91. 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

90. 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?

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:

• White Coat, Black Art: One clinic, Hundreds of Languages. Here is how it works. Friday, December 02, 2016. One Clinic, hundreds of languages: Here’s how it works

• Juckett G. and Unger, K. (2014). Appropriate Use of Medical Interpreters. Am Fam Physician. 2014 Oct 1;90(7):476-480. Appropriate Use of Medical Interpreters

• NSHA Central line for interpreters: Accessing Interpretation Services NSHA

• McKeary, M. and Newbold B. (2010). Barriers to Care: The Challenges for Canadian Refugees and their Health Care Providers. Journal of Refugee Studies (2010) 23 (4): 523-545,  Barriers to Care: The Challenges for Canadian Refugees and their Health Care Providers

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

53. CASE: Disease Stigma

A patient has been followed by you, his family doctor, for several medical issues and is being seen for a minor work-related injury. He is very negative and tearful but will not acknowledge his symptoms when asked.

You believe he is depressed and you know you can provide treatment for his depression. However, the patient is uncomfortable seeking treatment or having you document your findings in his record because of the stigmatizing effect of having a mental health disorder known in a remote community.

• What steps should you take to address his depression?
• What factors external to your family practice must be considered?
• Do you think that it is likely or unlikely that the patient’s concerns about confidentiality are valid?
• What policies and procedures should be in place to maintain privacy and confidentiality in rural communities. How should these be enforced?

Some Values and Ethics Issues to Consider

• Respect for privacy and confidentiality
• Respect for patient autonomy
• Community and family relationships
• Respect for human dignity
• Honesty, trust and truth-telling
• Patient-provider relationships
• Patient safety
• Stigma
• Vulnerability
• Equality of access

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

2. CASE: Treatment and/or Termination? Tough Choices

Melanie is a 21 year old who was recently involuntarily committed after she started a serious fight at a local shelter, thinking that one of the leaders was trying to steal her favourite T-shirt. Melanie has schizophrenia and is well-known to both the police and mental health care providers. She has been living on and off the streets since she left home when she was 16 years old, and has a rather strained relationship with her parents. They have been trying to support her and often provide money for her medications. When Melanie is taking her medications, she is able to find work and has talked about going back to school. However, Melanie finds the side effects of the medications awful and stops taking them, leading to being kicked out of apartments or friends’ places when she gets too aggressive.

In doing Melanie’s work-up upon admission, it was discovered that she is about 7-8 weeks pregnant. While trying to determine what to do with respect to the pregnancy, she is placed on medications that minimize teratogenic effects for the fetus, and that may have some success in stabilizing Melanie’s condition (although it is recognized that this is not the “gold standard” treatment). Melanie’s mother, Krystine, was named by Melanie as her substitute decision-maker (witnessed by her psychiatrist at the end of her previous admission), despite some of the challenges in their relationship, and she endeavours to do the best for her daughter. The team has been in discussion with Krystine about treating Melanie and about her pregnancy.

Melanie has indicated that she doesn’t know who the father is, as she has had several partners over the last few months. She also alternates between saying that she wants the baby to saying that the baby is cursed and she should be rid of it. Krystine indicates that Melanie has not talked to them about having children, only about trying to get well to go back to school.

Both Krystine and the health care team have some questions and concerns about how to move forward with Melanie’s treatment. The health care team calls for a clinical ethics consultation.

• If the medication regime doesn’t stabilize Melanie, would it be ethical to move to a different treatment plan, knowing that this might cause substantial harm to the fetus?
• Should the possibility of terminating the pregnancy be discussed further?
• Should an attempt be made to find and notify the biological father?
• How do the dynamics if Melanie’s family relationships factor into this case?
• Can or should someone other than Melanie make these decisions?

Some Values and Ethics Issues to Consider

• Capacity
• Respect for patient autonomy
• Living at risk
• Vulnerability
• Patient-family relationships
• Substitute decision-makers
• Beneficence and non-maleficence