94. Case: Mr. Rattan Wants to Stay

Mr. Rattan has been a resident at Ocean Wind, a retirement community offering a range of options for accommodation, for the last ten years since his partner died.  Currently he has a studio apartment in the assisted living wing, which provides assistance with ADLs.

Mr. Rattan has been diagnosed with dementia.  In the last few months his younger daughter, who typically visits on her way home from work, has become concerned that his current living situation doesn’t meet his needs and wants him to move into the locked dementia unit in a different wing of the building.  She has started to make arrangements for Mr. Rattan to move.

When his daughter talks with him about moving, Mr. Rattan seems amenable to this option.  But twice when staff have come to discuss moving with him he refuses, saying that he’s comfortable where he is and that he doesn’t want to spend the extra money.

Mr. Rattan’s elder daughter and son have both called Ocean Wind to reinforce that Mr. Rattan has told them he doesn’t want to move and that they want his wishes to be respected.  Mr. Rattan does not have an personal directive in place.

Staff have expressed some concerns about Mr. Rattan, indicating that he seems frequently to be confused and disoriented at the end of the day.  They are also considering requesting a capacity assessment, but there is disagreement about whether that is an appropriate next step.

The manager at Ocean Wind has contacted you as the chair of the ethics committee looking for support with this case.


 

Questions:

What will make this case clinically challenging?

What will make this case ethically challenging?

How might the ethics committee support Ocean Wind in addressing these challenges?

What would change (if anything) if Mr. Rattan had a personal directive identifying his son as the substitute decision maker?

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93. Case: End of Life with Dementia

Mr. Shah lives in a continuing care facility. A nurse recently commented; “My patient, Mr. Shah, has an advance directive that he wrote last year and that requests medical assistance in dying when he is no longer able to recognize his wife. His dementia has worsened quickly and recently he’s asked who his wife is after she visits, although he’s happy with her when she’s here. Are we obligated to do anything about his request for medically assisted death?”

73. Case: Compulsive Hoarding – Bessie

Bessie is 65 years old and is living with schizophrenia. She has recently been discharged from hospital, and is now receiving mental health support services at home.  For a while the team has attempted to visit Bessie twice a day. She initially refused to let the team into her apartment and has now allowed health care providers inside.

Upon entering the flat, the team observes many hazards including insects, spoiled food, and broken furniture and appliances in the apartment.  The team notices an eviction notice by the door. They are concerned with Bessie’s living situation, but not sure about what to do.*

*(Case adapted from http://www.nicenet.ca/tools-compulsive-hoarding-the-ethical-dimensions)

What are some of the important details in this case that can help the team to decide how to act?

What are the key ethical principles that apply in this case?

Is this a situation where the team can break their confidentiality with Bessie? Why/why not?

What options does the team have to address this situation?

______________________________________________________

Some values and ethics issues to consider:

Respect for Confidentiality

Respect for Autonomy

Capacity

Informed consent

Quality of life

 

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.

29. CASE: Complicated Caring

Mr. Sundown is a 78-year old African Nova Scotian who is a patient in an internal medicine clinical unit at the Halifax Infirmary. He has a variety of serious medical conditions including diabetes, coronary artery disease, and advanced COPD. He is experiencing progressive respiratory failure on the basis of a difficult-to-treat pneumonia. Mr. Sundown has Alzheimer’s disease and, when out of hospital, lives at home in Dartmouth, where he is totally dependent on his family and visiting VON nurses.

During this admission, the clinical unit nurses and attending physician are having a difficult time communicating with him. On some occasions, Mr. Sundown appears to recognize his wife and children and speaks a few seemingly appropriate words.

Mrs. Sundown and her children make regular visits to the hospital. Mrs. Sundown is a physically healthy person. She is shy and tends to defer in her decision-making to her eldest son, Peter, who has power-of-attorney for both his parents. He lives in Toronto and usually visits home twice yearly. There are two other siblings, Don and Paulette, who live in Halifax.

Mrs. Sundown and Peter are members of a fundamentalist faith. Mr. Sundown is a life-long agnostic, while Don and Paulette attend protestant churches. They all get along pretty well as long as no one brings up religion.

At a health care team conference, there is discussion of the possibility of withholding further potential treatment (including mechanical ventilation) for Mr. Patterson whose health condition is rapidly deteriorating. The attending physician and most other members of the treatment team believe that this is in Mr. Sundown’s best interests, given his apparent low quality of life and what they perceive to be his potential for prolonged suffering.

On a review of Mr. Sundown’s health record, the charge nurse notices that Peter Sundown is listed as the next-of-kin on the admission notes, and that an advance directive has not been made. Family members report to the attending medical resident that Mr. Sundown has not clearly indicated his wishes/ preferences for medical care and treatment at the end-of-life.

The attending physician is aware that the relevant intensive care unit is full and that there are five other very ill patients waiting for urgent admission. He calls for an ethics consult.

  • What issues should be discussed during this meeting?
  • Who should be present at this meeting?
  • What weight should resource allocation have in this case?

