Cases – Ethics In Practice

Care During Short Staffing

The Medicine program in your hospital has been struggling with high volumes of acutely ill patients, and short staffing due to sick calls and burnout. Normal “surge” protocols are no longer working and even the float pool is depleted. The headlines are describing a dire situation indeed, with patients and families reporting long waits for call bells to be answered, and patients left in pain and without help to get to the bathroom. After a straight week of being unable to fill all vacant nursing assistant shifts, and months of overtime, the staff on one unit ask for an ethics consultation, to help them identify priorities for care. This is a situation that might benefit from a meeting to identify the major ethical concerns and collaborate on interventions that could relieve some of the pressure on staff. You attend the unit just before morning shift report. Gathering as many people as possible, you convene a short unit meeting to identify the biggest...

Conflict resolution at the end of life and the role of the ethics consultant

Ms. Bearchild is a 64-year-old woman with end-stage renal disease and moderate dementia. She often experiences paranoia and agitation as a result of her progressing dementia. The team has involved behavioural consultants and attempted various environmental and staffing changes to reduce some the behavioural symptoms of her dementia, but still, she is often combative and screaming. Sedation is often used when other methods of calming Ms. Bearchild have failed. Ms. Bearchild’s two adult children are her substitute decision-makers. When she attends dialysis, Ms. Bearchild is either actively resisting or she is extremely sedated. She is not a candidate for kidney transplant. Due to her resistance and distress, the dialysis team sometimes needs to stop her dialysis runs before completion. She is experiencing significant fluid build-up. The SDMs want dialysis to continue and do not support a comfort care approach. They wish their mother to remain ‘full code.’ They express concern that the health care team is focusing too much attention on her...

Public Health Crisis

Your organization includes several pediatric and neonatal intensive care units, located in different hospitals. The facilities were built at different times in recent history and so have different layouts – some with open bays, some with multi-bed rooms, and some with private rooms. The province has been facing a public health outbreak where hundreds of people are testing positive for a little-known pathogen. While public health experts figure out what is going on, it has been determined that the number of people entering and leaving the facility should be absolutely minimized and that anyone entering the facility should fully dressed in PPE – which itself is in short supply. As a result, all NICU and pediatric units have been observing a strict policy of allowing only one parent at a time to be present. Staff, also in short supply, are spending time ensuring that parents coming onto the unit are donning and doffing PPE appropriately. The number of positive cases in the community...

Who Decides at the End-of-Life? Option 1

September 2, 2022September 2, 2022 by Admin Comment Closed

You explain that where no Power of Attorney has been assigned by the patient or a court, then decision-making authority falls to the next-of-kin. This would be a spouse, if there is one, then an adult child, then a parent. “He’s not actually married, so I guess it’s his mom then.” You remind Mr. Garcia that if Mr. Black regains his ability to communicate or otherwise has an improvement in his cognitive state, the care team should consider assessing his capacity. If it is at all possible, Mr. Black should be included in discussions about his care. After recording the details of the consultation, you return to your other duties. A couple of weeks later you are lunching with a social worker friend in the hospital cafeteria. She mentions that morale in the ICU is very poor. “A lot of the nurses feel that the ICU docs don’t listen to them,” she tells you. “We had a patient die last week who really...

Living at Risk

Marta is a 73 year-old woman, living in her own apartment. She has early-stage dementia with non-insulin-dependent diabetes (requiring oral medications), mild renal impairment, obesity, and moderate COPD due to previous smoking history. Her son, Ivan, came to visit after a 10-month absence and was shocked by the state of her apartment. He found a charred saucepan on her stove, garbage that had not been taken out for weeks, a foul-smelling cat litter box, and moulding food in the fridge. He took Marta in to her family doctor to express his concerns about her living situation. Her family doctor completed an assessment that revealed, among other things, that Marta has not been taking her medication reliably and that she has deficits in executive functioning. After determining that Marta lacks decision-making capacity in the areas of health care and accommodation, the family doctor activated Marta’s Personal Directive in these domains. In her Personal Directive, Marta has named Ivan as her Agent...

Should we enact a slow code for this neonate?

