ETHICS ISSUES
RESPONSE by Rabbi Harold Stern
For the Director of Admissions there is no issue. Mr. P has been on the list for more than three years. "His wife made me promise he would get the next available private room and it's his turn. Fair is fair, he deserves it. What's the point of keeping a list if you don't follow it?" But other staff point out that Mrs. P died two years ago, that Mr. P's dementia is now so advanced that he could not possibly benefit from the single room while he might suffer from losing the CNAs who know him and who he, possibly, recognizes.
For the Director of Social Work the case is equally clear. Ms. O is an extremely private women who is suffering terribly from having to share a room with others. She is becoming depressed and tearful. Even though she has only been here a few months, her need is greatest. "Our mission is to serve the needs of our residents. Ms. O should get the room."
The Administrator is willing to accept whatever the team decides. But it wouldn't make me at all unhappy if the damned N family finally got their mother a private room and stopped calling me." At this point the Medical Director leaves. "Call me when you decide."
The Director of Nurses points out that if we only moved Ms. M to the room, her three current roommates and the staff on her floor would have a party. "She's up all night demanding things, she keeps everyone else up, and OBRA says we can't medicate her to shut her up. With our lousy call bell system we can't tell which resident in the room is ringing until we go to the room and check them all. A private room would allow us a serious behavioral management plan for her, would benefit three residents and meet the needs of the staff. Don't the staff needs matter at all here?"
The Director of Pastoral Care also has a suggestion. "Mrs. K is dying of breast cancer. She's only 63 and her children are all visiting constantly and her husband, who is overwhelmed, is practically living here. She has issues to resolve with her God and with her family and good-byes to say. I know we have offered them the chance to meet privately in a lounge, but she is in too much pain when she tries to transfer and when we give her enough pain medicine to handle sitting up it makes her drowsy. Our call is not just to serve our residents but to serve mankind. Don't her spiritual needs and the needs of her family count?"
At this point the Director of Development makes another suggestion. "The L family is very rich. They want Mama L to have a private room. They have already bought a van for the home which we use to take residents on trips. They are discussing the possibility of redecorating all the resident lounges. While I'm not suggesting that the rich are more deserving, didn't John Stuart Mill say the right choice is that which provides the greatest good to the greatest number? Surely that would mean Mrs. L."
The Administrator suggests that the Ethics Committee could resolve the issue. "I just want to do what's right and just."
This is a common problem in the long-term care setting. The planning of future facilities would do well to consider creating a predominance of single room units, assuming that most residents would trade more capacious accommodations of double rooms in exchange for privacy. Some residents may still opt for double rooms to avoid loneliness or, to facilitate summoning necessary assistance.
There are competing and compelling reasons for each of the dramati personae mentioned to receive priority consideration for the currently available private room. As the Director has agreed to abide by the decision of the facility’s ethics committee, let us, as the committee, identify the ethical issues raised. In general, the issues raised can be viewed through many ethical lenses. I see a common ledger of the principle of utilitarianism derived from John Stuart Mills and John Bentham. The ethical dilemma derives from the conflict of principles. The Director of Admissions raises the issue of veracity- “fair is fair,” and truthfully represents what s/he promised the resident’s wife at the time. “Rule” utilitarianism mandates not breaking promises. A countervailing value is that of non-malfecience raised by other staff—will moving the resident from the familiar surroundings and personnel be true to her best welfare. Would the well intentioned “upgrade” cause a double effect that would not be in his best interest at this point in time. Perhaps the Director of Admissions’ promise to his wife did not consider Mr. P.’s current mental status. If there are children we should discuss the risk benefit ratio with them in terms of his current level of functioning and his ability to adjust to the change. Moving a dementia resident will cause harm. We are guided by the principle of primum non nocere! First, do no harm!
As for Ms. O., embarrassed at having to share a room, we might suggest that she receive therapy to look at the overriding issue of depression. Isolating her in a private room, while avoiding her embarrassment, might not be in her best interest. The Administrator’s concern—damage control—while pragmatic, does not obviate the facility’s obligation to meet the real and psychodynamic issues raised by her family. As for Ms. M., the demanding resident, one wonders if true justice and taking the needs of staff would be served by “passing the buck” to other staff members who would bear the brunt of her demands, unless an interdisciplinary team looks at the cause of her discontent and decides upon an equitable course of action.
Mrs. L., whose family’s largesse can serve the “ greater good”—espouse the utilitarianism of Jeremy Bentham and John Stuart Mill—achieving happiness for the greater number justifies the means of achieving it. On the flip side of the coin, is happiness the only value in life? What about other values like health and morality? As for Mrs. K., who is dying of cancer, the chaplain raises the question of whether the definition of beneficence extends to spiritual health and welfare as well. While we may be moved by his empassioned plea, the young woman actively dying and suffering from the ravages of pervasive breast cancer, surrounded by her family, can we judge that her needs and those of her family are greater than those of other residents whose capacity may not be as intact as Mrs. K.’s? Are capacity and quality of life the sole criteria for determining distribution of scarce resources?
The issue of distribution of scarce resources and autonomy appear to be paramount as we look at the parental role the ethics committee is asked to assume. Ethics discussion as this one involve competing and equally compelling values. In the current case, we would need more information to make an informed decision that would best serve the needs of the residents involved. Are there any advanced directive documentation such as a living will to guide our decision making process, or, alternatively, can we satisfy the criteria of “ clear and convincing” at this level of need? The same root cause analysis should be conducted to determine the most informed decision for the committee with as much input from the patient, family or friends as possible to truly best meet the patient’s needs, not necessarily those of the staff or the family, respectively. Under the circumstances, the best ethically driven plan would be to allow the breast cancer patient to utilize the room for time with her family, the “greatest good” that does no harm to the resident. What are your thoughts on this situation from an ethical and pragmatic perspective? Please write us at NYCLTCEN and we will publish your responses in the next issue.
Ethics Issues published in the Spring 2000 edition of the Ethics Network News, 6(2).
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Director of Spiritual Care
Daughters of Jacob Health Services
Shady Groves SNF, like many older homes, was built with two and four bedded rooms plus a small number of private rooms. Last night Mrs. Q died quietly in her sleep after living the final 11 of her 98 years in her own room at Shady Groves. Staff is now assembled to decide who will be transferred to this scarce resource.
Article available on-line at: https://www.angelfire.com/on/NYCLTCethicsnetwork/My2000ethicsissues.html
Date posted: 5/5/00
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