capacity – Ethics In Practice

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...

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...

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

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...

Now and Then

Mr. Hendricks is a 58 year old with early-onset dementia that has progressed rapidly in the last three years. He is living in a continuing care facility with a nephew, Frank, as his substitute decision maker. Mr. Hendricks has an advance directive, written twenty years ago, which specifies that if he were to develop dementia he wishes to refuse any interventions aimed at cure, including antibiotics for pneumonia, and states that he would find a life with moderate or advanced dementia not worth living. Cold and flu season is coming up, and staff at the continuing care home are wondering what their responsibility is if Mr. Hendricks develops pneumonia as well as whether Mr. Hendricks should receive the annual flu shot. Their concern is amplified because, contrary to Mr. Hendricks’ expectations, he seems to find considerable pleasure in his life with worsening moderate dementia. Frank, Mr. Hendricks’ nephew, lives two provinces away and says that while they had a loving relationship, he...