The Problem
Identify the people, departments, & organizations involved in this problem.
Brice (patient), Patricia (brice’s sister), Alfie (Nurse),ER department, Dr. Shelly (ER physician), Social Work, Brice’s current employer,Provincial Health Care Regulation (Mental Health Act)
Describe the relationship between Alfie and Dr. Shelly in this context
The power imbalance between Alfie and Dr. Shelly, making it difficult for Alfie to speak up and challenge the physician’s decision.
Autonomy
Brice’s autonomy and rights would be taken away from him if form 4.1 states that he is at risk to injure himself or others.
Mental Health Act
Involuntary admission must be based on accurate assessment findings.
OPTION #1: Alfie is unsure about his initial assessment and therefore reluctantly agrees to sign the section 2 of form 4.1. Brice is admitted into the psychiatric unit to complete his detox and have further assessment done. Alfie is not sure this was the best call but he knows that the psych unit is great with dealing with patients who have SUDs and are withdrawing.
Strengths and Limitations
Strengths:Does not get into an argument with Dr.Shelly, Brice will still get good care in the Psych unit, which Frees up a bed in the Emergency department
Limitations:
Ilegal
Ignoring Brice’s autonomy
Brice feels his concerns were not heard and can decrease his trust with the hospital system.
Creates another barrier to Brice accessing health care in the future because he now is a part of the mental health act
Creates more stigma towards Brice as he now is seen as a mental health patient.
What is Brice's perspective on his situation?
He is seeking help voluntarily to safely withdrawal from fentanyl as well as prevent relapse. He states his desire to continue working at his new job. He is experiencing healthcare barriers due to stigma, both racial and due to his SUD.
Describe Brice's social context
Hx of homelessness, depression, suicide, as well as his substance use that creates more stigma and issues with accessing health care.
Brice is a visible minority and although was born in Canada he was raised by parents who immigrated here and therefore may have different cultural practices that can create bias.
Brice is living with his sister Patricia, and got a new job which he enjoys.
Justice
Addressing systemic bias and discrimination due to stigma against substance use therefore not treating everyone equitably. Brice is voluntarily seeking help and the Dr. wants to treat him as a psych case and not as a withdrawal patient.
Ethical Code of Practice
Doctors not following his ethical code of practice and could face legal ramifications.
Option #2: Alfie refuses to sign the section 2 form 4.1 until another assessment is done by Dr.Shelly.. Dr.Shelly does not change his findings, Alfie knows that's wrong so Alfie reports Dr. Shelly to ethical services.
Strengths and Limitations
Strengths/Benefits
- Alfie advocates for patient autonomy
- prevents misuse of the Mental health act.
-Upholds Alfies legal and professional accountability
Limitations/Harms
- Weakens relationship with Alfie and Dr. Shelly and cause a conflict.
- Dr. Shelly might retaliate
- Uncomfortable work environment
- Reporting to ethical services may take a long time.
What is Alfie's perspective on the situation?
He assessed Brice, and his findings are consistent with the pt experiencing fentanyl withdrawal. He also determines that Brice does not pose a danger to himself or others. He is concerned about the ethical and legal implications of signing Form 4.1 when they are not consistent with his own assessment, and is worried that Dr. Shelly is not making decisions based on Brice and his experiences, but based on Dr. Shelly's own internal bias.
Environment
Environment is within the emergency room which is already a high stress area. Brice is a young man, and therefore may not appear as acutely unwell or sick as someone who just had a major MI, for example.
Non-Maleficence & Beneficence
Providing safe care for this patient and connecting him to resources within the health care setting so that he can return to his life safely.
Hospital Policies
Document with integrity, no biases, advocating for patients
OPTION #3: Alfie is unsure how to proceed as his assessment is not consistent with Dr.Shelly’s. He lets the doctor know that he believes that a third opinion should be consulted before he agrees to sign the form. Alfie contacts Addictions Medicine Services as well as the psychiatrist on call for a consultation.
Strengths and Limitations
Strengths/Benefits
Advocates for Brice so that he is being seen by another person before further steps are taken.
Upholds the trust between pt/nurse
Reduces stigma that the patient is being labeled
Consistent with the values of both nursing and medical ethics to do no harm
Limitations/Harms
Delays the diagnosis and Brice being treated specifically for his substance use withdrawal (methadone may not be ordered right away)
What is Dr. Shelly's perspective on the situation?
He displays bias against Brice, viewing him as a “frequent flyer” and assuming Brice is there for drug-seeking behaviours. He has documented inaccurate information, potentially leading to an inappropriate involuntary admission.
What other hospital resources are available to Brice?
Social work - to connect Brice with resources within the hospital and the community so that he has supports outside of the hospital once he has detoxed, and therefore avoid relapse.
Addictions medicine consultation- to help Brice to detox safely and look into possibility of methadone treatment.
Substance Use Support Outreach - to help once Brice is out of the hospital.
Integrity
Alfie must uphold ethical standards and not falsify medical documentation.
Legal and Professional accountability
Signing an inaccurate Form 4.1 could lead to legal consequences.
OPTION #3
Summarize the ethical problem
Brice is experiencing fentanyl withdrawal and seeks medical help (with support from his sister, Patricia) to prevent relapse. Dr. Shelly appears to hold a bias against patients with substance use disorders as seen when calling Brice a “frequent flyer” and being dismissive towards Brice, only spending a few minutes assessing him. When Dr.Shelly filled out form 4.1 inthe mental health act Alfie notices that Dr.Shelly’s documentation is not aligning with his own findings. (stating he is experiencing a manic psychotic episode rather than being in active withdrawal.)
Are there any additional contexts to consider?
Brice is a visible minority and although was born in Canada he was raised by parents who immigrated here and therefore may have different cultural practices that can create bias.
Fidelity
Alfie wants to maintain fidelity by maintaining accuracy while documenting. Dr.Shelly breaks fidelity by failing to provide honest and accurate care seen by falsely documenting Brice as having a manic episode and in danger to others, which is not consistent with alfie's assessment.
What is an example of an assessment tool used when someone is going through opioid withdrawal?
COWS: Clinical Opiate Withdrawal Scale
Why do you think this is the best option?
We chose this option because it involves more people in making the decision for how to proceed with Brice’s care. It is a more just approach because therefore it is not one person’s opinion against anothers. As well, this advocates more for the patient by looping in addictions medicine services as they will also have great resources for Brice once he leaves the care of the hospital. We believe this will help create more of a trusting and caring relationship between Brice and the entire care team (as well as his sister) so that Brice can have greater success in not relapsing and having a safe life once he has safely withdrawn from fentanyl.