Barrier in the system

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This topic contains 4 replies, has 4 voices, and was last updated by  kelsiemaloney 1 year ago.

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  • #222

    UserIDSW2016
    Participant

    You are a social work student working on an Interprofessional team:

    This case involves an older man who has Alzheimer’s Disease, does not speak English, and was suspected of being violently assaulted. It was assumed that this assault might have resulted in a traumatic brain injury causing him to be “behavioural” (shouting, hitting the door, throwing items) and dysphasic. The patient’s family has been very supportive, purchasing a new home that they hoped would be accessible for their father. It was too much for the family to have him at home and despite the long waitlist to relocate to a senior’s facilities, they were not able take him home due to his behavioural tendencies. Nor would a group home take him because of his age. These circumstances have forced this man to return to the hospital where he is locked behind a half door (a door that unlocks from the outside and covers the bottom half of the opening with wood and the upper half with glass) for the majority of the day and cannot communicate with anyone due to language barriers and loss of speech.
    It is observable that the patient becomes more behavioural when he has been stuck behind his door for long periods of time. There has been discussion around medicating this man in order to move him to a senior’s facility; however, some members of the team feel medicating the patient is unethical, whether or not it improves his quality of life. They refer to this as “snowing” the patient. Ultimately it is the family’s decision; however, the idea of medicating the patient is conflicting with members of the teams personal values. In addition to the decision needing to be made around medication, the patient is stuck in his room until something more suitable is available that meets the needs of a behavioural older man living with Alzheimer’s Disease and a traumatic brain injury.

    As a social worker, how do you approach this situation?
    Are this man’s rights being violated?
    Is there a barrier in the system for people in situations like this? How might you handle this if you think there is?
    How do you cope with a situation that conflicts with your personal values?
    What different perceptions of quality of life might there be that would influence a decision in this case?
    What issues of power are relevant in this situation?
    Would the codes of ethics be helpful in resolving this scenario? If so, how? If not, why not?
    How would you go about resolving this issue?

    #223

    sr861062
    Participant

    As I read this case study, I became evidently upset – I cannot fathom how this man feels. Thank you for sharing this case study.

    As a social worker, how do you approach this situation?
    There are many directions one could possibly take to approach this situation. I think, above all else, as a social worker, I would want this man to feel safe, respected, and cared for – even if that just means going to his door to smile and say hello. If the man cannot speak English, or if he is nonverbal, I would try to find a way to communicate with him, through an interpreter perhaps – institutions like hospitals have a tendency to dehumanize patients, and in order to undo said dehumanization, I believe it is crucial to maintain communication with people to show that they are valued. Also, I am curious about the family’s involvement with this person’s care plan – have they visited him at the hospital? Additionally, there is an apparent gap in community resources pertaining to this population, and it is something that I would work hard to address and advocate for – with an increasingly aging population, Nova Scotia needs to prioritize the needs of elderly people and their families. As for how the patient is being treated in this hospital, I may refer him to the patients’ rights advocate if he feels as though his rights are being violated.

    Are this man’s rights being violated?
    As a student also doing their placement in a hospital setting, this is a difficult question to answer. While I can understand the reasoning behind placing someone in a more secure environment temporarily because they are a danger to themselves or other people, I also believe this should be a last resort. While the patient’s behavioural problems may cause him to act in a volatile manner at times, a hospital is not a jail, and therefore, to lock a person in a room for extended periods of time seems unethical to me; I cannot blame him for becoming upset and acting out after being locked in his room for hours on end. What is being done in between periods of being locked up? Does he have contact with co-patients, hospital staff, and/or visitors? Also, is it necessary that he is placed in such a room permanently?

    Is there a barrier in the system for people in situations like this? How might you handle this if you think there is?
    There does seem to be a barrier in the system for people like the person described above. An avenue that I may explore in this situation may be adult protection, especially if a history of assault/violence is suspected.

    How do you cope with a situation that conflicts with your personal values?
    When I encounter a situation that conflicts with my personal values, I talk about it with my supervisor and do a lot of ongoing introspection (journaling helps) in order to better understand why I feel that way, while also attempting to understand why the person on the other side of the equation feels the way they do. Ultimately, it’s not about me – it’s about the person I am trying to support and it’s important to respect that in order to achieve an egalitarian practice framework. Otherwise, I am exercising my “power” over that person by assuming the way I think and do things is the “right” way and that I know what’s “best” for them.

    What different perceptions of quality of life might there be that would influence a decision in this case?
    From the above description, some of the members of this patient’s care team believe that medicating him is unethical, regardless of whether doing so improves his quality of life or not. Medicating people can often be a divisive conversation; some people believe that quality of life can be improved by medication, while others are adamant that quality of life is hindered by it. If someone belongs to the anti-medicating camp, then what is being considered as an alternative to this route? Being unmedicated and locked in a room for extended periods of time doesn’t exemplify a quality of life to me. On the other hand, overmedicating someone can have equally damaging effects – living in a drug-induced haze can also inhibit the quality of a person’s life.

