Mr. Smithwick is an 86-year-old patient who lives alone, and who was admitted to your hospital after a fall left him with a fractured hip. He has had multiple admissions to Emergency that were the result of mobility issues, and being able to safely move about in his three-storey home. He is well aware of the risks of living in his current residence, and is capable of making decisions involving his health care, including discharge. Although Mr. Smithwick no longer requires medical care from your hospital, the team feels uncomfortable discharging him home, and believes that he would benefit, and be at far less risk of falls in long-term care.

What are some of the ethical issues in this case?

Does the team have an obligation to protect Mr. Smithwick from (potentially) avoidable risk?

Does Mr. Smithwick, on the other hand, have a right to live at risk?

What safeguards are in place to ensure Mr. Smithwick is making an informed decision?

What mechanisms can be implemented to address the potential moral distress of staff?

Mrs. Potter is a 93-year-old resident of your long-term care home who once traveled the world as a culinary expert, sharing her love of food with many. She now has end-stage Alzheimer’s. In the last year it has worsened to the point that she is no longer capable of making her own medical decisions, and she has begun to experience difficulty swallowing solid foods. Three months ago a daughter of Mrs. Potter, her Power of Attorney, consented to have her mother be provided a pureed diet in order to reduce the risk of choking. At present time, however, this daughter believes that the pureed diet is affecting the quality of her mother’s life (even though Mrs. Potter has not expressed this herself). After being completely informed of the risks and benefits, she requests that her mother be given solid foods. The staff feel uncomfortable with the daughter’s request due to the real possibility that Mrs. Potter will choke on solid foods, and are unsure of what to do.

What are some of the ethical issues in this case?

Does a resident have the right to live at risk?

Does a substitute decision-maker (SDM) have the right to consent to their loved one living at risk? Does it matter if this is what their loved one would have wanted?

What mechanisms can be implemented to address the potential moral distress of staff?

Mrs. Green, a 75-year-old patient with renal failure, currently on dialysis, who also has COPD, moderate dementia, diabetes and a new diagnosis of stage one breast cancer. There is also a past history of depression according to the family. She has been admitted to your ICU after falling down her stairs at home and is in critical condition with multiple fractures to her hip, ribs, wrists and neck. Mrs. Green does not have the capacity to make her own medical decisions and has recently started to refuse eating. Upon discussion with GI Specialists, the team agrees that the patient is not an appropriate candidate for a PEG (feeding) tube. The patient’s daughter, who is her POA, insists that the you proceed with the placement of the PEG, stating that if the tube is not placed she will contact her lawyer and proceed with legal action against the physician and hospital. Because of this, the attending physician agrees, and orders the PEG to be placed.

What are some of the ethical issues in this case?

Do we know the patient’s wishes, or values?

Will the fact that the team feels the patient is not medically appropriate (considering risks, benefits, and likelihood of success) for a PEG tube be the deciding factor? That is, can the daughter demand the PEG tube and expect that the team provides it?

What mechanisms can be implemented to address the potential moral distress of staff?

The patient is a 27-year-old man who has severe schizophrenic illness and type-I diabetes. Before treatment in your secure treatment unit, he was treated successively in different settings with good success. He had been brought to your secure treatment unit after a near-fatal assault on a patient in another hospital. His stay has been characterised by periods of relative health alternating with periods of withdrawal and aggression, at which time he would become very depressed. During these periods, he talks about hearing “voices” which he claims were the reason he attacked others physically, including staff, in the past.

He also refuses to accept his insulin during periods of depression but agrees to his schizophrenia medication; this is appropriately managing the illness, despite the periods of withdrawal and aggression. The only treatment that helps him to recover to some degree from his depressive episodes is electroconvulsive therapy (ECT), even though he had once expressed his wish to not receive it when he was capable. Although he has been found incapable of consenting to treatment during depressive episodes, he refuses ECT each time it is presented, and he has to be forcibly restrained while his insulin is administered.

The staff find it distressing to have to forcibly restrain the patient so often, and to inject him with insulin against his will. They feel that restraining him compromises their caring relationship with him. Also, they feel uncomfortable in having to inject him with insulin, which he needs for his type-I diabetes, since he is adamantly refusing. Unfortunately, this is the only way to keep him from ketoacidosis until he recovers from his depression after a few weeks of ECT.

What are some of the ethical issues in this case?

Which of the treatments (if not all) should/should not be administered?

When capable, what did the patient refuse exactly? What did his refusal mean?

What documentation is available?

Do prior expressed capable wishes apply only to somatic disease or do they also apply to mental health conditions?

Does the patient have the right to refuse psychiatric intervention in prior expressed wishes from a mental health point of view? If so, what if he becomes violent?

Would this only apply to mental health patients with periods of stability? What if the patient became permanently incapable?

What mechanisms can be implemented to address the potential moral distress of staff?