Balancing denial, hope, and clinical recommendations

By Julie Hann and Andria Bianchi

Social workers are essential contributors to healthcare teams in both acute care and rehabilitative settings. With the goal of social work being to address psychosocial issues through supportive and resource counselling, they contribute to successful patient-centred and, oftentimes, family-centred experiences. There are, however, many ethical dilemmas that social workers encounter because of the nature of their work. As a result of these dilemmas, social workers and bioethicists often work in collaborative partnerships to determine ethically defensible decisions in light of systemic constraints and pressures.

The following case serves as an example to help depict the kinds of ethical dilemmas that social workers may encounter in their practice. While aspects of this case will differ depending on the individuals involved, location of the patient and healthcare organization, etc., the general themes and resulting questions may still occur:

Mr. J was recently admitted to an acute care hospital; this was his sixth admission in the last nine months. Mr. J has multiple medical comorbidities, such as diabetes, osteoarthritis, and chronic heart failure. Before his hospitalizations, Mr. J was living independently. Over time, however, his capacity to thrive while living independently has diminished. It has become difficult for him to leave the house to do groceries (his fridge is frequently empty), pick up medications, attend medical appointments, and socialize at the local seniors’ centre, all of which were activities that he used to do and value. It has also become challenging for him to clean his house and manage personal hygiene. He has limited financial resources and one son who resides in another country.

Upon attaining medical stability in acute care, Mr. J was transferred to a nearby rehabilitation centre for a short term admission. Mr. J informed the rehab team that the goal of his admission was to make enough functional gains to get back to his “old self” (i.e., to live independently, manage groceries, maintain upkeep on his household and personal care, walk to the seniors’ centre, etc.).

After receiving two weeks of intensive rehab, the clinical team agreed that Mr. J would not be able to make further progress in terms of physical gains. The team planned to arrange for Mr. J’s discharge, which would plausibly involve receiving therapy, medical care, and personal support at home (some of which would need to be privately funded).

Upon informing Mr. J of this news and the proposed plan, he responded by saying “I am going to get better” and that he just needs one more week of therapy to make gains. Mr. J expressed hopefulness about returning to his “old self” and begged the team to allow him to stay.

Social workers are frequently involved in discharge planning conversations that are similar to Mr. J’s; these situations often give rise to an influx of questions that are relevant to social work practice and have ethical implications. For example, if Mr. J cannot pay for additional care (since home care may require private finances), then is it ethically permissible to let him stay in rehab for a longer period of time? Should patients on our waitlist be factored into the decision-making process about Mr. J (e.g., if a number of people are waiting for beds then should Mr. J’s discharge be forced)? Since we cannot guarantee whether a person may make some functional gains, should we give Mr. J just one more week? Would we offer this to other patients? Ultimately, the question is: What is the most ethically defensible option to pursue for patients who maintain a persistent denial about making functional advances/attaining certain goals when the team has a clinically justified reason to disagree? Should we ever accommodate patient requests in certain circumstances? If so, which ones?

The above questions are particularly complex in publicly funded healthcare systems when all patients have a right to receive care and resources are limited. Additionally, our system has a duty to provide care that is in the best interest of patients, but clinicians and patients may disagree about what is best.

In order to answer these complex questions, it may be useful (at least as an initial step) to contemplate the purpose of a hospital and/or rehabilitation centre. If the purpose of a particular healthcare setting is to assist people to become medically stable (based on available evidence and clinical judgment) so that they can go home and strive to make further gains, then it may be defensible to discharge Mr. J. This may be especially justifiable from an ethics perspective if Mr. J has resources available to help him thrive in the community (e.g. supportive family members, financial stability, secure housing), whereas we may owe more to patients who do not have such supports available (for more information on this, see April’s ethics column on equality vs. equity).

Sometimes what appears to be persistent denial serves a greater purpose in giving hope and motivation in otherwise discouraging circumstances. Social work is framed by the following tenants: the presumption of patient/client capacity; the right to live at risk; the right to self-determination and choice; offering the most effective and least intrusive support; and maximum independence possible. These central tenants may seemingly conflict, however, when it comes to cases such as Mr. J’s. For instance, one may ask: How are a patient’s self-determination and choice, as well as maximum independence resolved in light of a clinical perspective which suggests that there are limited functional gains to be made?

 

There are no clear-cut solutions to address conflicting views about recovery between the rehab team and patients. Social workers try to help patients navigate their options within the limitations of the healthcare, community and individual environments. This means that sometimes a person will discharge home, despite believing they have not reached their full rehab potential. In other cases, they will continue in rehab, though often in a community program such as convalescent care or on a reactivation (reintegration) unit. In the latter case, the patient will have time to allow potential gains to occur and/or to adapt to a new “normal” before determining next steps.

 

Julie Hann, MSW, RSW is a Social Worker at the University Health Network and Andria Bianchi, PhD is a Bioethicist at the University Health Network.