    What issues of power are relevant in this situation?
    Many issues of power are evident in this situation. It seems as though the patient’s power has been virtually stripped from them, while other people have the right to make important decisions regarding his life. His doctors have the power to determine what type of care he receives in hospital, the types of medications he receives (if any), the room he lives in, his diagnosis. The patient’s family has the power to make treatment decisions on his behalf because he has been deemed incompetent to make such decisions himself; they also have the power to choose whether to communicate with him or not. The community supports (such as group homes and seniors homes) have the power to prevent this person from accessing their services.

    Would the codes of ethics be helpful in resolving this scenario? If so, how? If not, why not?
    The code of ethics may be a helpful guide in resolving this scenario. Regarding value 1 (respecting the inherent worth and dignity of persons), the social worker in this scenario must address the lack of respect for this individual’s dignity and worth if they detect unethical treatment on behalf of the team. Additionally, value 2 (pursuit of social justice) would be helpful in guiding the social worker to advocate for equitable access to resources in order to meet the basic needs of the patient. Value 4 (integrity in professional practice) exemplifies how important it is for social workers to remain ethically accountable; in this case, it is the duty of the social worker to address any ethical dilemmas and work to rectify unethical practices.

    #229

    WayneRyanDalSLWK
    Participant

    As a social worker, how do you approach this situation?

    This seems like a difficult situation that has no clear answer or approach. As a social worker, I would first want to make sure the client was at least safe and happy where they are. I would also want to make sure that they do not regress other than perhaps naturally from their illness. Of course to do this I would need to find a way for this person to be able to communicate, if possible. This person is already disadvantaged enough and not being able to communicate can be incredibly dis-empowering and frustrating. I am assuming here but part of his behavior may be due to his inability to communicate and not be heard and this may be his way to voice his frustration. If we are able to establish a way to communicate for them to have some meaningful social interaction so they are not stuck in their room all day. It may be possible to work with them on some behavioral management too. But that may be difficult depending on the severity of their Alzheimers.

    Are this man’s rights being violated?

    I am not so sure their rights are being violated here. It isn’t like a group home isn’t taking him because of strictly their Alzheimers and behavioral issues. A lot of group homes or senior facilities are only equipped or trained to work with so much and they may not be able to care for the client as needed. If anything taking him may be more harmful than the hospital where he sits all day. However, the group home saying they won’t take him because of his age seems wrong as I have worked with many older adults in such settings. Still not convinced they would be denying him his rights in this case. Especially since many, but definitely not all, group homes are privately operated. He is also receiving some care in his current setting so I do not think he is being oppressed in some way. However, I am concerned they are considering just medicating him in hopes it takes care of him until he can be moved elsewhere. It would make me question if this was even safe for him and also make me wonder if he is getting the level of care he should be.

    Is there a barrier in the system for people in situations like this? How might you handle this if you think there is?

    There certainly is a barrier for disabled people in the system. There is a serious lack of resources for people living with a disability in our society. The waitlists are never ending and take years for a place to open up for someone. Sometimes what is open isn’t what meets the need for the client but it is the best option for them at the moment until the ideal placement opens up. Because of this I have to realize I just can’t go into this case and expect to solve all the problems for this client. I would make sure that anywhere the client would go is a good fit, even if not ideal, where their needs can be met and they do not regress in some way. Ideally I would want their well being to improve.

    How do you cope with a situation that conflicts with your personal values?

    At the end of the day I have to know I did all that I could do within my capacity as a social worker within whatever organization I am working for. That includes using my own values in my work. If I did and I feel as though more could be done to help the client then it isn’t me that is the issue. It is the system. The system may need to change but I also have to keep in mind that I just can’t change the whole system overnight. You can bit by bit over time. Also it is easy to criticize the staff at the hospital for his care but they also may not have the resources they need to work with the client. Contrary to popular belief hospitals don’t always have the resources they need. They do a good job at working with what they do have.
    I think I also have to keep in mind though that not everyone shares the same values as myself though. So just because I may not agree with situation doesn’t mean everyone else will too. It is quite possible the client may not agree with them too. So I cannot let my values ignore other people’s values too.

    What different perceptions of quality of life might there be that would influence a decision in this case?

    I think my reaction to this case was influenced by my own idea of what a good quality of life is. Although I doubt it, perhaps this is the best quality of life this person can get. I think there quality of life can be better and perhaps that may mean getting this person access to a placement that is better for him. The hospital staff may see what their quality of life can be and this may have resulted in the client’s current situation. I think the staff and myself are client focused so they want what is best for the client and I think that would mean a decision in the case that leads to the best outcome for the client.

