99. Case: Talking About an Adverse Event

You are a respiratory therapist working in a large hospital seeing a range of patients, but primarily working with the teams in the Emergency Department and ICU.  With one complex patient in ICU there was a miscommunication that resulted in improper settings being used for ventilation and this resulted in the patient having a longer-than-expected ICU stay.  You feel responsible for this and as part of the adverse event disclosure process you are going to talk to the family about it.  How will you prepare for the conversation?


Your loved one, who has dementia and COPD, is in ICU and you know that there was a mistake with their ventilator because you overheard some of the nurses talking about it.  You feel that the ICU environment is making your loved one’s dementia worse, and you’re angry that someone’s carelessness has resulted in harm to your loved one.  The nurses let you know that the respiratory therapist wants to talk to you about the incident.  You’re willing to have the conversation, but you’re tired from looking after your loved one and frustrated by your whole experience in the hospital.  What is most on your mind when you go into this conversation?


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?
  • Why is it important to have this conversation from each person’s perspective?
  • Which values and principles are reflected in the commitment to ensuring that the conversation happens?
  • What can be done to help ensure that this is a “good” difficult conversation?

References:

Alberta Health Services. Disclosure Done Well – Early Disclosure: Unsure If Care Is Reasonable. Published March 16, 2018. https://www.youtube.com/watch?v=i2uEHmElX5M

Bonney, W. (2014). Medical errors: moral and ethical considerations. Journal of Hospital Administration. 3(2): 80-88. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=2ahUKEwjjwa2Z7PzgAhUV854KHa5sCPkQFjABegQIBBAC&url=http%3A%2F%2Fwww.sciedu.ca%2Fjournal%2Findex.php%2Fjha%2Farticle%2Fdownload%2F3475%2F2226&usg=AOvVaw2VCJ0K19IQYyW329XHm_C_

Brené Brown on Blame: https://www.youtube.com/watch?v=RZWf2_2L2v8

Canadian Patient Safety Institute. (2011). Canadian Disclosure Guidelines: being open with patients and families. CPSI. https://www.patientsafetyinstitute.ca/en/toolsResources/disclosure/Documents/CPSI%20Canadian%20Disclosure%20Guidelines.pdf

Canadian Medical Protective Association. Disclosure – Maintaining Trust. https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/adverse_events/Disclosure/disclosure-e.html

Canadian Medical Protective Association. Disclosing Harm from Health Care Delivery. Version 3, 2017. https://www.cmpa-acpm.ca/static-assets/pdf/advice-and-publications/handbooks/com_15_disclosure_handbook-e.pdf

Nova Scotia Health Authorities. 2017. Disclosure of Patient Safety Incidents. Patients First. http://www.nshealth.ca/sites/nshealth.ca/files/patientinformation/1448.pdf

Advertisements

85. Case: Adam’s Story

Adam Snowdon, a 16 year-old Sydney boy, was diagnosed with ALS (Amyotrophic Lateral Sclerosis) 18 months ago.  The disease has progressed rapidly over the past three months and over this period Adam has quickly begun losing the ability to use his right arm to the point now where it is no longer effectively functional.  He is also beginning to have difficulty standing and walking and is showing early signs of respiratory, swallowing and speech problems.  His doctors speculate that Adam will die within a year and that in the months prior to that he will likely become “locked in” and unable to communicate at all.

Adam has always been a rambunctious boy.  He has had numerous behavioral issues throughout his childhood, proving to be quite a handful for his parents.  He has run away from home several times, has been suspended various times and expelled from two schools. Adam has also been detained by the police on four occasions for possession of alcohol and marijuana.

Adam is currently living at home in Sydney with his mother Nancy Snowdon and older brother David who just turned 17.  Nancy works part time as a school librarian.  She has full-time custody of her two sons.  Nancy has been suffering from clinical depression for several months now.  She has been under emotional strain since Adam became ill.  She is currently taking antidepressant medication and is receiving counseling from a chartered psychologist.  Through this treatment appears to be helping Nancy, she is still struggling to cope.  On a few occasions she has missed appointments with Adam’s doctor, simply feeling unable to face the situation on her “bad days”.  On those occasions Adam missed his appointments altogether as he shows no initiative in attending his medical appointments on his own.

