77. Case: Accommodating Requests: Which Differences Make a Difference?

 

Michelle Yoder is 8 months pregnant and a member of the Amish community.  She requests that only female health care providers and staff be involved in providing her care during labour and delivery.

Michelle Federov is 8 months pregnant.  She requests that only white health care providers and staff be involved in providing her care during labour and delivery.

 

Discussion:

  • What are the ethical concerns raised by these cases?
  • How are your responses different to these two scenarios?
  • How do you think health care organizations should respond to requests like these?

Resources:

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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

19. CASE: Craig’s Right to Choose?

Craig Renaldo is a 14-year old boy who was recently diagnosed with a right lower leg malignant vascular tumour. Staging investigations have been negative for distant metastases. Craig’s attending medical oncologist, Dr. Purvis, consults a pediatric orthopedic surgeon, Dr. Mendes, who recommends a below-knee amputation. Dr. Purvis concurs with this recommendation given the aggressive nature of the tumour and the lack of other effective treatments – chemotherapy and radiotherapy have had poor response rates in relevant clinical trials. Dr. Purvis estimates that Craig has a seventy percent chance of survival with the surgery and a twenty percent chance without it.

Craig grew up in the Jehovah’s Witness (JW) faith and has been very active in the JW youth community. For the last two years, he and his younger sister Stacy have been living with their maternal aunt and uncle due to the tragic death of their parents in a motor vehicle accident. Uncle Bob and Aunt Kay are strong adherents to their JW faith. Craig and Stacey have a twenty-year old sister, Jane, who is a college student. She left the JW faith community after the death of her parents.

Craig and his aunt and uncle participate in an informed consent process for the proposed surgery including a lengthy sit-down discussion with Dr. Purvis and Dr. Mendes and some other members of the health care team. At the end of this dialogue, Craig and his aunt and uncle, in full agreement, emphatically state that they will not consent to blood transfusion during the surgery due to their religious beliefs. Dr. Mendes indicates that he is unwilling to operate on Craig without such consent given the vascular nature of the tumour and the high likelihood that whole blood transfusions will be required.

The surgical resident contacts Jane who has not been permitted to see or speak to her siblings for the past two years due to her JW fellowship. She expresses concern for the welfare of her brother and is alarmed by the refusal of consent for blood transfusion. Jane strongly believes that blood should be transfused if it is absolutely necessary during the surgery.

The unit manager contacts Legal Services and the health district’s legal counsel, in turn, contacts the Children’s Aid Society (CAS). The CAS supervisor indicates an interest in being involved in health care decision-making in these circumstances. A formal clinical ethics consultation is arranged.

  • What are your ‘gut’ responses to this scenario?
  • What ethics principles and values are at play?
  • Who should make this decision?
  • If the decision is a substituted one, how should such a decision be made?

 

Some Values and Ethics Issues to Consider

  • Substitute decision-making
  • Capacity
  • Spirituality and religious beliefs
  • Patient-family relationships
  • Respect for professional integrity
  • Respect for patient autonomy
  • Compliance with policy

10. CASE: At a Crossroads…

Sandra Livingstone, age 45, was admitted to the hospital with diffuse ischemic encephalopathy – a very significant, global brain injury – secondary to sustaining a massive stroke at home. It is now ten months after her admission. Ms. Livingstone is on an acute internal medicine unit where she has been living since her discharge from the intensive care unit.

She is unable to communicate with others and appears to be in profound distress, spending much of her time screaming and obstructing the attempts of nurses to care for her. She is unable to eat and drink due to neurological damage to her swallowing mechanism. She has just managed to remove her J-tube for the fourth time despite being in arm restraints and having her hands padded on a twenty-four hour basis. Trials of various medications to target her intense agitation have been unsuccessful.

The consultant neurologist, Dr. Bailey, recently reassessed Ms. Livingstone. In his opinion, her neurological status is now stable and the prognosis for further neurological recovery is extremely low. He comments that “this is the way she will always be”.

Ms. Livingstone had not made a personal/ advance directive prior to her stroke. Her statutory decision-maker is her father, Mr. Livingstone, a person of strong religious faith. He believes that his daughter is “still in there” and that she will eventually recover sufficiently to allow him to take her home. He refuses to discuss the possibility of withdrawing life-sustaining treatment, i.e., her J-tube.

The clinical unit’s social worker, Mr. Roberts, has been exploring alternative residency options for Ms. Livingston. Given her current health status and long term, significant care requirements, Ms. Livingstone cannot be formally classified for placement in a continuing care facility. Her local rural hospital has declined to accept her for care through a transfer from the tertiary care centre.

A health lawyer from Legal Services and a clinical ethics consultant are asked to participate in a health care team conference to explore potential ways forward.

  • What issues should be discussed at this meeting?
  • Which of these issues are ethics issues?
  • What decisions need to be made?
  • How should the decision-making be prioritized?
  • What resource allocation and policy issues in this case have ethical implications?

Some Values and Ethics Issues to Consider

  • Substitute decision-makers
  • Capacity
  • Compliance with policy
  • Spirituality/ religious beliefs
  • Patient-family relationships
  • Respect for human dignity
  • Quality of life
  • Resource allocation

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