    What issues of power are relevant in this situation?

    I think the power issue here is that the man is disabled and unable to communicate. He is a huge disadvantage because he is unable to have a say in his care. So it is other people that are making decisions for him. Even if his family, who may be an alternative decision maker, may want what is best for him it doesn’t mean it is what the client wants. Yet the client is unable to communicate that. So anyone involved in the clients care has the ability to make decisions about his care while he doesn’t.

    Would the codes of ethics be helpful in resolving this scenario? If so, how? If not, why not?

    I think the respect for dignity is important here. I think it would help because it would help to ensure that the client is getting the care they need and their rights are respected. It may help the client in this situation but it might not as well. I think it depends on the resources the clients needs to fulfill their needs and whether or not they are available. If they are available then I think people would make sure that the client does get the care they need.
    How would you go about resolving this issue?

    This is a really complex issue that doesn’t have a clear answer. I think it would be too easy for me to just say here is exactly what I would do. I do not know enough about the client and their situation to really say what I would do. Ideally, I would make sure that there is a way for someone to communicate with the client. I would also want them to have more meaningful interaction with people. Ideally there would be some behavior management too if possible. If a placement came up elsewhere that could meet his needs then I would try to facilitate a transfer there but this may not be a possibility.

    #230

    UserIDSW2016
    Participant

    Hi there,

    I appreciate the reply and comments/questions!

    I am going to try my best to answer your questions:

    In terms of communication, the staff are very considerate and try their best to communicate with the patient. Our recreational therapists and therapeutic assistance work very closely with the him. They make an effort to interact with him in and outside of his room as appropriate. They also try and make the time in his room more enjoyable by putting on movies and providing music. And the entire staff treats him respectfully and talks to him when they walk by his room. His family visits on a regular basis and are extremely supportive, but it is hard for them because they have hope for their Dad to return to who he was prior to the brain injury and Alzheimer’s Disease.

    As you mentioned, a patients’ rights advocate has been involved. Unfortunately, I was not at that meeting therefore do not feel comfortable addressing her position in the situation. However, I am under the impression that she had challenges in navigating through the various layers involved in this case causing her hands to be tied. Nonetheless, the patient is now on a list to be placed in long-term care if a facility will take him when a room becomes available (which gives me hope!)

    With regards to your questions around his room situation, in my opinion it is extremely sad and unethical that he is locked behind the door as well; however, as you mentioned, it is a last resort and part of the reason behind the half door. He does not necessarily have the ability to communicate with other patients unless they walk by his room and chat with him through the door, but because this is a surgical unit there is not a lot of communication among patients who are in more accessible situations. He is actually on an inappropriate floor that does not match his diagnosis. He is also not fluent in English, which creates another barrier in terms of communication. It is necessary that he is placed in such a room because he has a history of violence and continues to be a risk to himself and others, which is why his family cannot take him home. Because of his new deficits, he is very unpredictable and his behaviour changes on a day-to-day basis.

    A Brain injury combined with Alzheimer’s Disease makes for a very complex case. In conclusion, I do not think my justification of this patient’s circumstances justifies the barriers in the system and believe a larger systemic analysis should be conducted to determine what must to be changed to address the needs of elderly people and their families in Nova Scotia. It is very unfortunate that being placed in a facility from hospital includes a long wait-list and assessment of behaviours. I think the system is failing all individuals in situations like this patient, and putting pressures on hospital staff, as well as care facilities.

    #231

    kelsiemaloney
    Participant

    Thank you for sharing this case, as it is very thought-provoking.

    As a social worker, how do you approach this situation?
    While initially reading this case study, my initial thought was how there is a need to treat this man with respect and no differently than any other client. Although there are some barriers, like not speaking the same language, there are ways to manage this, i.e. an interpreter. It appears as though his family is a good support system and would know him the best prior to Alzheimer’s Disease and the traumatic brain injury, therefore their voice needs to be heard by the interprofessional team while caring for the man. As discussed, the family tried to take care of the man but it was out of their abilities. I would ensure to have good communication with the family to learn more about the man, which could allow for me to learn how I can communicate with him or recognize signs of distress. From there, I would open the communication with the family about medication. Personally, I believe that attempting medication for the patient is a good idea – keyword attempting. While learning of his current situation, ‘locked behind a half door for the majority of the day and cannot communicate with anyone due to language barriers and loss of speech’, if medication would allow for him to be around others and to have more control over his day-to-day life I think that is the best route to take. By no means do I think ‘snowing’ should occur, to my understanding this essentially means over-medicating the individual to the point they no longer have any control over themselves. Keeping the family in control of the decision, I believe I would try to encourage attempting to medicate the man enough so that he can have more control on his life. For example, a person experiencing depressive symptoms may not have any desire to get out of bed. However, it is possible that through appropriate medication that they will be able to overcome some of the depressive symptoms that they are experiencing and able to leave their home, therefore I believe that they would be experiencing a higher quality of life. Overall, I am not always for medication or against medication, I believe that it is something that needs to be considered on a case-by-case basis, and discussed interprofessionally, with the family, and with the individual (even if communication may be difficult).

