89. Case: Who Has a Right to Know?

Kevin is a14-year-old admitted to hospital with persistent headache, muscle spasms, tremors, significant motor impairment, fever, cough and symptoms of liver damage.

A diagnosis of lipoid pneumonia has been made and his clinicians are very suspicious that he has been inhaling nitrite compounds. Eventually they are able to confirm this when one of the team talks with friends who are leaving after a visit with Kevin.

When the physician confronts Kevin with this information, Kevin pleads with him to not tell his parents. His parents have been regular visitors and appear to be very concerned about their son’s condition. They have repeatedly asked the doctors to explain what is happening.

Several follow-up discussions with Kevin have not changed his mind; he does not want his parents to know anything about his drug abuse history. “You are my doctor aren’t you? That means what I tell you is just between you and me, doesn’t it?”

The physicians and rest of the team are unsure how to answer him. They do not know whether they should respect Kevin’s wishes in this regard.

At the suggestion of the team, the charge nurse has requested an ethics consultation. How will you prepare for this consult? What are the key ethics issues?

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84. Case: Who’s Who

 

Pierre is a representative with a company that manufactures devices for use in joint-replacement surgeries.  He is often present in surgeries when his company’s products are being used.  Recently, as a patient was being wheeled into the operating suite the patient asked the surgeon who Pierre was and why he was there.  The nurse explained that Pierre was a with a device manufacturer and was there to provide support if needed.  The patient then asked, “But isn’t that a conflict of interest?”

Is there a conflict of interest?  How should the nurse respond to the patient?  And what should the hospital include in a policy designed to address these types of situations?

 


Resources:

 

83. Case: Strings Attached

 

A local business owner and philanthropist, whose parent recently died after living with Huntington disease for 15 years, approaches the hospital foundation to offer a significant donation in exchange for creating a new neurological research centre which would be named in memory of the philanthropist’s parent.  The hospital has identified its area of greatest need as improving access to primary care for patients in the remote communities it serves, but the donor is not interested in contributing to that mandate.

Is the hospital in a conflict of interest?  What is the nature of the potential conflict of interest?

 


Resources:

82. Case: Setting Up Shop

 

Arya is an occupational therapist who provides support for children with autism spectrum disorder.  She frequently recommends sensory integration tools to parents, but most of these are only available online through US-based websites and often that is a barrier for parents.  She is considering starting a side business importing and selling these products, but is aware that there will likely be a perceived conflict of interest.  Arya approaches her manager for guidance.

If disclosure is not enough to eliminate the perception of conflict of interest, what could Arya do?  If the perceived conflict of interest cannot be effectively managed, what should Arya do to meet her patients’ needs?

 


Resources:

81. Case: Lending A Helping Hand

 

Alison is a nurse who is working in an endocrine clinic part-time while also working on her Ph.D.  She is studying two different approaches to patient education about diabetes management.  She is putting together her research ethics application.  Alison makes a case for the logistical necessity of her being involved in recruiting patients. Her colleague and friend, Jason, will also help to recruit patients for the study.  Alison proposes that she will disclose that the research is for her Ph.D and that the patient’s decision about participation will not affect care, but Alison and Jason aren’t sure about what Jason should tell patients about their relationship.

Do you think that Jason has a conflict of interest?  If so, how should it be managed?  And does Alison’s disclosure adequately address concerns about her conflict of interest?

 


Resources:

80. Case: Less Talk

 

David is a patient waiting in a treatment room at a walk-in clinic.  He can hear the physician chatting and laughing with someone outside, and from the conversation he guesses that the physician is talking with a pharmaceutical sales representative.  David has been waiting for almost two hours with a high fever.  As the conversation outside continues, David becomes increasingly angry.

Do you think that the physician might have a conflict of interest?  If so, how should it be managed?

 


Resources:

79. Case: It’s the Little Things

 

A patient asks your colleague, Arya, “Where are you from?”  When Arya replies, “Winnipeg,” the patient says, “Oh, but where are you from originally?”  Arya, whose family immigrated to Canada before she was born, is clearly frustrated by this.  You were present during the exchange and were uncomfortable but didn’t know what to say at the time.

Discussion:

  • What are the ethical concerns raised by this case?
  • What might you say to Arya afterward?
  • How might your employer support Arya in addressing these sort of situations?

 

 Resources:

 

 

78. Case: Health Care for New Canadians

 

Ahmed arrived recently in Canada as a refugee from Syria.  He was diagnosed in the refugee clinic with prostate cancer and has arrived for a follow-up visit.  The interpreter has called in sick and Ahmed speaks very little English.  Ahmed’s 13-year-old son, Bashir, has accompanied him and is acting as a translator for his father.  The health care team at the clinic would like to make some decisions today about treatment approaches, but Bashir seems uncomfortable with translating both questions and responses.