Malik was born at 32 weeks gestation after an otherwise unremarkable pregnancy to parents of Iranian descent who identify as Shia Muslim. Malik had Respiratory Distress Syndrome and required mechanical ventilation until day five, with nasal continuous positive airway pressure for an additional four days. After three weeks the team noticed he had a distended abdomen and his clinical status deteriorated to the point of reintubation. After an evaluation, the team discovered a malignancy involving his small bowel, liver, diaphragm, and abdominal wall. The pediatric oncologist was consulted by the NICU. She determined that the prognosis was very poor, and that infants diagnosed with this kind of aggressive malignancy usually lived only two months. She explained to the parents that there are no long-term survivors known in the literature, but that she’d reach out to an authority on this malignancy at another medical center who may know more. This authority confirmed the dismal prognosis and recommends against chemotherapy or other aggressive...

Who Decides at the End-of-Life?

Near the end of the workday, you get a call from a nurse in the ICU. He’s been asked to call by one of the ICU doctors. They have a patient who is probably terminal and the family don’t agree about withdrawing treatment. Who gets to decide? The nurse, Gabriel Garcia, seems rushed, but you take a moment to ask a couple of questions about the patient and note his Medical Record Number. Aaron Black is a 28-year-old male with a diagnosis of glioblastoma (an aggressive brain cancer). His condition has deteriorated suddenly. Mr. Black is in and out of consciousness. He cannot answer simple questions when he regains consciousness. “Are you in doubt about whether he has capacity to make his own decisions?” They are not. He clearly lacks capacity. “Is there a Power of Attorney?” “There’s nothing on paper. He’s so young—I don’t think they were expecting this.” Your hospital has a policy regarding decisions made for adults who lack decision-making capacity. It...

Harm Reduction in the Hospital – Option 2a

February 28, 2021February 28, 2021 by Admin Comment Closed

You ask Dora about her wishes regarding being treated in the hospital versus being discharged and attending appointments for her antibiotic treatment in a community health clinic near her house. She makes it clear that she would like to continue being treated in the hospital. The hospital is a safe environment and her needs are being attended to. Her caregivers are alarmed by the risks that she poses to them, but Dora is fairly happy in the hospital. Respecting her autonomous wishes would mean keeping Dora in the hospital. However, there is still the option of discharging her nonetheless since she is not fully adherent to treatment, and treating her is multiply risky (Hepatitis C positive; exposure to hidden needles; possible fentanyl exposure). Considering this option, her caregivers point out two things. First they point out that discharge contrary to Dora’s autonomous wishes would be bad for her. She would be unlikely to continue with her treatment. Second, they point out...

Harm Reduction in the Hospital

Dora is a patient in her thirties. She is an inpatient on a regular medical/surgical unit at the University hospital. Years ago, she was in a car accident and sustained a spinal-cord injury and she is now a paraplegic. As a result, Dora uses a wheelchair to get around. She is in the hospital for IV antibiotic treatment because of a blood infection the doctors suspect was caused by her opioid use. She began using after the car accident. Her antibiotic treatment is delivered via a PICC line (peripherally inserted central catheter). Normally, a patient requiring this treatment could receive antibiotics at home. But Dora will not let community health nurses into her house, and due to her IV drug use it is uncertain or unlikely that she will be present at home when she needs to receive her antibiotics. The care team has determined that being an inpatient at the hospital will make it more likely she will receive her...

Difficult Discharge

It is Thursday afternoon. You receive a call from one of the hospital Discharge Planners, Zahra. Zahra requests your assistance with decision making about a patient named Mr. Roberts. She provides you with a summary of what has happened since Mr. Roberts was admitted to the hospital six weeks ago. Zahra explains that Mr. Roberts is an 83 year old who police brought to the hospital six weeks ago. The police had received a call about an elderly man walking back and forth on the same street over the course of two hours during a snowstorm, without a winter coat or boots. The police told the Emergency Department staff that Mr. Roberts was unable to tell them his address, and that he appeared disoriented and confused. Mr. Roberts was admitted to hospital with a urinary tract infection (UTI), delirium, and ‘failure to thrive.’ Dr. Suleman identifies and contacts Mr. Roberts’ substitute decision makerDr. Suleman was Mr. Roberts’ physician on admission to the...