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.

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.

64. CASE: Implementing an Anti-Obesity Strategy

The local health district is in the final stages of adopting a comprehensive organizational anti-obesity policy. Its development was led by a working group of diverse stakeholders from across the district and included an extensive consultation process.

One aspect of the policy that generated a lot of discussion and debate at the working group was the suggestion that messaging should be designed to increase stigma and social pressure around obesity.  This strategy was defended recently in a leading bioethics journal and has been implemented in other jurisdictions.  Ultimately the group was convinced to include this suggestion in the policy because of the success that such messages had in decreasing smoking rates.

Prior to ratifying the new policy, senior leadership requested that the district medical advisory committee review it.  One of these reviewers is clearly upset by the policy; he sent feedback in very personal terms implying that increasing stigma and social pressure around obesity made the policy unreasonable and unethical.

• What values are relevant to the policy issues under consideration?
• Why would the reviewer deem the policy to be unethical?
• What are the conflicting values among the reviewer and the policy makers?
• Is there other information you would like to have before responding to the reviewer?
• How will you (the working committee) respond to the reviewer and why?

Some Values and Ethics Issues to Consider

• Empathy
• Respect for autonomy
• Respect for dignity
• Community health ethics
• Living at risk
• Organizational ethics
• Compliance with policy
• Social justice
• Social determinants of health
• Responsibility for health

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

54. CASE: Professional Role

While doing a weekday home visit to an elderly patient, a VON nurse in a small community finds the patient’s son at home. The patient has mentioned that her son teaches at the local elementary school, but he has never been present during any of the nurse’s previous visits to the house.

On a weekday visit he appears to be drinking heavily and the patient seems uncomfortable and ill at ease.  During the next few weeks the son is there on several more occasions and appears to be either drunk or “hungover”. The nurse is also a member of the town’s school board.

• What is this health professional’s responsibility to her patient? To her patient’s son?
• What should her immediate concerns be?
• What is her responsibility as a member of the school board?
• How should she proceed in this situation?
• Can/should this individual segregate her role as a nurse with her role as a school board member?
• Should she mention what she knows about the son/teacher to her colleagues at the school board?
• How are the ethics issues at hand affected by the rural setting?

Some Values and Ethics Issues to Consider

• Professional boundaries
• Duty to provide a safe work environment
• Living at risk
• Duty to accommodate
• Duty to provide care
• Community and family relationships
• Respect for human dignity
• Respect for professional integrity
• Compliance with policies and procedures
• Respect for privacy and confidentiality
• Overlapping roles and responsibilities
• Patient safety

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

52. CASE: Community Values

A patient in your rural community that you have treated for COPD for several years missed her last two appointments. When you speak with her after church, she indicated her husband lost his job as a logger and no longer has family health insurance to cover the cost of the treatments. She refuses to accept charity but does indicate she will be willing to clean your home and office as “payment” for your healthcare services.

• Should a healthcare professional accept bartering as payment?
• What ethics issues should be considered here?
• How are these ethics issues affected by the rural context?
• Should the health of the patient take precedence over compliance with your organizational policy and/or your professional code of conduct?
• What other creative solutions are there that will allow the patient to receive the treatments?

 

Some Values and Ethics Issues to Consider

• Social justice
• Professional boundaries
• Duty to provide care
• Community and family relationships
• Respect for human dignity
• Respect for professional integrity
• Compliance with policies and procedures
• Respect for privacy and confidentiality
• Overlapping roles and responsibilities
• Patient-provider relationships
• 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

47. CASE: Collegial Responsibilities

You are a pediatric critical care specialist working in the ICU taking care of a newborn infant who suffered a severe, prolonged reduction in blood flow to his brain at the time of birth. The consulting neurologist has indicated that the infant’s prognosis for functional neurological recovery is very poor in the unlikely event that he survives the next few days.  You and the neurologist have spoken at length with the parents about the grim prognosis. They have decided that withdrawal of intensive care modalities and the initiation of optimal palliative care are consistent with their values. They have requested a day to hold their baby and to allow extended family to come and be with them prior to stopping the mechanical ventilation.
You have now gone home after handing the case over to a physician colleague who is on call for the unit that night, explaining that the family will notify staff when they are ready to withdraw life support.

You receive an agitated call from the ICU charge nurse at 2 am, as the family has requested life support to be discontinued but she is refusing to write an order for this, saying that she knows nothing about it. The parents are very distressed about this turn of events.

[Modified version of a case authored by Alixe Howlett]

• What are the boundary issues, if any, in this case?         
  
• Are there issues with communication between team members?
• How should this be addressed?         
• How should you deal with this situation when receiving the call at 2 am?         
• Who should be involved in deciding next steps?
  

Some Values and Ethics Issues to Consider

• Compliance with policies and procedures
• Respect for professional integrity
• Patient-provider relationships
• Trust
• Respect for patient autonomy
• Respect for dignity
• Patient-family relationships
• End of life decision-making
• Patient-centered care
• Professional boundaries

44. CASE: Whose Business Is It?

Brent Wathorn, 78, has been living at Halfway Lake Manor for about 6 years. His main complaint has been that he is lonely and has had difficulty connecting with the other residents. This has been a source of distress for staff at times, as they would like him to feel more ‘at home.’

Norma Carkner, 75, moved to the Manor about a month ago. She has limited cognitive abilities as the result of a stroke, but is still able to express herself reasonably well and make some choices if given enough time.

Staff members have noticed that Brent and Norma have been spending much time together and have found them kissing on occasion. While there is no evidence of a sexual relationship beyond this, some of the staff is quite concerned about the possibility.

Given his loneliness, they wonder if Brent may be putting pressure on Norma. Other staff point out how happy both Brent and Norma seem together. Much of the discussion has focused on whether and to what extent they should intervene or say something to family members.

• What values/assumptions might be at play here for staff members?
• What ethics concerns are you considering in this scenario?
• Should the staff discourage this relationship?
• Should the staff notify Brent and/or Norma’s family about the relationship?

Some Values and Ethics Issues to Consider

• Honesty, trust and truth-telling
• Compliance with policies and procedures
• Respect for privacy and confidentiality
• Respect for patient autonomy
• Respect for dignity
• Quality of life