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Ethical Dilemmas in Nursing

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Rafeena Baksh

on 9 October 2014

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Transcript of Ethical Dilemmas in Nursing

Thank
you!

Ethical Dilemmas in Nursing
Learning Objectives
Discuss the facts and statistics underlying the situation.

Identify the ethical dilemma that exists in the case study.

Explore the perspectives of the CNA Code of Ethics, CNO Practice Standard, Public Health Ethics and other laws/policies in relation to the case study.

Discuss the ethical principles underlying the choices of each individual in the situation and evaluate the costs and benefits of potential choices.

Identify and discuss the ethical decision to be made by the nurse.
Homelessness Here
Homelessness describes the situation of an individual or family without stable, permanent, appropriate housing, or the immediate prospect, means and ability of acquiring it.

It is the result of systemic or societal barriers, a lack of affordable and appropriate housing, the individual/household’s financial, mental, cognitive, behavioural or physical challenges, and/or racism and discrimination.


(Canadian Homelessness Research Network, 2012)
Defining Homelessness
Structural Factors
Individual and Relational Factors
Systems Failures
47.5%
SINGLE ADULT
MALES BETWEEN

YEARS OLD
25 & 55
The situation of an individual or family without stable, permanent, appropriate housing, or the immediate prospect, means and ability of acquiring it.
Stephen Gaetz, Jesse Donaldson, Tim Richter, & Tanya Gulliver (2013):
The State of Homelessness in Canada 2013. Toronto:
Canadian Homelessness Research Network Press.
Home less ness
Warrant
Basis

Rebuttal


Every year in Toronto
29,000
persons use emergency shelters, and on any given night
5,000
are without homes.


Every night in Toronto:

• 447 people are living on the streets
• 3,970 people are staying in shelters



Chambers, C., Chan, A., Gardam, M., Hwang, S. W., Jamieson, F., Khan, K., ...Yang, J. (2011). Active tuberculosis among homeless persons, Toronto, Ontario, Canada, 1998-2007. Emerging Infectious Diseases, 17(3), 357+.

Chronically homeless individuals account for

less than 15 %
of the homeless population, but consume

more than 50%
of the resources in the
homelessness system.
(Gaetz, Donaldson, Richter & Gulliver, 2013)
Including a higher risk of
contracting infectious diseases
such as
Homeless individuals have a higher risk of:
Tuberculosis
The increased risk factors and comorbidities experienced by homeless individuals may increase their risk for primary or reactivated TB, complicate delivery of health services, and negatively affect treatment outcomes.
Individuals who are under-housed have high rates of infection
(71 cases/100 000),
making them a high-risk population for TB.



Adam, H. J., Guthrie, J. L., Bolotin, S., Alexander, D. C., Stuart, R., Pyskir, D., Brown,E. M., Rea, E., Chedore, P., & Jamieson, F. B. (2010). Genotypic characterization of tuberculosis transmission within Toronto's under-housed population, 1997-2008. The International Journal of Tuberculosis and Lung Disease, 14(10), 1350–1353

Homeless TB patients often seek care when disease is advanced and highly contagious.
(Chambers, Gardam, Hwang, Jamieson, Khan & Yang, 2011)
Moreau, D., Gratrix, J., Kunimoto, D., Beckon, A., Der, E., Hansen, E., ...Ahmed, R. (2012). A shelter-associated tuberculosis outbreak: a novel strain introduced through foreign-born populations. Canadian Journal of Public Health, 103(6), 408
+

[Editorial]. (2011). Rooting out tuberculosis in homeless communities.
The Lancet, 377 (1).
During 2001-2002, a large shelter-based TB outbreak occurred among homeless persons in Toronto.

A coroner's inquest into the death of a homeless man in whom pulmonary TB developed during the course of this outbreak revealed the
challenges of managing TB in homeless populations.
Mr. Landry is someone without a permanent address and does not have access to health care. His health needs may be greater than the community since he does not have homes like others in the community.

