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99. Case: Discussion with Staff on New Scheduling

You are the manager of an outpatient clinic that serves patients from throughout the Maritimes.  Many of these patients travel for their appointments and are trying to minimize time away from work, so after a discussion with the Patient Feedback team the decision is made to open the clinic on Saturdays and Sundays on a trial basis.  It is also hoped that this will reduce wait times for appointments.  You must tell your team about this change, which you suspect will be unpopular.  How will you structure the conversation?

In addition, you need to determine a fair process for deciding who will take the weekend shifts.  Some of your staff have children, while others do not.  Several staff members have other commitments on the weekends, such as sports teams and volunteer work.  You want to approach the conversation about staffing in a way that won’t create resentments between colleagues and are wondering how to do that.

You’re the only dietician working in an outpatient clinic and you’ve got an 8-year-old child as well as a parent whom you’re caring for at home.  You’ve caught wind of a plan to open the clinic on weekends and you’re angry because you know that you will be required to work weekends, and this will reduce the time you have with your family and increase costs for caregiving.  What are you planning on saying as you go into a meeting to discuss these changes?

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 the ethical concerns raised by this situation?
  • Are there aspects of decision making that could have been handled differently to reduce the likelihood of having difficult conversations?
  • What sorts of supports might help this difficult conversation to go well?

References:

Danigelis, A. 2010. How to Communicate Employee Expectations Effectively https://www.inc.com/guides/2010/08/how-to-communicate-employee-expectations-effectively.html

Gooch, K. 2018. 7 healthcare leaders on conducting difficult conversations with peers. Becker’s Hospital Review, Published September 28, 2018. https://www.beckershospitalreview.com/hospital-management-administration/6-healthcare-leaders-on-conducting-difficult-conversations-with-peers.html

Forbes Coaches Council. 13 Ways Managers Can Initiate Tough Conversations With Employees. Published September 28, 2018. https://www.forbes.com/sites/forbescoachescouncil/2018/09/28/13-ways-managers-can-initiate-tough-conversations-with-employees/#196674672d9e

Hampbley, C. Managing Difficult Conversations with Practice Staff. Physicians Practice, February 9, 2017. https://www.physicianspractice.com/staff/managing-difficult-conversations-practice-staff

Ontario Medical Association.  Managing Your Medical Office Staff – An HR Guide for Physicians. Section C: Motivation and Retention. https://www.oma.org/wp-content/uploads/1_managingyourmedicalofficestaff.pdf

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76. Case: Supported Decision Making and the Rights of Persons with Disabilities

Supported Decision Making and the Rights of Persons with Disabilities

Freya Pedersen is a 23-year-old with a developmental disability.  The surgeon is discussing an upcoming surgery with Freya and her parents.  Freya tries to express herself, but it is hard to understand her speech.  The surgeon is in a rush and just hands the consent form to Freya’s mother for a signature.  You are the next member of the team to talk to Freya and have witnessed this interaction.

Discussion:

  • What are the ethics concerns raised here?
  • How do you start the conversation with Freya?
  • How might you prepare for the next appointment with Freya?

Resources:

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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.

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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.

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68. Case: Big Yellow Taxi

Following the bankruptcy of the local taxi service, a community hospital recognized that several of its frail, elderly patients who don’t drive had exceedingly limited options for getting to the hospital for their appointments. A few community volunteers were able to help out in the short term, but increasingly found that they were not necessarily able to keep up with the need or cover all of their gas and insurance costs on their own. Some hospital leaders argue that paying for these transportation costs may actually decrease overall costs for the organization, as this should lead to fewer emergencies and a greater involvement by these patients in maintaining their health. However, finding the money to cover the transportation costs and determining more concretely who will or will not qualify for this service will not be easy. Others argue that this isn’t a cost that the hospital should take on and that this is something that the community or the province needs to address.

What ethics issues do you identify in this case?

What values are involved in this case (e.g., equity, fairness, trust, good care…)?

How might this issue be different in a rural setting as compared to an urban setting? Is this a relevant factor to consider in determining what should be done?

Resources:

Asthana, S., A. Gibson, G. Moon, and P. Brigham. 2003. Allocating resources for health and social care: the significance of rurality. Health and Social Care in the Community. 11:6 486-493.

Danis M. 2008. The Ethics of allocating resources toward rural health and health care. In Klugman C, and Dalinis P eds. Ethical Issues in Rural Health Care Johns Hopkins University Press Baltimore Maryland 71-98.

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69. Case: On The Road Again

Judy and Richard live in a rural community where the closest hospital is a four hour drive away in good weather. Travelling to the hospital for specialist appointments often entails an overnight stay and additional time away from work for both Judy and Richard. In discussing the recent trips to the hospital with their family doctor, Judy indicates that she is not sure how much longer she can keep doing this and asks about options for care closer to their community. The family doctor is aware that this is an issue for several of her patients, and is advocating for a different approach to some forms of specialist care, such as making more use of telehealth and other technological options as well as the possibility of travel subsidies for some patients. Richard asks about whether arranging for some specialists to come to the community once a month might be another option…

What ethics issues do you identify in this case?

What are some of the different perspectives around issues of access to care that may impact whether and how we provide health care in a variety of urban, urban-rural, rural and remote settings?

What values are involved in this case (e.g., equity, fairness, trust, good care…)?

How should Canada, with its large rural and remote areas, address issues of access to care?

