fjournal%2Findex.php%2Fjha%2Farticle%2Fdownload%2F3475%2F2226&usg=AOvVaw2VCJ0K19IQYyW329XHm_C_

Brené Brown on Blame: https://www.youtube.com/watch?v=RZWf2_2L2v8

Canadian Patient Safety Institute. (2011). Canadian Disclosure Guidelines: being open with patients and families. CPSI. https://www.patientsafetyinstitute.ca/en/toolsResources/disclosure/Documents/CPSI%20Canadian%20Disclosure%20Guidelines.pdf

Canadian Medical Protective Association. Disclosure – Maintaining Trust. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/adverse_events/Disclosure/disclosure-e.html

Canadian Medical Protective Association. Disclosing Harm from Health Care Delivery. Version 3, 2017. https://www.cmpa-acpm.ca/static-assets/pdf/advice-and-publications/handbooks/com_15_disclosure_handbook-e.pdf

Nova Scotia Health Authorities. 2017. Disclosure of Patient Safety Incidents. Patients First. http://www.nshealth.ca/sites/nshealth.ca/files/patientinformation/1448.pdf

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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

 

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

91. Case: What is Best for Angela?

Angela Flores is a six year old with some minor developmental delays caused by traumatic birth.  She has recently been diagnosed with a brain tumor and her prognosis is poor.  The health care team is trying to determine goals of care and a develop treatment plan.

Angela lives with and is cared for by her paternal grandparents, Jean and Rod, but there is no formal custody arrangement in place.  Angela’s parents have separated and her mother, Tina, has moved to Ontario to seek work on the understanding that she will send for Angela when she finds a job and an apartment.  Tina is in regular contact with the health care team by phone.  Angela’s father, Aaron, is sporadically involved in her life, coming and going unpredictably.

Angela’s grandparents are advocating for comfort measures only while Tina wants to pursue active, aggressive treatment and is asking whether there are any research studies that Angela could be enrolled in.  Aaron is currently in town and he wants to involve a homeopath in Angela’s care.

Jean and Rod appear to be frustrated with both Tina and Aaron and feel that they are best placed to make decisions for Angela.  Meanwhile, both Tina and Aaron emphasize that they are Angela’s parents and expect to be involved in decision making.  They get very upset when they perceive that decisions have been made without them.  There have been a couple of family meetings involving all four adults, and every time someone has stormed out of the meeting.

Jean and Rod are worried that Angela will be significantly distressed by the whole process of getting treatment as it will significantly disrupt her routine and there is another family member who recently died of cancer and Jean and Rod say that his treatment was painful, ineffective, and resulted in a “bad” death.  Jean and Rod are also very unwilling to involve Angela in any discussions about her diagnosis, prognosis, and treatment, saying that “there’s no way she can understand and it will just upset her.”

The health care team is also divided regarding what they believe are appropriate goals of care for Angela and some members who have worked with Angela for a long time are experiencing significant moral distress at the prospect of moving to palliative care.    They also aren’t sure how to approach conversations with the family given the level of conflict present, and are concerned that the conflict between the adults is interfering with making appropriate decisions for Angela.

How might you approach this 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?

88. Case: Whose Problem Is It?

Case substantially modified from “Obesity in Kids: When Appeals to Vanity Don’t Work,” Virtual Mentor 8(10): 377-380, October 2006 – see virtualmentor.ama-assn.org

Nicholas has the option of spending the summer in an intensive weight reduction program at a health facility in Ontario. This highly regarded program accepts only 10 adolescents each summer, based on medical problems related to obesity. Nicholas has cardiomegaly, hypertension and pre-diabetes. At 14, Nicholas is 5 feet 7 inches tall and currently weighs 285 pounds.

The health team caring for Nicholas is quite concerned about him and believes that this program would be a great option. While traveling to Ontario and being separated from his family might be hard, the weight reduction program would likely have a very positive benefit on Nicholas’s health.