Nathan has to balance Landry’s need for resources with those in the community. As Nathan thinks of both the benefits and risk of the choices he follows the ethical principle of justice.


Fidelity
Nonmaleficence
Beneficence
Veracity
Mr. Landry’s claim is that he wants his freedom which reflects the basic principle of autonomy.

Mr. Landry’s follows the ethical principle of veracity by being honest about what he wants.


Autonomy
- The respect for individual liberty

Justice
- The equitable distribution of potential benefits and risks

Fidelity
- The duty to do what one has promised

Nonmaleficence
- The obligation to do or cause no harm to another

Beneficence
- The duty to do good to others

Veracity
- The obligation to tell the truth

Ethical Principles
Nathan

Value differences
What is the Ethical Dilemma?
Mr. Landry doesn’t want to go to the hospital because he doesn’t want to lose his freedom and he wants to be able to drink when he wants to drink.

Nathan tries to see Mr. Landry’s point of view and as a public health nurse is aware of the need to protect the public from Landry’s communicable disease. Mr. Landry does not have a home so it will be difficult to treat him outside the hospital.

Who is involved?
The community which Mr. Landry lives in.
Mr. Landry
Nathan
Exploring Different Perspectives
Mr. Landry
Nathan
Mr. Landry doesn’t want to go to the hospital for treatment because he doesn’t want to lose his freedom and he wants to be able to drink if and when he wants.
Nathan understands Mr. Landry’s point of view and is aware of the need to protect the public from Mr. Landry’s communicable disease.

If Nathan listens to Mr.Landry he will honour the principle of Autonomy.
By not listening to Mr.Landry Nathan follows these ethical principles:
CASE STUDY: JOHN LANDRY
Ethical Decision
Exploring the Options
CNO, RNAO, Policies
Ethics and Values
Ethics and Values
Limits to Client Choice

Many ethical issues in primary health care mainly focus on ethics of caring for individual clients

Public Health Ethics = focus on the population’s well-being (not just the individual); balance between harm, risk and benefit within the community

Client well-being = facilitating health and welfare, removing harm

Client choice = supporting self-determination, right to information to make choices, consent

Truthfulness = providing information to ensure client is informed, maintaining complete honesty while avoiding omissions

College of Nurses of Ontario –
Practice Standard: Ethics (2009)

Safe, competent and ethical care = f
ulfill ethical and professional obligations

Health and well-being = assist individuals/communities achieve optimum level of health

Promoting and respecting informed decision making = recognizing right to be informed and make decisions

Choice = respecting and promoting autonomy concerning values and needs while making informed decisions

Dignity = respecting worth and advocating for respectful treatment

Justice = upholding equity and fairness in receiving health services according to individual needs

Canadian Nurses Association –
Code of Ethics (2008)
CNA, CNO & Public Health
Canadian Nurses Association. (2008). Code of Ethics. Retrieved from http://www.cna-aiic.ca/~/media/cna/files/en/codeofethics.pdf

College of Nurses of Ontario. (2009). Practice standard: Ethics. Retrieved from http://www.cno.org/Global/docs/prac/41034_Ethics.pdf

Do not have the right to choose when their choice endanger others..

Canadian Nurses Association. (2006). Ethics in practice for registered nurses: Public health nursing practice and ethical challenges. Retrieved from http://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/ethics_in_practice_jan_06_e.pdf
Nursing Ethics – Public Health
Public health nurse = a community health nurse who integrates public health science and nursing theory/science (combines epidemiology, health promotion/protection, illness and disease prevention, determinants of health and primary health care, injury prevention, and population health

Role duality = well-being of individual clients as well as that of the greater population; recognizing the health of both are linked
While knowledge of TB is essential for quality care, TB clients emphasize the importance of nurses’ ability to calm fears, challenge stigma, and help with addressing other non-related TB concerns.
Protector of the community
Public Health Nursing
Bender, A., Peter, E., Wynn, F., Andrews, G., & Pringle, D. (2011) Welcome intrusions: An interpretive phenomenological study of TB nurses' relational work. International Journal of Nursing Studies, 48, 1409–1419.

