60. CASE: Health Care Providers Under Quarantine

My story starts in early April, during a routine day shift in our minor care area. A previously well middle-aged man, recently returned from Hong Kong, presented with fever. Because SARS was already recognized and we’d gone through the recent experience of a crash intubation with our first case at Vancouver General, this patient was isolated at the triage area and we gowned and masked to examine him. Apart from a temperature of 37.8°C, his vital signs were normal and he looked well. He had no other symptoms, and his physical examination, CBC, urinalysis, and chest x-ray were all normal. Although the patient did not fulfill the case definition of SARS then in existence, I kept him in isolation just in case. When I went in to give him discharge instructions, I did not wear a mask and stood just inside the doorway, about two meters from him. Almost predictably, he returned with the full SARS syndrome just over 24 hours later. And wouldn’t you know it, by then, the case definition of SARS had changed!

I briefly wondered if I could pretend I was not in his room unmasked, but the thought of potentially disseminating a lethal virus persuaded me to do my civic duty and tell my boss. Two hours later Public Health phoned to inform me I was officially quarantined. Needless to say, my husband, also a physician, was incredulous and my kids were terrified. I thought it was kind of funny for the first day, like someone was playing a bad joke. Then the reality began to hit home, and I can tell you the reality was difficult to live with. This is what Public Health told me.

  • I must stay inside my house (preferably within my bedroom) 24 hours a day
  • I must not touch anyone in my family
  • I must wear an N95 mask if anyone is in the same room as me
  • I must not prepare uncooked food for my family
  • I must not sleep with my husband
  • I must use a separate bathroom
  • I must not touch anything in the house that the kids might later touch
  • I must not use the family computer or the main phone
  • I cannot have outside visitors
  • I cannot shop for groceries
  • I cannot go for a walk

The quarantine requirements were not voluntary, but were enforced by Public Health, who contacted me daily to gauge my cooperation. If I did not comply, it was clear that I would be legally compelled to do so. All this took place under the shadow of potentially transmitting SARS to my family, the people I love more than anything in the world. My nine days of quarantine were a blur of extreme boredom, some highly emotional episodes, and a re-evaluation of what I do for a living. One of our daughters moved out for the duration. Another celebrated her 16th birthday without a hug, cake or present from her housebound mother. And my son told me daily how much he wanted a snuggle. I felt guilty that my colleagues, all of whom are already overworked, had to pick up extra shifts to cover me during my enforced absence. As if all this were not enough, it slowly dawned on me that I wasn’t earning any income, and would have to put in extra shifts after my quarantine was over. I decided I never wanted to see another N95 mask again…

What did I learn from my experience? First, it is very isolating and lonely to be isolated. I hugely appreciated the calls and emails I received from my colleagues while I was off. It helped enormously to know they were thinking of me, and didn’t think this was my fault. Second, I think all emergency physicians should consider the financial implications of a sudden enforced quarantine. None of us have disability insurance that would commence quickly enough. To be under quarantine is difficult enough without the added burden of a financial penalty. Although I suffered an occupational exposure, I was not covered by Workers’ Compensation. I believe we need to negotiate with our hospitals and governments to put financial packages in place. Many hospitals are starting to compensate self-employed health care workers for income missed during quarantine. I would go further and suggest a per diem rate for days confined due to occupational exposures. Although no one can compensate me enough for nine lost days of my life, a token payment certainly wouldn’t hurt. Finally, as emergency physicians we do a far more difficult and noble job than I had ever realized. The consequences of what we do to care for our patients and protect the public are risks that put ourselves and our families in potential danger. This is something we never think about or acknowledge, but maybe we should. And maybe we should celebrate ourselves more than we do. I have huge admiration for my emergency medicine colleagues who had far worse exposures than I did in the early phase of the SARS crisis.

  • What values are involved here and for whom?
  • What ethical considerations have to be balanced in such quarantine situations? How is the most appropriate balance achieved?
  • How would you respond to this physician’s concerns? Do you feel there is any legitimacy to her complaints?

