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?
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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.

67. Case: What is Angela’s Choice?

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 he 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?

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

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

42. CASE: “Oops, Did I Say Too Much?” The Ethics of Confidentiality

You work with a variety of patients and families, and often see firsthand both the joys and disappointments that can come with trying to manage mental health issues. Over time, you have developed some special expertise in working with patients with schizophrenia and often are asked by family doctors for assessments and/or support with treatment plans.

While there have been some real successes, you have also been involved in a number of situations where patients have gone off of their medication(s) with varying outcomes. Some patients have had run-ins with the law while others have retreated from the world and live on the “fringes”, while still others, unfortunately, have committed suicide.

At a party yesterday, you had a chance to catch up with your goddaughter, Sherrie. She is twenty two, has an active social life and has just started dating someone seriously. As Sherrie talks about her new boyfriend, Jonas, she mentions that he has had some issues with his medications – “which you would understand all about being that you work in mental health” – and has stopped taking them completely.  More details about Jonas and his interests are shared as the conversation continues, and you start to get a bad feeling.

You believe that Jonas is a patient you were asked to assess a few years ago. If you’re right and this is the same person, Jonas has paranoid schizophrenia and a tendency to get very aggressive and potentially quite violent when he is not taking his meds. You feel as if you would never forgive yourself if you let something happen to your goddaughter, so should you tell Sherrie what you know?

  • What are your options for action in this situation?
  • What process would you use to decide what to do?
  • What are the competing values you would weigh?
  • Should Sherrie’s safety or Jonas’ privacy take precedence?


Some Values and Ethics Issues to Consider

  • Patient- family relationships
  • Compliance with policies and procedures
  • Respect for privacy and confidentiality
  • Overlapping roles and responsibilities
  • Professional boundaries
  • Honesty, trust and truth-telling
  • Community relationships

15. CASE: Acceptable Judgement?

Sara Thornton, an unemployed 19-year old woman, lives with her 28 year old sister, Fran, and Fran’s boyfriend, Alan. Both sisters were diagnosed with bipolar I disorder in their mid-adolescence. They are both estranged from their alcoholic mother, the only living parent.

Fran has learned to manage her illness reasonably well through lifestyle changes, participation in group psychotherapy sessions, and the regular use of mood stabilizer medications. She has a stable, functional relationship with Alan and works full-time as a paralegal at a local law firm.

Sara, on the other hand, ‘loves to party’ and has an established pattern of binge drinking to dangerous intoxication. She snorts cocaine several times a month. Despite her older sister’s advice, she often takes ‘drug holidays’ from her mood stabilizer medication in order to enjoy the up-shift phase of her mood cycle and to ‘get a lot of stuff done.’ She has a rather stormy relationship with her current clinical psychologist at the Bipolar Clinic of the local psychiatric hospital.

Fran was informed about psychiatric advance directives at her last visit with her private psychiatrist. She decides to complete one and provide the instruction that she wishes to be treated with antipsychotic medications and ECT if these treatment modalities are considered necessary by her psychiatrist in the event that she loses capacity and is hospitalized for her mental illness. She has a past history of refusing medications while in full-blown mania and this has delayed her recovery from these episodes. She names Alan as her proxy substitute decision-maker.

Fran encourages Sara to write a psychiatric advance directive (PAD) as well. Sara decides to name a friend of hers, who is also a person with mental illness, to be her substitute decision-maker. Because she had a bad side-effect experience with the use of an atypical antipsychotic medication during one of her manic episodes, Sara indicates in her PAD that she does not wish to receive antipsychotic medication if and when she loses the capacity to make her own health care decisions during a manic episode. Following hospital policy, Sara’s social worker forwards her completed PAD to her electronic health record.

Three months later Sara presents to the psychiatric hospital ED in full-blown, acute mania. She is threatening to kill her new boyfriend. She is admitted to hospital on an involuntary basis. The psychiatrist on her clinical unit, Dr. Control, knows both sisters from previous hospitalizations and calls Fran about her sister’s emergency admission. With support from Fran, Dr. Control challenges the validity of Sara’s PAD claiming that, in all likelihood, Sara lacked capacity when she made it. He orders intramuscular antipsychotic medication for management of Sara’s acute mania. The nurse preparing this medication for injection notices that Sara’s PAD was witnessed by her family doctor. She calls the ethics support line.

  • How would you handle this request?
  • What issues need to be considered?
  • Who should be making care decisions in this case?
  • Who should determine the validity of a personal directive?

 

Some Values and Ethics Issues to Consider

  • Capacity
  • Substitute decision-making
  • Respect for professional integrity
  • Respect for patient autonomy
  • Professional competence
  • Care for the vulnerable
  • Beneficence and non-maleficence
  • Advance care planning

12. CASE: Should Steve Go Home?

Throughout his life, Steve was the athlete that everyone admired. He played all sports well, especially excelling at basketball. While being quite competitive, Steve was a team player who enjoyed being a part of the team experience.

Unfortunately, while ‘horsing around’ with his friends last summer, Steve dove off a dock into water that was too shallow. His head cracked on the bottom resulting in a spinal cord injury. He is no longer able to walk and has slowly been regaining some control over a few of his fingers.

At 17, Steve felt that his life was over and has had difficulties participating in his rehabilitation program, saying things like, “What’s the point if I’m never going to walk again?” and, “I can’t even go to the bathroom by myself!”

Steve’s family, friends, and health care team rallied around him providing lots of support and encouragement. Over the past month-and-a-half, the health care team noticed some positive changes in Steve’s involvement in his rehabilitation program. He is participating more and talking about wanting to get out of the rehab facility. Accordingly, the health care team was working with Steve on a discharge plan in three weeks, if his progress continued. All of this seemed to indicate that Steve was beginning to see a new life for himself – until one of the Recreation Therapists came to the team meeting three days ago.

Steve and Andrea, the Rec Therapist, developed a close working relationship over his time at the rehab facility. Steve often shared with Andrea what he was really thinking and this has been helpful for the health care team to identify what interventions and supports may be needed. Steve confided to Andrea (three days ago) that the only reason that he was working so hard at learning to use his motorized wheelchair was so that he could control the joystick well enough to ensure that he could kill himself by driving off the same dock where his injury occurred.

A consult with a psychiatrist who specializes in persons with spinal cord injuries reports that Steve is not depressed and does not seem to have the intent to follow through with his plan of suicide. He said that this expression may have been primarily an indication of Steve’s ongoing frustration and adjustment to his spinal cord injury.

Even with this information, the team is conflicted about what to do. Their own hopes that they were making progress with Steve have been challenged too. The team agrees to consult the ethics support service.

  • How would you handle this request?
  • What values appear to be shaping the dynamic for team members? For Steve?
  • What are the ethics concerns?
  • How should the health care team reconcile the difference in opinion between the psychiatrist and those who believe Steve’s plan to commit suicide?

 

Some Values and Ethics Issues to Consider

  • Capacity
  • Respect for patient autonomy
  • Moral distress of health care providers
  • Respect for professional integrity
  • Honesty, trust and truth-telling
  • Patient-provider relationships
  • Compliance with policy