Canadian Nurses Association. (2006). Ethics in practice for registered nurses: Public health nursing practice and ethical challenges. Retrieved from http://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/ethics_in_practice_jan_06_e.pdf

Community Health Nurses Association of Canada. (2003). Canadian community health nursing standards of practice. Revised 2008. Retrieved from http://www.chnc.ca/documents/chn_standards_of_practice_mar08_english.pdf

Canadian Community Health Nursing Standards of Practice
Promoting Health

Building individual and community capacity

Building relationships

Facilitating access and equity

Demonstrating professional responsibility and accountability
Public Health Ethics
Ethics
of
public health: professional ethics towards common good

Ethics
in
public health: considerations between collective good and individual rights

Ethics
for
public health: advocacy in consideration for healthy communities to benefit all

Canadian Nurses Association. (2006). Ethics in practice for registered nurses: Public health nursing practice and ethical challenges. Retrieved from http://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/ethics_in_practice_jan_06_e.pdf

Justification of Public Health Intervention (Upshur, 2002)
Harm Principle
= power exercised over an individual against will to prevent harm to others, not just individual own good

Least Restrictive or Coercive Means
= full restrictive authority/power employed only as last resort

Reciprocity Principle
= facilitate individuals and communities for their efforts

Transparency Principle
= all stakeholders involved in decision-making process, maintain clar
ity and accountability

Upshur, R.E.G. (2002). Principles for the justification of public health intervention. Canadian Journal of Public Health, 93(2), 101-103.

Public Health Orders
Public Health can place an active TB on DOT therapy

Failure of treatment compliance = threat to public’s health and safety

Medical Officer of Health = legal authority under the Health Protection & Health Promotion Act (HPPA) to prevent TB spread
Order compliance to treatment and/or
isolation, detainment if absolutely necessary

Ontario Lung Association. (2009). Tuberculosis: Information for health care providers. 4th ed. Ontario Ministry of Health and Long-Term Care. Retrieved from http://www.on.lung.ca/document.doc?id=475

Health Protection & Promotion Act (1990) Guidelines – Communicable Diseases
Statute 22: Order by MOH re communicable disease = after confirmation, may act to decrease or eliminate public health risk
Includes (but not limited to):
Time frame of direct compliance to orders
Submitting to examination, mandatory testing, and placing self under the care and treatment of a physician
Preventing spread of infection

Ontario Ministry of Health and Long-Term Care. (1990). Health protection & promotion act. Last amendment 2011. Retrieved from http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90h07_e.htm

Health Protection & Promotion Act (1990) Guidelines – Communicable Diseases (con’t)
Statute 35: application from MOH to Ontario Court of Justice upon failure to comply to MOH orders concerning communicable disease

Includes:
Apprehension, admission and detainment in hospital and placed under physician care
Treatment for disease

Ministry of Health and Long-Term Care. (1990). Health protection & promotion Act. Last amendment 2011. Retrieved from http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90h07_e.htm

John Landry
Name : John Landry
Sex: Male
Age: 52 years old
Marital Status: Single


Patient background:
John Landry has worked in many northern communities as a miner. Since coming to Toronto, he has not been able to find a job. He has been living in rooming houses, shelters and sometimes on the street.

Reason for visit:
increasing fatigue
persistent cough lasting more than 3 weeks with blood-streaked sputum
night sweats
weight loss

Patient diagnosis:
Active pulmonary tuberculosis

Treatment:
Hospitalization is the best option to prevent the spread of his infection as his housing situation prevents out-patient treatment. Mr. Landry refuses to go into hospital for treatment. Pt stated "I don' t want to go to the hospital for treatment because I want to have my freedom and be able to drink if and when I want to".



