101. Case: A Question from Family About Outcomes

You are caring for a patient following a severe stroke. The attending physician has been very clear with the family that it is unlikely that the patient will survive and that, if he does, it will be with very significant impairments. Still, the family takes any movement or facial change as an indication that he is improving. They are praying for his full recovery and today, at the end of your shift, the eldest child asks you when you think her father will be ready to go home.  How will you respond to the question?

---

Your family has strong faith convictions and a firm belief that “where there is breath, there is hope”.  Your father had a stroke unexpectedly and you found him slumped over when you came home from class.  You feel guilty because you stopped on the way home to get coffee with a friend.  The doctor said that your father’s “prognosis is poor”, but you’ve heard lots of stories about doctors being wrong. You also feel strongly that if you believe that your father will recover this will help to bring it about and that the converse is true, that if you allow yourself to think or talk about your father’s death it could cause it to happen.  So, you ask the doctor when they think your father will be able to come home. How would you respond if the physician says, “I don’t think your father will be able to go home…”?

---

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?
• What might be some of the undercurrents that influence the direction the conversation takes?
• What makes this a difficult conversation for each participant?
• Who else might be involved in having subsequent conversations with the family about care decisions?

References:

Barley, S. 2010. Having the difficult conversations about the end of life. The BMJ 2010; 341, published 16 September 2016 https://www.bmj.com/content/341/bmj.c4862

Lippe, M. 2018. Drawing the line between hope and false expectations. Blogpost, Reflections on Nursing Leadership. Published online 09/19/2018 https://www.reflectionsonnursingleadership.org/features/more-features/Drawing-the-line-between-hope-and-false-expectations

NSHA Library Services: Conversations about serious illness: https://library.nshealth.ca/SeriousIllness/GOC

Welsh, A. 2016. At end of life, doctors and families often differ in expectations. CBC news, published May 17, 2016. https://www.cbsnews.com/news/better-doctor-family-communication-needed-at-end-of-life-study/

Woelk, C.J. 2008. Management of Hope. Can Fam Physician; 2008 Sep. 54(9): 1243-1245 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2553443/

98. 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

62. CASE: Formula Feeding Resource Book

Andrew Godwin is a relatively new staff person working for Public Health. He is learning about the WHO Code of Marketing Breastmilk Substitutes and the importance of promoting breastfeeding as a norm in Nova Scotia, as part of the Healthy Eating Strategy.

He has received several phone calls from new parents asking him why the province’s formula feeding resource book is not online and requesting him to consider adding it to the electronic resources. What should Andrew do?

• Identify the values that are relevant to this discussion and select the ones that you think should guide Andrew’s response. 
• Would it be appropriate to post this booklet online? Why or why not?

Some Values and Ethics Issues to Consider

• Duty to provide care
• Honesty, trust and truth-telling
• Respect for autonomy
• Transparency
• Community/ public health ethics
• Compliance with policy
• Patient-centred care

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

35. CASE: Competing Interests?

A medical device had been developed by a physician who provides care at your local hospital. The department he works in wants to begin to use that device on a regular basis. A process to guide this action has been developed by the physician in question and his team. They would like the ethics committee to review the process to ensure fairness and discuss any ethics aspects of the possible adoption of a medical device developed by a practitioner.

• What ethics issues would you consider?
• Who else should be involved in this review?
• What other organizational policies could align with this issue and/or be consulted to inform the review process?

Some Values and Ethics Issues to Consider

• Conflict of interest
• Fairness
• Patient safety
• Transparency
• Resource allocation

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

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