Some Values and Ethics Issues to Consider

  • Duty to provide a safe work environment
  • Duty to provide care
  • Respect for individual liberty
  • Community/ public health ethics
  • Consent
  • Disclosure of adverse events
  • Health care provider relationships
  • Risk
  • Patient safety
  • Compliance with policy
  • Disclosure of adverse events
  • Non-maleficence
  • Privacy and confidentiality
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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

34. CASE: To Tell or Not to Tell

The head pathologist of the regional hospital informs the head pathologist of the tertiary care centre that the post-mortem examination of a former patient, Mrs. Dempsey, has revealed that she suffered from a neurological infection called CJD (Creutzfeldt-Jakob Disease). The tertiary centre pathologist reports this to the VP of Acute Care who determines through investigation that Mrs. Dempsey had brain surgery at the tertiary care centre a year and a half ago. At that time, Mrs. Dempsey had a few symptoms consistent with CJD but this diagnostic possibility was not considered by the attending health care team. The surgical instruments used in the Mrs. Dempsey’s surgery were sterilized as per standard protocol and subsequently used in other neurological surgeries at the centre.

Some relevant CJD facts:

  • The involved infectious agent is a prion
  • Prions are transmitted only by neural tissue (brain/nerves) to neural tissue exposure
  • Unlike most infectious agents, prions can survive standard sterilization procedures
  • CJD is a progressive, devastating neurological infection that leads to disabling illness and premature death
  • The usual incubation period from a person’s exposure to CJD to symptomatic infection is 12 to 28 months
  • There is no way to conclusively determine that a person has CJD prior to post-mortem autopsy
  • There is no known treatment for CJD

An ad hoc disclosure working group is struck. In the course of using their hospital’s disclosure policy’s decision-making framework, a participating infectious disease specialist, Dr. Bugg, reports on the clinical literature (evidence) related to CJD disease and its transmission. He expresses his informed opinion that, in the particular circumstances under consideration, there is a theoretical, extremely low risk of past transmission of CJD to patients who had surgery utilizing the potentially contaminated instruments for the month after Mrs. Dempsey’s surgery. Dr. Bugg also comments that, in the last twenty-five years, there have been no reported cases of CJD (world-wide) resulting from patients’ exposure to contaminated surgical instruments.

  • Using your institution’s disclosure policy decision-making framework (or that provided on NSHEN’S website under the “Ethics Resources” tab at http://www.nshen.ca/docs/nshen_adverseevents.pdf), what do you think are the key issues to be considered?

As per Step 7 in NSHEN’s framework, the working group members collaboratively develop a list of benefits and burdens for each of three identified potential disclosure options, i.e., non-disclosure, disclosure to those who have been exposed, and external-public disclosure.

  • Given the facts as presented and using the framework indicated, what decision would you support and why?

 

Some Values and Ethics Issues to Consider

  • Accountability
  • Honesty, trust and truth-telling
  • Compliance with policy
  • Medical error
  • Disclosure of adverse events
  • Patient safety
  • Transparency

32. CASE: To Report or Not

Dr. B is the epidemiologist and director of infection control for an academic health centre. The reportable disease statutes and regulations in Dr. B’s province specify that hospitals and other health care facilities throughout the province are required to track nosocomial infections (infections not present in patients prior to their admission to the hospital) and to “rapidly report outbreaks” to the local health department. What constitutes an “outbreak” is not specifically defined in the statute or in the regulations. This determination is left to the discretion of each facility’s epidemiologist.

As the hospital’s epidemiologist, Dr. B is charged with collecting data on all reportable diseases. He is responsible for determining when the threshold for an outbreak has been met. His staff provides him with data indicating that the rate of several nosocomial infections has been increasing steadily. The increases have been sustained over a period of three and a half months and are statistically significant. Although Dr. B’s data lag behind by approximately one month due to data collection limitations, all indications are that the rates will remain at their current elevated levels or may even escalate. In Dr. B’s opinion, these increases constitute a nosocomial outbreak and should be reported to the local health authorities.

The hospital is still reeling from the political fallout resulting from intense media attention on a young patient with epilepsy who was left unattended and who suffered a serious fall during a grand mal seizure. The patient is now in a persistent vegetative state. The hospital administration, risk management, and the legal counsel for the medical centre and the university are highly sensitive about the incident. The situation has upset the provincial health minister as well, who has expressed his concern about its reflection on him and his chances for re-election. He is said to have told those close to him that he will “make heads roll” in order to appear to have dealt adequately with the situation.

