Analysis of an Ethical Dilemma

Analysis of an Ethical Dilemma

Introduction

This study illustrates an ethical dilemma that I faced while treating an 86-year-old woman at her home. The ethical dilemma was caused due to several factors such as the expectations of the client (client/ consumer rights), organizational expectations (employer, governmental and payer-source regulations) and my own personal values (one's moral philosophies, perceived social responsibilities, sense of professional duty) and how they all interact with each other. The case is a classic example of a seemingly simple yet frequent dilemma encountered by occupational and physical therapists in the United States serving clients who are covered by Medicare (the government's health insurance) for home health. The study is aimed at highlighting the various ethical principles involved in clinical decision-making, and it suggests methods for resolution of ethical dilemmas. Although the study is based against the backdrop of the US health care system, students and health care practitioners globally can relate to it.

The ethical dilemma in the case discussed below involved whether or not to continue treating a client who clearly needed occupational therapy services based on medical necessity, yet the payer-source (Medicare) coverage criteria for services to be delivered at home was questionable. That is, should one continue to treat the client and uphold the principle of beneficence yet run afoul of the law, or should one discontinue treating the client to uphold the law but possibly cause harm to the client?

The Case Scenario

Three years ago, Ms EH, an 86-year-old woman, was referred to me after a debilitating stroke affected her right side (pre-morbidly her dominant side). Ms EH was admitted under home health after running out of Medicare allowable days at a skilled nursing facility (SNF). Ms EH needed considerable assistance with all activities of daily living (ADL) and was primarily wheelchair-bound due to her inability to walk independently. She lived with her 88-year-old husband Mr. RH, who was also not in the best of health. Due to financial constraints the couple opted against long-term or assisted living placement in favor of their trailer home. Ms EH demonstrated good rehabilitation potential and progress with all her home health services.

One night, approximately three weeks after her return home from the SNF, Mr. RH suffered a massive myocardial infarction. He was hospitalized and underwent cardiac catheterisation. It indicated diffuse blockage of multiple vessels and he was deemed a poor candidate for surgery. Subsequent medical interventions were primarily conservative with a poor prognosis. He was later transferred to a nursing home. Ms EH obviously was very concerned and depressed about the situation. She was devoted and would visit Mr. RH for four to six hours everyday at the nursing home after being driven there by her friends and family. No one could persuade Ms EH to avoid the exertion. She would simply state, "He has always been there for me. Shouldn't I?"

Soon after her husband's admission to the nursing home, Ms EH began to have difficulty keeping up with her appointments with me and the other home ...