“And one last thing – we have had a shortage of assistive devices for the past 2 months; there are only about 50 walking frames for the whole hospital. The physiotherapy department is really suffering!” This is what my clinician told me after orientation on my first day of a neurological block. My block was at a tertiary hospital with a large physiotherapy department split into different areas specializing in orthopaedics, general, and neurological. We had to share a measly 50 walking frames for an entire hospital consisting of thousands of patients! The main patient type I was set to see were those with CVAs typically presenting with a hemiplegia, thus they are quite disabled and in dire of an assistive device. How would I decide who was more in need to receive an assistive device? McKneally, Dickens, Meslin and Singer (1997) state that questions of resource allocation can pose practical and ethical dilemmas for clinicians. These authors go on to state that the court expects physicians and health professionals to show allegiance to their patients regardless of budgetary concerns, or lack or resources as a result thereof (McKneally, Dickens, Meslin, & Singer, 1997). I still had my patient’s best interest at heart; I just to be more creative in my approach to treatment due to the barrier of lack of resources.
I was quite frustrated because the lack of resources was preventing me from reaching goals with my patients.I found myself reserving assistive devices for the patients who were extensively unstable when mobilizing and the elderly. However, according to Fortes (2002) it is a morally unacceptable criterion for the allocation of resources to be based on age (amongst other things such as gender, ethnic origin, religion, sexual preference or race). Basically, according to this reference my thinking was unethical and immoral.After learning of this immoral criterion, in the future I will attempt to allocate resources based solely on the extent of disability, thus need, and not on the patient’s age.
One day my clinician informed me that one of my patients was being discharged home until she would later be placed at a step down facility. I had been seeing this patient daily, mobilizing her by assisting her on her hemiplegic side and placing a chair on her unaffected side. Because I had previously conducted a subjective assessment with this patient, I knew that when she went home her daughter will be able to care for her. However, it was an unsettling feeling to know that I was discharging a patient who was not safe to mobilize safely and independently and who was dependent on furniture to get around. I apologized to the patient and explained the shortage of the assistive devices to the patient. I knew that she could possibly have an assistive device issued to her at the step-down facility, however, I still did not feel completely comfortable discharging her in that state. According to McKneally, Dickens, Meslin and Singer (1997) patients should be informed of cost constraints on care in a sensitive way. McKneally, Dickens, Meslin and Singer (1997) go on to say that one should avoid blaming administrative or governmental systems during discussions with the patient as it may reduce confidence and increase anxiety in an already vulnerable patient. When I discharged the patient, I apologized for the lack of the assistive device and reassured her that she would be receiving good rehabilitation at the step-down facility and they she would most likely get an assistive device.
When working in a government funded hospital, it is very likely that resources will be limited, thus the allocation of resources may pose an ethical dilemma. What I have learned after consulting different references is that the criteria for allocating resources should not be discriminatory, which was obvious to me, but I did not realize that considering the patient’s age could be seen as morally unacceptable. Through all of the ethical dilemmas, however, the clinician must still have the patient’s best interest at heart. I also learned that one can inform the patient of the lack of resources, but not to blame any party (government or administrative) to avoid triggering anxiety in patients. The most practical lesson learnt is that physiotherapy will require creativity in treatment approaches; patients might have to use tables and chairs to assist them with their gait!
Fortes, P. (2002). A study on the ethics of microallocation of scarce resources in health care. Journal Of Medical Ethics, 28(4), 266-269. http://dx.doi.org/10.1136/jme.28.4.266
McKneally, M., Dickens, B., Meslin, E., & Singer, P. (1997). Bioethics for clinicians: 13. Resource allocation. Canadian Medical Association, 157(2), 163. Retrieved from http://www.cmaj.ca/content/157/2/163.full.pdf