Dr. B’s infection control staff believes that they have identified the probable cause of the outbreak. They have found that healthcare providers are frequently not adhering to basic hand-washing regimens that are required by standard infection control procedures. Observers on the units report that only 30% of healthcare workers wash their hands between patient contacts. The situation is even worse in the ICUs where only 10% of physicians wash their hands between patient contacts. The welfare of every patient on every unit of the hospital is jeopardized by this situation. Dr. B plans an aggressive internal communications campaign to increase awareness of the current low levels of hand washing and to emphasize the importance of infection control in the care of patients.

Dr. B relays his findings to the hospital leadership and maps out his plans for an aggressive communications campaign. He receives a less than lukewarm response. He is questioned about the provincial reporting requirements. He is told that, since the parameters defining “outbreak” are not specifically defined, it is highly doubtful that the institution is experiencing an outbreak. Hospital administrators agree that the situation must be monitored closely. However, they instruct Dr. B not to report the nosocomial outbreak to the local health agency. In addition, they advise him not to disseminate data on the levels of hand washing observed on the units and instruct him to limit his campaign to a general message emphasizing the importance of hand washing in any successful infection control effort. He is told to monitor the situation closely. In response, Dr. B calls the ethics committee for assistance.

[Case modified from: Ann E. Mills, Edward M. Spencer, and Patricia H. Werhane, Developing Organization Ethics in Healthcare: A Case-Based Approach to Policy, Practice, and Compliance, Hagerstown, Maryland: University Publishing Group, 2001, Case #11 by Margaret Skelley, pp. 41-42]

  • What is your gut feeling as you read through this case?
  • What values are at play for Dr. B? For the hospital administrators?
  • Would a decision-making framework be relevant or helpful in this situation?
  • How would you approach this situation when Dr. B. called for an ethics consult?

 

Some Values and Ethics Issues to Consider

  • Accountability
  • Transparency
  • Medical error
  • Patient safety
  • Compliance with policy
  • Duty to provide care
  • Risk
  • Honesty, trust and truth-telling
  • Respect for professional integrity

7. CASE: Unknown Risks

A person who was a first responder at an accident comes into the Emergency Room with blood/body fluid on himself. The patient who was involved in the accident was immediately sent to Halifax where he later passed away. His family had refused to allow his blood to be drawn for testing. The first responder is concerned about disease transmission and wants this brought to ethics. The request came via the Patient Care Manager in the Emergency Department.

  • What are the ethics issues in this case?
  • Who has decision-making authority in this case?
  • How will you proceed with the request?

Some Values and Ethics Issues to Consider

  • Respect for privacy and confidentiality
  • Respect for patient autonomy
  • Duty to provide care
  • Patient-family relationships

 

5. CASE: Caring for a “Difficult” Patient

A female patient in her mid-forties has been on the GI service for several months now due to severe Crohn’s Disease, which has left her with multiple draining abdominal fistuli. She has recently moved out of the province but her condition could not be treated adequately in the local hospital so she was transferred back to Nova Scotia. She has no GP. She has one sibling, a sister, who lives elsewhere in NS.

The patient does much of her own care, refusing nursing care inconsistently off and on. She is also unpredictably non-compliant in regards to medications and other treatments. Staff members describe her as extremely demanding and emotionally abusive to them, particularly when it comes to nurses and residents. She has a history of depression and anxiety, but has refused psychology support. As a result of her long hospital stay she is now VRE+ and MRSA+ so is being cared for in isolation. She has experienced 2 admissions to ICU during this admission and has had a cardiac pacemaker inserted. Interestingly, her behaviour has showed marked improvement following each of these ICU admissions, i.e., less abusive, more appropriate.

Nursing staff is feeling extremely frustrated, manipulated, and abused. They are asking for this patient to be transferred off the GI unit. The ethics consult requestor (charge nurse) feels GI is the most appropriate service for her to be on given her diagnosis and severity of her chronic illness, but also concerned for staff morale.

  • Is this an appropriate situation for an ethics referral? Why or why not?
  • If yes, what are the ethics issues?
  • Should the health care providers be asking for the transfer? Do they have a duty to provide care?
  • What ethics issues arise around the patient’s mental health and non-compliance issues, and how do they factor into this case?
  • How would you respond to this request?

Some Values and Ethics Issues to Consider

  • Duty to provide care
  • Duty to provide a safe work environment
  • Moral distress among health care providers
  • Responsibility for health
  • Respect for autonomy
  • Respect for professional integrity
  • Staff morale
  • Organizational culture
  • Responsibility for health

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