Adam’s health care providers have not been able to establish a trusting relationship with him.  They find it generally difficult to engage him in conversation, and he is especially uncomfortable discussing the ALS.  He refuses to discuss the details of how his disease will progress or his preferences regarding options such as ventilators etc.  He has, however, stated emphatically that he has no intention of allowing them to “put him in the hospital do die”.

Adam’s father, Ted Snowdon, is an engineer in Alberta.  He and Nancy divorced relatively amicably when Adam and David were nine and ten respectively.  Mr. Snowdon has not played much of a role in the lives of both of his sons after the divorce but he visits every summer and they all go camping.  He has remarried to Clarice Snowdon who has shown little interest in the boys.  Since Adam’s diagnosis, Mr. Snowdon has been flying out to Sydney regularly to be involved with decisions around organizing care for Adam. Mr. Snowdon feels strongly that decisions about Adam’s future care need to be made immediately.

Dr. Kerrigan is Adam’s family physician.  She is concerned that Adam’s condition is getting worse very rapidly and is anxious about the decisions that will have to be made about Adam’s care.  In particular, Dr. Kerrigan is worried about the relationships within the family.  She knows that Mr. Snowdon feels strongly that his son should be hospitalized and eventually ventilated.  He has stated that Adam is “too young” to know what he wants and is worried that Nancy is not able to handle keeping Adam at home, even with home care support.  Dr. Kerrigan is concerned that Mr. Snowdon will dominate the decision-making process at the critical time and that Adam’s and his mother’s wishes may be overridden or altogether neglected.  Beyond her concerns about the family dynamics, she is uncertain as to Adam’s decision-making capacity – and Mrs. Snowdon’s for that matter – and is also unclear on the more basic question of who ought to be making decisions about Adam’s care.

Since Adam became ill he has been seeing a neurologist at the local hospital, Dr. Watson, and Dr. Kerrigan are in touch frequently regarding Adam’s care and have discussed Dr. Kerrigan’s concerns around the family dynamics and the decision making that will need to occur in providing end of life care for Adam.  Dr. Watson has requested a consult from the hospital ethics committee.  Mr. Snowdon and his wife have flown in from Calgary just for this meeting.  Adam was asked to participate in the meeting but he flatly refused, saying he wanted to spend time with some of his friends instead.

Participants’ Roles:

Ethics consultant #1 (facilitator)

Ethics consultant #2 (ethics facilitator)

Ethics consultant #3 (recorder)


Nancy Snowdon (Adam’s mother):  Very concerned about her son’s welfare.  Feeling overwhelmed, isn’t sure what to do.

Mr. Ted Snowdon (Adam’s father):  Skeptical of Adam’s decision making capacity and can’t understand why Adam is acting the way he is.

David Snowdon (Adam’s 17 year old brother):  David is scared, angry with both parents, worried about Adam, and worried about his own life. Most of all, he wants peace for Adam.

Dr. Watson (neurologist):  wary of the complex relational issues at stake, as well as the challenges of making decisions for young ALS patients like Adam.  Wants to make decisions as soon as possible before Adam is no longer able to express his own views.  Feels in over his/her head, wants the committee to get this sorted out as much as possible.  Dr. Watson has been developing an interest in bioethics and is considering becoming a member of the ethics committee.

Dr. Kerrigan (family physician):  Concerned about the toll this is taking on Nancy, Adam and David.  Worried that Mr. Snowdon is driving discussions around care.

Jamie Lee (patient services coordinator):  Has been taking a bioethics course and is eager to apply her/his newly developed skills.

65. Case: Conflict in an Ethics Consultation

The next three cases are from our Advanced Clinical Consultation Workshop facilitated by Paul Hutchinson, Imagined Spaces. These cases were submitted to us from Paul.

I find it is often team conflict that can lead to an ethics consult and this will find its way into the consultation space. This can present in a couple of ways:

  • Staff will become quiet and hesitant to speak and it can become difficult to deal with the real issues.

OR

  • Conversation will become heated and emotion laden.

One case I remember was in dealing with a young mom whose child had been hospitalized since birth. Part of the reason for this long hospitalization was due to an error in care. This was a very young mom with two other children.  She had very few community or family resources and so proper housing and resources for care of her children were issues.