Airborne
Precautions

LANDRY, JOHN
Exploring the Options
Option 1:
Directly Observed Therapy or DOT
This therapy is designed to help individuals managing the treatment of TB

A DOT worker will provide support during treatment and will ensure medication is taken correctly

DOT can take place in any setting at no cost to the client

DOT workers will watch for any harmful side effects and continue working with clients until treatment is completed

Ministry of Health. (2014). Canadian Tuberculosis Standards 7th Ed. Retrieved from
http://www.respiratoryguidelines.ca/tb-standards-2013

Directly Observed Therapy
Costs and Benefits for Mr. Landry
Ministry of Health. (2014). Canadian Tuberculosis Standards 7th Ed. Retrieved from
http://www.respiratoryguidelines.ca/tb-standards-2013

Mr. Landry
may still engage in drinking which, combined with the medication used to treat TB could result
in hepatotoxicity

Treatment is free

Mr. Landry will be monitored and have support during his treatment
Mr. Landry maintains freedom and autonomy in his life, including freedom to drink if he pleases


Adequate housing is not provided
Directly Observed Therapy
Costs and Benefits for Nathan RN
Ministry of Health. (2014). Canadian Tuberculosis Standards 7th Ed. Retrieved from
http://www.respiratoryguidelines.ca/tb-standards-2013

Mr. Landry would still be a threat to public health as he may spread TB

Mr. Landry will be provided with support and treatment as an outpatient

Respecting client choice
Option 2:
Supportive Housing
Many supportive housing programs provide options for Toronto’s homeless population

Options include: shared accommodations in a house, or single rooms with common a bathroom and kitchen for a unit, with or without supportive staff

Programs in Toronto include: Ecuhome Corporation, Deep Quong Non-Profit Homes, CRC Self-Help Inc. and Homes First Society

East York Housing Help Centre. (2014). Supportive Housing. Retrieved from
http://www.eastyorkhousinghelp.ca/find-a-home/social-housing/supportive-housing/

Supportive Housing
Costs and Benefits for Mr. Landry
East York Housing Help Centre. (2014). Supportive Housing. Retrieved from http://www.eastyorkhousinghelp.ca/find-a-home/social-housing/supportive-housing/

Ministry of Health. (2014). Canadian Tuberculosis Standards 7th Ed. Retrieved from http://www.respiratoryguidelines.ca/tb-standards-2013

Some housing options will have rules Mr. Landry must follow, which may infringe upon his freedom
Mr. Landry will have housing and be able to treated away from shelters
Responsibly Wet Houses may lead to Mr. Landry developing hepatotoxicity
Responsibly Wet Houses allow for drinking
Supportive Housing
Costs and Benefits for Nathan RN

Shared accommodation or common spaces such as kitchens or bathrooms places potential roommates at risk

Mr. Landry can
receive treatment in a homelike setting and exercise his personal freedom in a semi limited fashion depending on house rules

Option 3:
In Hospital Treatment
Treatment for TB may take place in a hospital setting after client is admitted

Proper isolation precautions and medication administrating can be handled by professional medical staff.

Treatment will be continuously monitored

Ministry of Health. (2014). Canadian Tuberculosis Standards 7th Ed. Retrieved from
http://www.respiratoryguidelines.ca/tb-standards-2013

Hospitalization
Costs and Benefits for Mr. Landry
Mr. Landry will be forced to give up his agency



There is no risk of hepatotoxicty due to alcohol consumption while in hospital

Mr. Landry will not be able to drink alcohol in the hospital
Treatment will be provided by professionals
Hospitalization
Costs and Benefits for Nathan RN
Not respecting client choice which my negatively impact Nathan’s relationship with Mr. Landry
Mr. Landry may be placed in isolation limiting the risk of transmission
Mr. Landry will be in the care of competent professionals who can monitor his progress and treat him effectively
Ethics and Values
CNO, RNAO, Policies
Ethical Decision
Exploring the Options
Centre for Research on Inner City Health. 2014. Homelessness & Health. Retrieved from http://www.stmichaelshospital.com/pdf/crich/homelessness-health.pdf,