Resources:

Browne, A. Issues Affecting Access to Health Services in Northern, Rural and Remote Regions of Canada. http://www.unbc.ca/assets/northern_studies/northern/issues_affecting_access_to_health_services_in_northern.pdf

Laurent, S. 2002. Rural Canada: Access to health care. http://publications.gc.ca/Collection-R/LoPBdP/BP/prb0245-e.htm

Rural Health Services Review Committee. 2015. Rural health services review: final report. Edmonton: Government of Alberta. http://www.health.alberta.ca/documents/Rural-Health-Services-Review-2015.pdf

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70. Case: Desperado

A few of Gary’s friends cornered you at the curling rink last week. They are very concerned about how Gary is doing and wonder why “you and the other folks you work with” aren’t doing something more for him. “Can’t you see how he is going downhill? What’s it going to take for you to intervene?” They clearly feel that Gary shouldn’t be at home, but also admit that he has rebuffed their attempts to talk to him too. Gary has refused to have meals provided, yard work done, etc. What Gary says is that he is able to do it himself, it’s his life, and why doesn’t everyone just get off his back about it?

Gary is coming in for another check-up tomorrow…and you also know that his friends will corner you again next week at the rink

What’s going on in this case?

What do you see as the key (ethics) issues?

What options do you have to address this situation?

What would you do next? Why, and what values are you using to support this approach?

Resources:

Austin, W., V. Bergum, S. Nuttgens, and C. Peternelj-Taylor. 2006. A Re-visioning of boundaries in professional helping relationships: exploring other metaphors. Ethics & Behavior 16:2 77-94.

Kullnat, M. 2007. Boundaries. Journal of the American Medical Association. 297:4 343-344.

Moules, N., M MacLeod, L Thirsk, and N Hanlon, 2010. “And then you’ll see her in the grocery store”: The Working relationships of public health nurses and high-priority families in Northern Canadian communities. Journal of Pediatric Nursing 25: 327-334.

Pugh R. 2007. Dual Relationships: Personal and Professional Boundaries in Rural Social Work.  British Journal of Social Work 37: 1405-1423.

Pugh, R., B. Cheers. 2010. Rural Social Work: An International Perspective. Policy Press.

Schank J., Skovholt T. 2006. Ethical practice in small communities: Challenges and rewards for psychologists. Washington D.C.: American Psychological Association.

Townsend T. 2009. Ethics Conflicts in rural communities: privacy and confidentiality.  In W. Nelson ed. Handbook for rural Health Care Ethics: A Practical Guide for Professionals. Hanover, NH: Dartmouth College 126-141. https://geiselmed.dartmouth.edu/cfm/resources/ethics/

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71. Case: With A Little Help From My Friends

Kerry is a long-time volunteer with palliative care services in her community. With the distances and difficulty of travel that some palliative care patients may face, she is glad to be part of a team that works to support patients who want to die at home. While every effort is made to provide all patients with the same level of support as they need it, Kerry has noticed that some patients and families seem to get a bit more in terms of members of the team going the “extra mile” to ensure that a medication is delivered or staying longer at the home. Most troubling for Kerry is the fact that this seemed to happen for the biggest health care fundraiser in the community, while a relative newcomer to the community seemed to get less of this type of attention. Kerry isn’t sure about whether and how to raise this as an issue with the broader team.

What assumptions, questions, and/or examples come to mind in relation to this case?

What do you identify as the ethics issues in this case?

What would you say to Kerry if she asked you what she should do? Why, and what values are you using to support this approach?

Resources:

Castleden, H, V. Crooks, N. Schuurman, N. Hanlon. 2010. “It’s not necessarily the distance on the map …”: Using place as an analytic tool to elucidate geographic issues central to rural palliative care.” Health & Place 16 284-290.

Crooks V, H Castleden, N Hanlon, N Schuurman. 2011. ‘Heated political dynamics exist…’: Examining the politics of palliative care in rural British Columbia, Canada. Palliative Medicine 25(1): 26-35.

Pesut B, Bottorff, Robinson C. 2011. Be known, be available, be mutual; a qualitative ethical analysis of social values in rural palliative care. BMC Medical Ethics 12:19.

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72. Case: My Way

You are part of team preparing for an upcoming accreditation visit. In meeting the listed standards, there has been much discussion among the team about the expectations for smaller rural facilities in relation to these standards. When there are fewer resources (people, equipment, budget) for meeting some of the standards as compared to larger urban facilities, is this taken into account? Many on the team have argued that the focus should be on demonstrating that the spirit and intention of a given standard has been met, and may be done so through adaptive, innovative ways as well as the standard approaches. Recognizing that the standards are there to help ensure quality, good health care for all patients, there is still some concern about whether the standards were written primarily from an urban perspective and whether there will be some flexibility in their application in a rural setting…

What do you identify as the ethics issues in this case?

What values are involved in this case (e.g., equity, fairness, trust, good care…)? Do we all mean the same thing when we talk about, for example, “good care”?

What is your perspective on standards for health care and how these may apply (or not) across different practice settings?

What are some of the innovative and/or adaptive approaches that you are aware of that your health facility has undertaken?

Resources:

Niemara, D. 2008 Ethical Dimensions of the Quality of Rural Health Care.  In Klugman C, and Dalinis P eds. Ethical Issues in Rural Health Care Johns Hopkins University Press Baltimore Maryland 119-131.

Rural Health Services Review Committee. 2015. Rural health services review: final report. Edmonton: Government of Alberta. http://www.health.alberta.ca/documents/Rural-Health-Services-Review-2015.pdf

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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?