Some Values and Ethics Issues to Consider

  • Advance care planning and personal directives
  • Substitute decision-making
  • Spirituality and religious beliefs
  • Resource allocation
  • Respect for patient autonomy
  • Respect for human dignity
  • Patient-family relationships
  • Quality of life
  • Capacity
  • End-of-life decision-making

24. CASE: Changing Care and Care-Giving

Kevin Henderson is an 83-year old man who is hospitalized in an internal medicine clinical unit at the local hospital. Kevin has a variety of serious medical conditions including severe Alzheimer’s disease, diabetes, coronary artery disease and advanced chronic obstructive lung disease. He is slowly recovering from a difficult-to-treat pneumonia, which required treatment with intravenous antibiotics.

During this admission, the clinical unit nurses and attending physician are having a difficult time communicating with Kevin. On some occasions, he appears to recognize his wife and children and speaks a few, seemingly appropriate, words to them.

Family members make regular visits to the hospital. Mr. Henderson’s wife, Nancy, has osteoarthritis that has been increasingly disabling of late. She is somewhat shy and tends to defer her decision-making to her eldest son, Peter. He lives in Toronto and usually visits home twice yearly. He has recently flown to Halifax to see his father and provide psychological support to his mother. Peter has power of attorney for his father’s financial matters.

There are two other children, Sandra and Paulette, who live in Dartmouth. They are estranged from their brother due to unresolved, significant conflict that arose from the sale of the family cottage two years ago.

When out of hospital, Kevin lives with Nancy at home in a rural area, where he is totally dependent on his family and visiting VON nurses. Nancy has been finding it increasingly difficult to care for her husband at home. She arranges to meet with her children in the clinical unit’s family room to discuss alternate living arrangements for Kevin. When they meet, Nancy states that she is not willing to make a decision about placing Kevin in a continuing care home on her own. She then looks to Peter to begin the discussion.

An advance/personal directive has not been made. Kevin, who was in denial during the early stages of his dementia, avoided talking to his family about his wishes for his care when his health condition got worse. Sandra recalls that while her father was well, he had once commented to her that he did not want to end up in a nursing home at the end of his life.

  • What ethics concerns should the family be considering as they seek a way forward?
  • Who should be making decisions about Kevin’s care?
  • How would you help to facilitate this discussion?
  • Should Nancy’s health and well-being be considered equally as Kevin’s?


Some Values and Ethics Issues to Consider

  • Capacity
  • Substitute decision-making
  • Patient-family relationships
  • Respect for patient autonomy
  • Advance care planning and personal directives
  • End-of-life decision-making

21. CASE: Balancing Concerns

“Where’s the door to my bathroom? Can’t a man get some privacy?”

“Uh oh, that’s Elias again. We’d better make sure he’s alright.”

“How many times are we going to have to go through this with him? Maybe we should just put the bathroom door on again.”

“The only problem is that on his ‘bad’ days, he often gets confused and trapped in the bathroom. Don’t you remember how long it took us to calm him down after that happened about five weeks ago? He was so worked up! Elias and his family agreed to taking the door off at the meeting about this a couple of weeks ago. It seemed the safer way to go. The problem is that Elias can’t always remember that this is something he said he wanted.”

“Well, that must have been on one of his ‘good’ days. We don’t seem to be having so many of them now. I’m finding it hard to have this conversation with him every shift!”

  • What are the ethics issues here?
  • Are there other options that could be considered in this case?
  • How would you suggest the health care team work through this issue?
  • Should Elias’ safety take precedence over his dignity?

Some Values and Ethics Issues to Consider

  • Capacity
  • Respect for human dignity
  • Quality of life
  • Living at risk
  • Patient safety
  • Beneficence and non-maleficence
  • Substitute decision-making
  • Organizational policy

18. CASE: When the “Truth” is Painful

Mrs. Sally Parrot, a 73-year old widow, has mild dementia of a presumed neurovascular type. She resides in her own small apartment in Serenity, a private continuing care community in Bedford, where she receives some assistance with housekeeping, meal preparation and organization of her medications. Sally is actively engaged in Serenity’s structured activities and, in particular, enjoys participating in the music program and walking group. One of her two children, Lorna, resides in Halifax and visits her once weekly.

Sally was recently diagnosed with slowly progressive, metastatic bowel cancer. After talking it over with Lorna and her son Fred, Sally decides to go ahead with a series of recommended palliative treatments: a short course of chemotherapy, de-bulking bowel surgery and low dosage radiotherapy.

After the chemotherapy, which she has tolerated well, Sally is admitted to hospital for her surgery, which involves removal of a section of large bowel that contains the primary tumour. Unfortunately, she develops post-operative delirium, which has been slow to clear over the past few weeks in hospital. At the present time, she is reasonably clear-headed in the morning, but her cognition deteriorates in a ‘sun-down’ fashion as the day progresses.