Butler-Jones, D. (2009). A reflection on public health in canada: Applying lessons learned for the next century of public health practitioners. Canadian Journal of Public Health, 100(3), 165-8.
physical health issues
mental health issues
substance use issues
injury and assault
infectious disease

Tuberculosis is an infection caused by the bacterium Mycobacterium tuberculosis.

Toronto: Communicable Disease Control. (2014). Tuberculosis. Retrieved from: http://www1.toronto.ca/wps/portal/contentonly?vgnextoid=02195dc06f002410VgnVCM10000071d60f89RCRD
Most people who breathe in the TB germs are able to stop them from growing. Most people's immune systems trap the TB germs and keep them inactive. This is called latent TB infection (LTBI).
In some people with LTBI, the TB germs become active when the body’s immune system cannot stop the germs from growing. The active TB germs begin to grow and cause damage to the body.
Latent TB
Active TB
Two assumptions that hold true for the general population simply do not hold in the homeless community:
that people with symptoms will seek medical help
that they will take treatment as prescribed

[Editorial]. (2011). Rooting out tuberculosis in homeless communities. The Lancet, 377 (1).
of homeless people with TB die within 12 months of diagnosis
20 %
Chambers, C., Chan, A., Gardam, M., Hwang, S. W., Jamieson, F., Khan, K., ...Yang, J. (2011). Active tuberculosis among homeless persons, Toronto, Ontario, Canada, 1998-2007. Emerging Infectious Diseases, 17(3), 357+.


In response to the inquest into the man's death and resulting jury recommendations, major changes to the management of homeless TB cases occurred in the public health and shelter systems, and local TB clinic capacity expanded.

This case resulted in the creation of a public health team dedicated to case management, contact follow-up, advocacy, education, health promotion, and active case finding among the city's homeless and underhoused population.


We are that Public Health Team.
(lead by Nathan, our hypothetical Public Health Nurse, of course)
Symptoms include:
• A bad cough that lasts 3 weeks or longer
• Coughing up blood or sputum (phlegm from deep inside the lungs)
• Weakness or fatigue
• No appetite, Weight loss
• Chills, Fever, Night Sweats
Toronto: Communicable Disease Control. (2014). Tuberculosis. Retrieved from: http://www1.toronto.ca/wps/portal/contentonly?vgnextoid=02195dc06f002410VgnVCM10000071d60f89RCRD
If you have active pulmonary TB, you have to remain in isolation!


Tuberculosis is preventable, treatable and curable.

Treatment for Latent TB
Treatment for Active TB
Treatment for TB disease involves taking medication everyday for 6-9 months. Although treatment can take a long time, a person can be cured of TB once treatment is complete.

• isoniazid (INH)
• rifampin (RIF)
• rifapentine (RPT)

isoniazid (INH)
• rifampin (RIF)
• ethambutol (EMB)
• pyrazinamide (PZA)
Centers for Disease Control and prevention. (2014). Tuberculosis: Treatment. Retrieved from: http://www.cdc.gov/tb/topic/treatment/default.htm
DO NOT drink alcohol while taking isoniazid (INH). It will damage your liver.

Toronto: Communicable Disease Control. (2014). Isoniazid (INH). Retrieved from:
http://www1.toronto.ca/wps/portal/contentonly?vgnextoid=e64d5dc06f002410VgnVCM10000071d60f89RCR
D&vgnextchannel=68895dc06f002410VgnVCM10000071d60f89RCRD
Centers for Disease Control and prevention. (2014). Tuberculosis: Treatment.
Retrieved from: http://www.cdc.gov/tb/topic/treatment/default.htm

All those with active TB, and those who have been in contact with active TB, must be identified, tested, and offered appropriate treatment. Case investigations and contact tracing include ascertainment of risk factors, including housing status.



