Nurs Ethics. 2015 Jul 9. pii: 0969733015583185. [Epub ahead of print]

Difficult healthcare transitions: Ethical analysis and policy recommendations for unrepresented patients.

Abdool R1, Szego M2, Buchman D3, Justason L4, Bean S5, Heesters A3, Kaufman H6, Parke B7, Wagner F8, Gibson J4.

Author information

• 1Centre for Clinical Ethics, Canada; Hôtel-Dieu Grace Healthcare, Canada; Joint Centre for Bioethics, University of Toronto, Canada; Department of Philosophy, University of Waterloo, Canada rabdool@uwaterloo.ca.
• 2Centre for Clinical Ethics, Canada; Department of Family and Community Medicine, University of Toronto, Canada; Joint Centre for Bioethics, University of Toronto, Canada michael.szego@utoronto.ca.
• 3University Health Network, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
• 4Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
• 5Sunnybrook Health Sciences Centre, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
• 6Department of Family and Community Medicine, University of Toronto, Canada.
• 7Humber River Hospital, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
• 8Department of Family and Community Medicine, University of Toronto, Canada; Joint Centre for Bioethics, University of Toronto, Canada.

Abstract

BACKGROUND:

In Ontario, Canada, patients who lack decision-making capacity and have no family or friends to act as substitute decision-makers currently rely on the Office of the Public Guardian and Trustee to consent to long-term care (nursing home) placement, but they have no legal representative for other placement decisions.

OBJECTIVES:

We highlight the current gap in legislation for difficult transition cases involving unrepresented patients and provide a novel framework for who ought to assist with making these decisions and how these decisions ought to be made.

RESEARCH DESIGN:

This paper considers models advanced by Volpe and Steinman with regard to who ought to make placement decisions for unrepresented patients, as well as current ethical models for analyzing how these decisions should be made.

PARTICIPANTS AND RESEARCH CONTEXT:

We describe an anonymized healthcare transition case to illustrate the fact that there is no legally recognized decision-maker for placement destinations other than long-term care facilities and to show how this impacts all stakeholders.

ETHICAL CONSIDERATIONS:

The case provided is an anonymized vignette representing a typical transition case involving an unrepresented patient.

FINDINGS:

As a result of a gap in provincial legislation, healthcare providers usually determine the appropriate placement destination without a clear framework to guide the process and this can cause significant moral distress.

DISCUSSION:

We argue for a team decision-making approach in the short term, and a legislative change in the long-term, to respect the patient voice, evaluate benefit and risk, enhance collaboration between healthcare providers and patients, and promote social justice. We believe that our approach, which draws upon the strengths of interprofessional teams, will be of interest to all who are concerned with the welfare and ethicaltreatment of the patients for whom they care.

CONCLUSIONS:

One of the main strengths of our recommendation is that it provides all members of the healthcare team (including nurses, social workers, therapists, and others) an increased opportunity to advocate on behalf of unrepresented patients.