    Are this man’s rights being violated?
    I believe that if the interprofessional team decided to leave the man stay locked in this room his rights would be violated without attempting other options. While reading this case, I put myself in his situation and I would hope that my family would try different approaches to allow for me to live a life outside of a hospital room with no interaction with others. To reiterate my views on medication, I do not think that medication should always be the route taken, however it should be considered when other options have failed. If after a trial period of medicating the man, his quality of life appears to be improving that is the optimal outcome. However, if the trial period of medication does not improve the quality of life of this individual, then medicating should stop immediately and the interprofessional team and family will need to come together again to brainstorm their next step.

    Is there a barrier in the system for people in situations like this? How might you handle this if you think there is?
    There is definitely a barrier in the system for individual’s in situations similar to this one. Primarily, the lack of communication the man has imposes the greatest difficulties on behalf of decision making for him. Once again, I would try my hardest to find a way that the man can communicate. I believe that there is such an assumption that if someone is non-verbal they cannot communicate. I do not know the specifics with this individual, but there may be other ways the man can allow the interprofessional team and/or family how he feels and what he thinks.

    How do you cope with a situation that conflicts with your personal values?
    In the past when I have had a situation that conflicted with my personal values, I made sure to be open in listening to the alternating values that are being presented. I believe that by keeping an open mind and respecting other values (as much as you can), it will hopefully allow for the people with opposing values to act in the same manner, which hopefully will allow for easier communication and a common ground to be easily attainable. In situations where a policy conflicts with my personal values is something that I find myself struggling with. In my future social work practice, I am hoping to work for an Agency that has policies and values that I believe in to alleviate any stress in terms of conflicting values.

    What different perceptions of quality of life might there be that would influence a decision in this case?
    This is a very interesting point, as quality of life is subjective. It is a matter of fact that each person in the world is a unique individual who has experienced different things in their lives that have brought them to where they are today. This question makes me think about comparing two people, one who was born visually impaired and one who becomes visually impaired in their adult life. Would they have the same quality of life, as they are both visually impaired but one had had the ability to see at one point in their lives? Perhaps the person who was born visually impaired feels they are very content with their life as they have never known any different, compared to someone who could once see. On the other hand, maybe the person who recently became visually impaired is grateful for their time they could see and now embraces a new perspective of life. Overall, it all depends on the individual and their values and beliefs.
    The concept of ‘quality of life’ is also influenced by the privilege that people have experienced in their own lives. For example, I feel that I have lived a very average life. Prior to the BSW program I have not taken into consideration the privilege that I live with simply because I am a Caucasian person. I have never had to think twice about ‘nude’ makeup not being similar to my skin tone or watching television shows that reflect similar families to my own. I believe that even these elements impact the quality of life someone has.

    What issues of power are relevant in this situation?
    It’s an interesting scenario to consider where ‘power’ falls in this situation. If we are considering the interprofessional team, the family, and the man; I would say that the power most likely falls in that order. I consider power in this scenario to be who is able to make the decisions that will impact the man’s quality of life. However, the interprofessional team and the family could be broken down further. For example, the interprofessional team may be include a doctor (MD), licensed practioner nurse (LPN), registered nurse (RN), social worker (BSW), and social worker (MSW). These professionals all hold differing levels of power amongst themselves, but as a team they probably hold more power than the family. On the other hand when considering the family, for example let’s say that the family consists of the biological son and daughter of the man and the biological son’s wife and two adolescent children. The members of the man’s family will also all hold different levels of power when attempting to make decisions that impact the man’s quality of life. Upon critically reflecting, it is interesting to see how little power the man, who’s quality of life is in question in this scenario, seemingly has the least amount of power.

    Would the codes of ethics be helpful in resolving this scenario? If so, how? If not, why not?
    I believe that the code of ethics is always a useful tool while working with any clients, no matter what their situation. A major value within the code of ethics is the pursuit for social justice, and this reflects what a social worker should be working towards with this man. The social worker should be advocating for the man’s rights and ensuring that he is being treated as an equal. The social worker can advocate for the man through the interprofessional team, the family, or higher up. A social worker in this setting should be able to see past the Alzheimer’s Disease, the traumatic behaviour, and violent behaviours and demonstrate respect and advocate for the dignity and worth that this man deserves.

    How would you go about resolving this issue?
    Please see the first question, ‘As a social worker, how do you approach this situation?’.

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