Andrew, G., Bender, A., & Peter, E. (2010). Displacement and tuberculosis: recognition in nursing care. Health & Place, 16, 1069–1076


Adam, H. J., Guthrie, J. L., Bolotin, S., Alexander, D. C., Stuart, R., Pyskir, D.,
Brown,E. M., Rea, E., Chedore, P., & Jamieson, F. B. (2010). Genotypic characterization of tuberculosis transmission within Toronto's under-housed population, 1997-2008. The International Journal of Tuberculosis and Lung Disease, 14(10), 1350–1353
Ethical values of a nurse are:
Fairness
Client well-being
Privacy and confidentiality
Respect for life
Truthfulness
Maintaining commitments
Client choice
Justice
transparency

Ethical values of a public health nurse:
Protecting and preserving the health of the public
Protecting the population’s well-being not just the individual
Fairness in the use of resources
Values the common good/ good for the larger community

freedom
ability to continue drinking

Mr. Landry
Community stake = overall health and safety of the immediate community and greater population, where existing inequalities can put certain groups at risk

Immediate community
= individuals the client would come into contact with more regularly (ie. Other homeless individuals in shelters or on the street, community clinics, health care/social service workers, etc)

Greater population
= individuals in public spaces that could unknowingly be exposed to a communicable disease (ie. Public transportation, shopping malls, educational institutions, etc.)



Community Health Nurses Association of Canada. (2003). Canadian community health nursing standards of practice. Revised 2008. Retrieved from http://www.chnc.ca/documents/chn_standards_of_practice_mar08_english.pdf
Case Study Summary
Mr. Landry is diagnosed with active pulmonary tuberculosis which is a communicable disease. His symptoms include increasing fatigue, persistent cough lasting more than 3 weeks with blood-streaked sputum, night sweats and weight loss.

Ethical Decision
After Nathan explains his condition to Mr. Landry, he is requested to voluntarily go to the hospital for TB treatment.
Nathan would then explain to Mr. Landry the nature of his condition, making sure to cover all aspects of the disease and stress the ease of communicability.

He would be informed that the best course of action would be to admit himself into a hospital/in-treatment program, as remaining in the community would put the public’s health at risk.

He would also need to discontinue his use of alcohol for the duration of treatment, as it is contraindicated with DOT therapy/TB mediation.
If not, then statute 22 (Order by MOH re communicable disease = after confirmation, may act to decrease or eliminate public health risk) applies.
If statute 22 does not work, then statute 35 (application from MOH to Ontario Court of Justice upon failure to comply to MOH orders concerning communicable disease) applies.
This leads to involuntary admission to hospital which includes apprehension, admission and detainment. Both of these options would be limits to client choice, as the potential for greater exposure of a communicable disease would come before the choices of an individual.
Reducing Tuberculosis
Primary prevention efforts:
shelter-based control measures
smaller shelter sizes
strategies to reduce mobility

Secondary prevention:
earlier detection and treatment of TB infection

Tertiary prevention :
treatment of active TB by health care providers with experience treating TB in homeless persons


sustainable housing program
References
References
Adam, H. J., Guthrie, J. L., Bolotin, S., Alexander, D. C., Stuart, R., Pyskir, D., Brown,E. M.,
Rea, E., Chedore, P., & Jamieson, F. B. (2010). Genotypic characterization of tuberculosis transmission within Toronto's under-housed population, 1997-2008. The International Journal of Tuberculosis and Lung Disease, 14(10), 1350–1353.

Andrew, G., Bender, A., & Peter, E. (2010). Displacement and tuberculosis: recognition in
nursing care. Health & Place, 16, 1069–1076.