Seeing how her mother has reacted to surgery, Lorna begins to wonder if the planned third phase of treatment, i.e., palliative radiotherapy, is the still the way to go. She decides to wait until her brother arrives later that week from Australia to sort this out. In the meantime, during the late afternoons and evenings, Sally has begun to ask her health care providers about why she is in the hospital. They tell her that she is in hospital for surgical treatment of her bowel cancer. However, Sally does not retain information for more than ten minutes late in the day due to her delirium-related confusion, so each time the direct care nurses inform her that she has cancer in response to her question, she responds in the same way – with surprise and significant emotional distress.

The nurses consider truth-telling in the disclosure of health information to be an important professional value and practice. However, they begin to wonder whether they are doing more harm than good in responding to Sally’s repeated questions in an honest and forthright way.

A group of nurses who are experiencing moral distress in these challenging circumstances get together and, with the knowledge of their health services manager, contact the clinical ethics service to make a formal request for ethics support.

  • What are the ethics issues in this case?
  • How would you work through the issues with the health care team?
  • Is withholding the truth from a patient ever the right decision?
  • Should alleviating the distress of the patient and/or the health care team be more of a priority than upholding the value of truth-telling?


Some Values and Ethics Issues to Consider

  • Honesty, trust and truth-telling
  • Capacity
  • Substitute decision-making
  • Respect for patient autonomy
  • Moral distress among health care providers
  • Patient-family relationships
  • Respect for human dignity
  • Patient-centered care
  • Respect for professional integrity
  • Beneficence and non-maleficence

11. CASE: Truth-Telling

The patient is an 89-year-old gentleman with moderate dementia and a history of COPD, swallowing difficulties, a CVA, and recent aspiration. The investigation of his aspiration uncovered a lesion in his lung- the physicians felt it was likely to be cancerous. Thoracic surgery verified that it was lung cancer and a determination was made that he would not be a candidate for surgery or chemo, but potentially for radiation if he were to become symptomatic.

Sometime later, the patient underwent a CT scan, which showed that the lesion had not grown much. The attending physician believes the patient is more likely to die from aspiration pneumonia than his cancer.

The patient’s son does not want him to be told about the cancer for fear he might become depressed and “give up.” According to the physician, the patient can engage in discussions about his health, i.e. diet, etc., but would need assistance from his son for any major decisions.

The health care team is questioning whether they are doing the right thing by following the son’s wishes and not telling the patient about his cancer diagnosis. They put in a call to the ethics line.

  • Identify the competing values in this case
  • How will you proceed with this request?
  • Who should make the decision about what information the patient receives?
  • How does one really know what is best for a patient?
  • Is withholding health care information from a patient ever the right decision?


Some Values and Ethics Issues to Consider

  • Honesty, trust and truth-telling
  • Respect for patient autonomy
  • Patient-family relationships
  • Capacity
  • Moral distress among health care providers
  • Respect for professional integrity
  • Substitute decision-making
  • Beneficence and non-maleficence

4. CASE: Expectations for Care

Ned is an elderly patient with relatively advanced dementia who is recovering from surgery to repair a hip fracture. He spends most of every 24-hour period screaming unless someone familiar sits with him. Staff members on the unit are becoming increasingly frustrated and stressed. The unit manager has received numerous complaints, verbal and written, from other patients on the unit and from some of their family members. She decides to call the ethics line.

  • What are the ethics issues?
  • What are the non-ethics issues?
  • What underlying values are at stake?
  • How would you respond to this call?

 Some Values and Ethics Issues to Consider

  • Moral distress among health care providers
  • Distributive justice
  • Resource allocation
  • Patient-centered care
  • Capacity
  • Empathy
  • Respect for human dignity
  • Quality of life

3. CASE: Superbugs

Jeannette Cutler is an 83-year old woman admitted to hospital after falling and breaking her arm.  She reports that she fell because she passed out, and so further investigations are being conducted.  She has mild dementia but is otherwise seemingly healthy.  Upon admission, she screens positive for MRSA and is subject to strict isolation procedures as per hospital policy.

Jeannette was a long-time volunteer at the hospital where she is now a patient. Jeannette is having trouble adhering to the isolation protocol, and several times a day she gets up and starts going into other patients’ rooms to “visit”.  The team has had discussions with her regarding the need for her to remain in her room, but they have failed to achieve the desired effect.

Staff is concerned that she is spreading MRSA and are considering various means of confining her to her room.  They aren’t sure how best to express respect for Jeannette while also ensuring that other patients are not unnecessarily exposed to harm.  They have contacted the ethics committee and the legal department asking for help in working through this case.

  • What ethics concerns are you thinking about as you respond?
  • Who should be involved in making this decision?
  • What are some competing values that arise in this case?
  • Should the well-being of others take precedence over Jeannette’s freedom of     mobility?
  • What potential creative solutions can you think of to resolve this issue?

 Some Values and Ethics Issues to Consider

  • Respect for individual liberty
  • Patient-centered care
  • Distributive justice
  • Policy compliance
  • Respect for autonomy
  • Responsibility for health
  • Quality of life
  • Respect for dignity
  • Capacity
  • Beneficence and non-maleficence