Category: Cases

The staff are eager to focus on how decisions are being made with patients and families, and whether or not the existence and meaning of the do not attempt resuscitation (DNAR) orders are discussed in establishing goals of care.   The concern is that goals of care discussions are not being had, or that they’re being established when patients are being transferred from continuing care because they’re in some degree of respiratory crisis. There is also concern that due to time pressures providers participating in goals of care discussions are not exploring DNAR orders in depth. Some team members say that it’s difficult to raise DNAR orders in goals of care conversations because some patients and many family members feel that the presence of the DNAR order means that they won’t get the same treatment as a patient without an order and so are then more prone to request that “everything” be done. One strategy that you identify in the course of the...

In gathering information from stakeholders, it is clear that many feel that it is possible to address the concerns about potential “strings” attached to the donation without refusing the donation outright, which will enable the organization to better achieve its goal of providing care that the community has identified as necessary.   Transparency can help the organization acknowledge both the conditions that accompany the donation and the reasons why the organization chose to accept the donation.  In developing recommendations aligned with this position, you draw on arguments that claim integrity can be maintained in this situation, and that disclosure might in fact strengthen relationships of trust.  Furthermore, the individuals favouring this option claim that the organization’s primary obligation is to provide care, and that any loss of trust or reputation that cannot be mitigated as described above will be offset by the ability to better meet the needs of the community....

You and the other consultants signal to each other that you’re uncomfortable with the manager leading the discussion, but aren’t sure how to break in.  The tone that’s been established thus far seems adversarial, and you can see that Daniel is getting frustrated. You try to break in with a question of clarification, but the manager continues to denigrate the treatment approach that Daniel is proposing.  The manager says that the team at this point just wants to “wash their hands” of the case and says that Daniel can do what he wants but h shouldn’t expect them to participate in pseudoscientific nonsense. With that, Daniel stands up, says, “fine!” and leaves the room.  You suggest that the meeting be adjourned for now, and reconvened is possible at a later point in time....

Because you and the rest of the consultant team focused on Daniel’s perspective initially, the team feels that the ethics consultants have sided with Daniel.  Many members of the team physically move their chairs away from the table and refuse to participate. You address the response by describing what you see and reiterating that the purpose of the discussion is to get all the perspectives into dialogue with each other.  You emphasize that there will be opportunity for the health care team to share their thoughts, but some members of the team remain disengaged for the remainder of the meeting. You eventually hear through various channels that the team felt that the consult was a “waste of time” and that they aren’t planning to engage ethics support again any time soon....

In preparing for the consult, it strikes the consultant team that concerns about the appropriate use of limited resources are generating much of the distress the health care team is experiencing, but most are unwilling to name it directly.  In doing some background research around strategies for managing ICU resources, you come across some articles mentioning exclusion criteria as one way of responding to the desire to use health care resources effectively. You mention these to the team during the consult, but they seem uncomfortable with the prospect of considering having to triage patients.  You acknowledge the role that resource allocation plays in health care practice and the fact that allocation decisions are always value-laden, but also that it’s more appropriate that allocation decisions be made so as to avoid bedside allocation and that it’s something that the organization’s quality team might need to address....

There are a number of system and organizational issues that seem to be contributing to the moral distress in this case when you look to determine the root causes of the distress that health care providers are experiencing.  These include questions of where certain types of care should be provided; could noninvasive ventilation be offered outside the ICU, for example, and is there a way to collaborate with the local continuing care organizations to reduce these admissions?  Are there hospital processes that could be shifted to make more effective use of available resources such as ICU beds? Most of these patients are coming in through the Emergency Department; are there processes there that are affecting these outcomes? You recognize that these systemic issues need to be dealt with, and report during the consult that you will be forwarding some recommendations about addressing the underlying systemic issues to senior leadership through the reporting process. You describe the systemic and organizational issues...

In terms of the range of challenges raised by this case, you feel that team functioning is one of the areas where the discussion in the consult might result in change, but are not sure what role the consult team would play in facilitating the discussion and so are reluctant to make that the focus of the consult.  You want to avoid being caught in the middle or feeling forced to “choose sides” regarding how people are dealing with their moral distress. You, therefore, mention at the outset of the consult that it can be an opportunity for the team to do some problem-solving in terms of how they’re responding to the distress they’re experiencing collectively and individually.  You report that you have sensed some concerns about fairness->justice regarding the distribution of the burdens of moral distress as you were doing intake. ...

Reflecting on the discussions you’ve had, you feel that the concerns about motivation relate to organizational integrity. You summarize the concern as being about the oil company purchasing a share in the goodwill that the health care organization has generated in the community and that it is not the purpose of the organization to confer goodwill to others.  In short, the organization has “sold out”. For those who raise these concerns, the short-term gain in terms of being better able to provide care does not offset the potential far-reaching and long-lasting damage to the organization’s reputation and to the relationships between the community and the organization. In working through these questions, the fact that integrity comes, in this case, with a very real price tag is raised in the discussion.  There is discussion about stewardship, and whether refusing the donation is in keeping with responsible management of resources. The recommendations shared with the board outline the reasons for maintaining integrity, based on the...

You decide that this situation is one in which the relevant parallel is a situation of increased risk, such as an outbreak of an infectious disease or a natural disaster, and therefore decide to use the all hazards plan as the starting point for your discussion with the working group. The discussion focuses on how to align limited human resources with the needs of clients, and the policy emphasizes how to triage patients....