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
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22. CASE: Double Effect?

The following call comes in to the ethics line:

“Hi. It’s Celine from Oncology. We have a patient here who is in the end stages of lung cancer and is in a lot of pain. The patient and his family are strongly Catholic. The patient’s pain doesn’t seem to be well-controlled. But the family won’t authorize increasing his dose of hydromorphone because they are concerned, based on the physician’s description of possible side effects, that they will be artificially shortening his life. One of the family members accused the team of trying to euthanize the patient. This is causing the team a lot of stress. Can the ethics committee help us out with this?”

  • How will you respond to this request?
  • Who would you speak to in order to gather the necessary information?
  • What are the conflicting values in this situation?


Some Values and Ethics Issues to Consider

  • Spirituality/ religious beliefs
  • Capacity
  • Patient-family relationships
  • Respect for patient autonomy
  • Substitute decision-making
  • Moral distress among health care providers
  • Respect for professional integrity
  • Professional competence
  • Beneficence and non-maleficence
  • 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

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

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

9. CASE: Right to Treatment

A 54-year-old male patient has been treated for cancer for 2 years, but his illness has not responded to the major lines of treatment. He has been admitted to hospital with worsening nausea and vomiting, abdominal pain, and failure to thrive.

A CT scan showed progression of disease as evidenced by new ascites along with peritoneal and bone metastasis. He remains on dialysis, but otherwise the treatment plan is symptom management.

His physicians have held several conversations with the patient and his family (wife and children) regarding his “code status.” The patient and his wife want him to be a “full code,” but the physicians feel it is not in his best interests given his terminal illness; they feel it will actually be harmful to him. ICU physicians were consulted and agree.

The patient and his family are Muslim and believe that everything needs to be done to prolong his life, otherwise they will “displease their God”. The patient’s wife is under considerable pressure from her husband’s brother to ensure everything is done to save him.

The patient is currently a full code and “stably ill”, but the physicians and nurses are worried about what will happen in the event he suffers a cardiac and/or respiratory arrest.

  • What are the competing values in this case?
  • How might you respond to this request?
  • What additional information could be shared between the patient/family and health care team to help resolve this issue?
  • What role does the patient’s faith play in this case?

Some Values and Ethics Issues to Consider

  • Respect for autonomy
  • Patient-family relationships
  • Spirituality and religious beliefs
  • Substitute decision-makers
  • Respect for professional integrity
  • Capacity
  • Pluralism and diversity
  • Beneficence and non-maleficence
  • End of life decision-making

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

2. CASE: Treatment and/or Termination? Tough Choices

Melanie is a 21 year old who was recently involuntarily committed after she started a serious fight at a local shelter, thinking that one of the leaders was trying to steal her favourite T-shirt. Melanie has schizophrenia and is well-known to both the police and mental health care providers. She has been living on and off the streets since she left home when she was 16 years old, and has a rather strained relationship with her parents. They have been trying to support her and often provide money for her medications. When Melanie is taking her medications, she is able to find work and has talked about going back to school. However, Melanie finds the side effects of the medications awful and stops taking them, leading to being kicked out of apartments or friends’ places when she gets too aggressive.

In doing Melanie’s work-up upon admission, it was discovered that she is about 7-8 weeks pregnant. While trying to determine what to do with respect to the pregnancy, she is placed on medications that minimize teratogenic effects for the fetus, and that may have some success in stabilizing Melanie’s condition (although it is recognized that this is not the “gold standard” treatment). Melanie’s mother, Krystine, was named by Melanie as her substitute decision-maker (witnessed by her psychiatrist at the end of her previous admission), despite some of the challenges in their relationship, and she endeavours to do the best for her daughter. The team has been in discussion with Krystine about treating Melanie and about her pregnancy.

Melanie has indicated that she doesn’t know who the father is, as she has had several partners over the last few months. She also alternates between saying that she wants the baby to saying that the baby is cursed and she should be rid of it. Krystine indicates that Melanie has not talked to them about having children, only about trying to get well to go back to school.

Both Krystine and the health care team have some questions and concerns about how to move forward with Melanie’s treatment. The health care team calls for a clinical ethics consultation.

  • If the medication regime doesn’t stabilize Melanie, would it be ethical to move to a different treatment plan, knowing that this might cause substantial harm to the fetus?
  • Should the possibility of terminating the pregnancy be discussed further?
  • Should an attempt be made to find and notify the biological father?
  • How do the dynamics if Melanie’s family relationships factor into this case?
  • Can or should someone other than Melanie make these decisions?

Some Values and Ethics Issues to Consider

  • Capacity
  • Respect for patient autonomy
  • Living at risk
  • Vulnerability
  • Patient-family relationships
  • Substitute decision-makers
  • Beneficence and non-maleficence

1. CASE: Sensitive Information

John is a young man with a traumatic spinal cord injury that has resulted in paraplegia. He is leaving the rehab hospital on a weekend pass and has confided to his chaplain that he intends to kill himself. The chaplain calls the ethics service for assistance.

  • Should the hospital issue the pass?
  • What are the ethics issues involved?
  • What information do you need to find out to move forward?
  • Who would you invite to a discussion about this issue?

Some Values and Ethics Issues to Consider 

  • Respect for autonomy
  • Beneficence
  • Non-maleficence
  • Duty to provide care
  • Living at risk
  • Moral distress
  • Compliance with policy
  • Respect for privacy and confidentiality