 

Discussion:

  • What are the ethical concerns raised by this case?
  • As a member of the health care team, how would you proceed?
  • What types of refugee health resources might be developed to support patients, families, and health care teams?

 

Resources:

60. CASE: Health Care Providers Under Quarantine

My story starts in early April, during a routine day shift in our minor care area. A previously well middle-aged man, recently returned from Hong Kong, presented with fever. Because SARS was already recognized and we’d gone through the recent experience of a crash intubation with our first case at Vancouver General, this patient was isolated at the triage area and we gowned and masked to examine him. Apart from a temperature of 37.8°C, his vital signs were normal and he looked well. He had no other symptoms, and his physical examination, CBC, urinalysis, and chest x-ray were all normal. Although the patient did not fulfill the case definition of SARS then in existence, I kept him in isolation just in case. When I went in to give him discharge instructions, I did not wear a mask and stood just inside the doorway, about two meters from him. Almost predictably, he returned with the full SARS syndrome just over 24 hours later. And wouldn’t you know it, by then, the case definition of SARS had changed!

I briefly wondered if I could pretend I was not in his room unmasked, but the thought of potentially disseminating a lethal virus persuaded me to do my civic duty and tell my boss. Two hours later Public Health phoned to inform me I was officially quarantined. Needless to say, my husband, also a physician, was incredulous and my kids were terrified. I thought it was kind of funny for the first day, like someone was playing a bad joke. Then the reality began to hit home, and I can tell you the reality was difficult to live with. This is what Public Health told me.

  • I must stay inside my house (preferably within my bedroom) 24 hours a day
  • I must not touch anyone in my family
  • I must wear an N95 mask if anyone is in the same room as me
  • I must not prepare uncooked food for my family
  • I must not sleep with my husband
  • I must use a separate bathroom
  • I must not touch anything in the house that the kids might later touch
  • I must not use the family computer or the main phone
  • I cannot have outside visitors
  • I cannot shop for groceries
  • I cannot go for a walk

The quarantine requirements were not voluntary, but were enforced by Public Health, who contacted me daily to gauge my cooperation. If I did not comply, it was clear that I would be legally compelled to do so. All this took place under the shadow of potentially transmitting SARS to my family, the people I love more than anything in the world. My nine days of quarantine were a blur of extreme boredom, some highly emotional episodes, and a re-evaluation of what I do for a living. One of our daughters moved out for the duration. Another celebrated her 16th birthday without a hug, cake or present from her housebound mother. And my son told me daily how much he wanted a snuggle. I felt guilty that my colleagues, all of whom are already overworked, had to pick up extra shifts to cover me during my enforced absence. As if all this were not enough, it slowly dawned on me that I wasn’t earning any income, and would have to put in extra shifts after my quarantine was over. I decided I never wanted to see another N95 mask again…

What did I learn from my experience? First, it is very isolating and lonely to be isolated. I hugely appreciated the calls and emails I received from my colleagues while I was off. It helped enormously to know they were thinking of me, and didn’t think this was my fault. Second, I think all emergency physicians should consider the financial implications of a sudden enforced quarantine. None of us have disability insurance that would commence quickly enough. To be under quarantine is difficult enough without the added burden of a financial penalty. Although I suffered an occupational exposure, I was not covered by Workers’ Compensation. I believe we need to negotiate with our hospitals and governments to put financial packages in place. Many hospitals are starting to compensate self-employed health care workers for income missed during quarantine. I would go further and suggest a per diem rate for days confined due to occupational exposures. Although no one can compensate me enough for nine lost days of my life, a token payment certainly wouldn’t hurt. Finally, as emergency physicians we do a far more difficult and noble job than I had ever realized. The consequences of what we do to care for our patients and protect the public are risks that put ourselves and our families in potential danger. This is something we never think about or acknowledge, but maybe we should. And maybe we should celebrate ourselves more than we do. I have huge admiration for my emergency medicine colleagues who had far worse exposures than I did in the early phase of the SARS crisis.

  • What values are involved here and for whom?
  • What ethical considerations have to be balanced in such quarantine situations? How is the most appropriate balance achieved?
  • How would you respond to this physician’s concerns? Do you feel there is any legitimacy to her complaints?

Some Values and Ethics Issues to Consider

  • Duty to provide a safe work environment
  • Duty to provide care
  • Respect for individual liberty
  • Community/ public health ethics
  • Consent
  • Disclosure of adverse events
  • Health care provider relationships
  • Risk
  • Patient safety
  • Compliance with policy
  • Disclosure of adverse events
  • Non-maleficence
  • Privacy and confidentiality

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