Bender, A., Peter, E., Wynn, F., Andrews, G., & Pringle, D. (2011) Welcome intrusions: An i
interpretive phenomenological study of TB nurses' relational work. International Journal of Nursing Studies, 48, 1409–1419.

Butler-Jones, D. (2009). A reflection on public health in canada: Applying lessons learned
for the next century of public health practitioners. Canadian Journal of Public Health, 100(3), 165-8.

Centers for Disease Control and prevention. (2014). Tuberculosis: Treatment. Retrieved
from: http://www.cdc.gov/tb/topic/treatment/default.htm

Centre for Research on Inner City Health. 2014. Homelessness & Health. Retrieved from
http://www.stmichaelshospital.com/pdf/crich/homelessness-health.pdf

Chambers, C., Chan, A., Gardam, M., Hwang, S. W., Jamieson, F., Khan, K., ...Yang, J. (2011).
Active tuberculosis among homeless persons, Toronto, Ontario, Canada, 1998-2007. Emerging Infectious Diseases, 17(3), 357+.

Canadian Nurses Association. (2006). Ethics in practice for registered nurses: Public health
nursing practice and ethical challenges. Retrieved from http://www.cna-aiic.ca/~/media/cna/page-content/pdf-en/ethics_in_practice_jan_06_e.pdf


Canadian Nurses Association. (2008). Code of Ethics. Retrieved from http://
www.cna-aiic.ca/~/media/cna/files/en/codeofethics.pdf

Community Health Nurses Association of Canada. (2003). Canadian
community health nursing standards of practice. Revised 2008. Retrieved from http://www.chnc.ca/documents chn_standards_of_practice_mar08_english.pdf

College of Nurses of Ontario. (2009). Practice standard: Ethics. Retrieved
from http://www.cno.org/Global/docs/prac/41034_Ethics.pdf

East York Housing Help Centre. (2014). Supportive Housing. Retrieved from
http://www.eastyorkhousinghelp.ca/find-a-home/social-housing/supportive-housing/

[Editorial]. (2011). Rooting out tuberculosis in homeless communities. The
Lancet, 377 (1).

Ministry of Health. (2014). Canadian Tuberculosis Standards 7th Ed. Retrieved
from http://www.respiratoryguidelines.ca/tb-standards-2013

Ministry of Health and Long-Term Care. (1990). Health protection &
promotion Act. Last amendment 2011. Retrieved from http://www.e
laws.gov.on.ca/html/statutes/english/elaws_statutes_90h07_e.htm


Moreau, D., Gratrix, J., Kunimoto, D., Beckon, A., Der, E., Hansen, E., .
..Ahmed, R. (2012). A shelter-associated tuberculosis outbreak: a novel strain introduced through foreign-born populations. Canadian Journal of Public Health, 103(6), 408+.

Ontario Ministry of Health and Long-Term Care. (1990). Health protection & promotion act.
Last amendment 2011. Retrieved from http://www.e-laws.gov.on.ca/html/statutes/english elaws_statutes_90h07_e.htm

Ontario Lung Association. (2009). Tuberculosis: Information for health care providers. 4th ed.
Ontario.

Ministry of Health and Long-Term Care. Retrieved from http://www.on.lung.ca
document.doc?id=475

Stephen Gaetz, Jesse Donaldson, Tim Richter, & Tanya Gulliver (2013): The State of
Homelessness in Canada 2013. Toronto: Canadian Homelessness Research Network Press.

Toronto: Communicable Disease Control. (2014). Tuberculosis. Retrieved from: http://
www1.toronto.ca/wps/portal/contentonly?vgnextoid=02195dc06f002410VgnVCM1000 071d60f89RCRD

Upshur, R.E.G. (2002). Principles for the justification of public health intervention. Canadian
Journal of Public Health, 93(2), 101-103.
References
List these priorities:
substance, health/health care, food, relationships, shelter
Which options should we choose?
Rafeena Baksh
Fiona Chettiar
Maria Elisa Maltese
Brittany Moodie
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