Indeed, one of the health team members, Matthew, feels strongly about this as he recalls what it was like to be the “fat kid” in class, putting up with the teasing and ridicule. After a family meeting, Matthew is almost incredulous that Nicholas isn’t sure about the program and that his parents aren’t really pushing him to go. He’s overheard saying to Nicholas’s mother on the way out of the meeting that, “I can’t believe that you aren’t sending him to the program. It’s his only chance! Any good parent would send their child.”

Amy, the team social worker, has been meeting with Nicholas and his parents and she shares a different perspective. Amy has noted that Nicholas isn’t really bothered by his weight in the way some other people are. He has his first girlfriend, is pretty popular, and doesn’t get teased very often by his peers (about his weight, at least). His parents are also ok with his body size. While they appreciate his health problems, they are really concerned that an (over)emphasis on his weight might hurt his self-esteem and cause him to lose focus on who he is as a whole person.

Further discussion among team members makes it clear that there is deep disagreement about how to proceed in this case. Should they put more pressure on Nicholas and/or his parents to agree to the camp? Is this over-stepping their role as health care providers? All agree that an ethics perspective would likely be helpful and give the clinical ethics consultation line a call.

78. Case: Health Care for New Canadians

 

Ahmed arrived recently in Canada as a refugee from Syria.  He was diagnosed in the refugee clinic with prostate cancer and has arrived for a follow-up visit.  The interpreter has called in sick and Ahmed speaks very little English.  Ahmed’s 13-year-old son, Bashir, has accompanied him and is acting as a translator for his father.  The health care team at the clinic would like to make some decisions today about treatment approaches, but Bashir seems uncomfortable with translating both questions and responses.

 

Discussion:

  • What are the ethical concerns raised by this case?
  • As a member of the health care team, how would you proceed?
  • What types of refugee health resources might be developed to support patients, families, and health care teams?

 

Resources:

74. Case: Compulsive Hoarding – Mary

Mary is a 72 year old woman who has been a compulsive hoarder for the last 10 years.  She can only move from room to room through pathways. She would like to move closer to her daughter and grandchildren, but she feels overwhelmed by the amount of stuff she has in her house. Despite the family’s efforts to help, her previous attempts to clean out her home have been unsuccessful. Mary has outpatient orthopedic surgery scheduled, and follow-up care will be provided in her home.  This is causing Mary anxiety and she is considering cancelling the surgery due to the shame she feels about the state of her home.*

*(Case adapted from Cermele, JA et al. (2001). “Intervention in Compulsive Hoarding: A Case Study”. Behavior Modification 25.2: 214-232.)

What are some of the important details in this case that would help you determine how to approach Mary and discuss her concerns?

What are the key ethical concerns if Mary decides to cancel the surgery?

What are the ethical concerns about follow-up care in this case?

What options do you have to address the ethical concerns about follow-up care?

_______________________________________________ 

Some values and ethics issues to consider:

Respect for Autonomy

Quality of life

Quality of care

Boundary crossing

Trust relationship

 

Resources

Gibson, Amanda K.; Jessica Rasmussen; Gail Steketee; Randy Frost; David Tolin. 2010. Ethical Considerations in the Treatment of Compulsive Hoarding. Cognitive and Behavioral Practice. Vol. 17, Issue 4:p. 426-438. http://www.sciencedirect.com/science/article/pii/S1077722910000945

Frost, Randy O.; Gail Steketee. 2014. The Oxford Handbook of Hoarding and Acquiring. Oxford University Press. 2014.

Koenig, Terry L Chapin, Rosemary Spano, Richard. 2010. Using multidisciplinary teams to address ethical dilemmas with older adults who hoard. Journal of Gerontological Social Work. February 2010; Vol. 53(2):137-147.

National Initiative for the Care of the Elderly (NICE). Compulsive Hoarding: The ethical dimensions. http://www.nicenet.ca/tools-compulsive-hoarding-the-ethical-dimensions)

Tompkins, Michael A..2014. ‘4.5 Ethical and legal considerations when helping a client with severe hoarding’. In, Clinician’s guide to severe hoarding: A harm reduction approach. Springer. November 2014.