Staff had very differing views of this mom and her care of her child as well as her behaviors in hospital (she would sometimes stay out late at night with friends and on return could be quite noisy). Some staff felt she avoided caring for her child and was leaving all the responsibility to staff. There was clearly a divisiveness with some staff feeling she was simply not a good mom and would never be able to care for her child and in some cases disempowered her by taking over care. Other staff felt this mom was doing the best she could given her age, education, and socioeconomic status and were very protective of her. Staff were being directed to document and be vigilant re anything that might bring doubt on her ability as a parent and perhaps have her children taken from her.

It was a very difficult situation, and it was ongoing when the consult occurred. It was clear values were being challenged and staff felt very strongly. Many staff felt that were being bullied and pressured by other professions and each other and this was a difficult consult to facilitate.

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

33. CASE: Ethical Advertising?

A hospital has placed billboards throughout the region with the following statement:  “Are You a Victim of Sexual or Domestic Assault?  Come to Warman Center Where We Will Treat You Immediately. Our Staff of Counsellors and Providers Have Received Special Sensitivity Training in This Area. You Are Our Main Concern.”

A twenty-five-year-old college student presents to the Warman Center’s emergency department stating, “My boyfriend assaulted and raped me and I need help.”  The registration clerk notices that there are fresh bruises and bleeding on her face, neck, and arms.  The student fills out registration information and is asked to sit in the waiting room.

Several hours pass. The young woman approaches the registration clerk and states, “I am really scared.  I have pain. I am terribly upset about what has happened to me, and I just can’t sit here any longer.”

The registration clerk responds, “Haven’t you seen all the ambulances come in?  We have patients with critical injuries like pneumothorax here.  You will have to wait your turn.”

Three and a half hours later, when a nurse calls out the student’s name to be seen, she is no longer in the waiting room.

(Case adapted from: Ann E. Mills, Edward M. Spencer, and Patricia H. Werhane (eds), Developing Organization Ethics in Healthcare: A Case-Based Approach to Policy, Practice, and Compliance, Maryland: University Publishing Group, 2001, p. 55)

  • What do you see as the organizational ethics issues?
  • How should these issues be addressed?
  • What values should be considered in this discussion?


Some Values and Ethics Issues to Consider

  • Accountability
  • Duty to provide care
  • Honesty, trust and truth-telling
  • Compliance with policy
  • Priority-setting

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

31. CASE: Stakeholders’ Role in Decision-Making

This case concerns parental involvement in decision-making related to maintaining a residential facility for adolescent patients. Due to a lack of sustainable funding, in consultation with the operations team, the facility board has made a decision to close the facility. The requestor indicated that the parents of the adolescent residents were concerned because they felt that they were not being respected within the decision-making process, i.e., their status did not feel equal to that of the health care professionals involved in the process.

The parents felt that they had not had adequate opportunity to express their concerns or to contribute their perspectives. They expressed concern over their current level of involvement in terms of:

  • Its contrast to their previous high level of involvement when the facility was being established
  • It not being in keeping with the organization’s commitment to transparency and accountability.

They described a secondary concern which had to do with the organization not honouring verbal promises related to the permanence of the residential facility that were made to the parents by hospital representatives when the facility was established.

  • Are there ethics concerns here?
  • How would you handle this request?

Some Values and Ethics Issues to Consider

  • Accountability
  • Resource allocation
  • Transparency
  • Compliance with policy
  • Duty to provide care
  • Organizational ethics

30. CASE: Awards – Who Gets Them and Why?

This case involves an organizational concern about inconsistency in the approach to applying for, being nominated for, and receiving awards.  Specifically, the requestor identified that there wasn’t a process or policy in place to objectively review each application and there were inconsistencies in the process for selecting those to receive individual awards.

Overall, the motivation for identifying these issues for consideration from an organizational ethics perspective was a genuine concern about maintaining the integrity of the awards and recognitions that are bestowed by the hospital. There is a strong desire to help ensure that suitable persons and teams are given appropriate awards and recognition now and in the future. Further, a clear commitment to the stewardship of these awards (especially for the ones that have a financial component) is connected with the need for exploring these issues.

  • How would your committee work respond to this request?
  • Upon which values could such a policy be based?
  • What process would you use to assist the policy-makers with this request?


Some Values and Ethics Issues to Consider

  • Compliance with policy
  • Fairness
  • Accountability
  • Resource allocation
  • Transparency
  • Organizational ethics