Ethical issues in rehabilitation: conceptualizing the next generation of challenges

Characterizing socially supportive environments relating to physical activity participation for young people with physical disabilities

PURPOSE

To explore the experiences of young people with physical disabilities relating to social inclusion and physical activity, in order to describe the characteristics of social environments that support participation in physical activity.

METHOD

An iterative, qualitative design employed in-depth, semi-structured interviews with young people with physical disabilities aged 12-18 (n = 11). Data were analyzed using interpretive thematic analysis.

RESULTS

Young people described several ways that their social environments help motivate and support them in their physical activity participation. These include providing: fair and equitable participation beyond physical accommodations; belonging through teamwork; and socially supported independence.

CONCLUSIONS

Supportive social environments characterized by equitable participation, a sense of belonging, and opportunities for interdependence, play a critical role in promoting the health and well-being of young people with physical disabilities. These characteristics are important to consider in the design of both integrated and dedicated physical activity programs.

Purposes and mechanisms of goal planning in rehabilitation: the need for a critical distinction

PURPOSE

To determine a preliminary typology of purposes and mechanisms ascribed to goal planning in rehabilitation. To demonstrate the importance of making a critical distinction between these different purposes and mechanisms when reviewing or designing research on goal planning in rehabilitation.

METHOD

A search of Medline, Embase, PsychINFO and CINAHL for articles on goal planning in rehabilitation. Articles were only included if they were about patient populations and made explicit statements regarding the function or purpose of goal planning in rehabilitation. Thematic analysis was used to qualitatively synthesise the purposes and mechanisms of goal planning described in the literature.

RESULTS

Four major purposes for undertaking goal planning in rehabilitation are identified: (1) to improve patient outcomes (as determined by standardised outcome measures), (2) to enhance patient autonomy, (3) to evaluate outcomes, and (4) to respond to contractual, legislative or professional requirements. The first of these purposes is associated with four distinct mechanisms with the remaining three purposes appearing to relate to one underlying mechanism.

CONCLUSIONS

This typology offers one approach for critically engaging with the wide-ranging issues in goal planning. Debate stemming from this work could facilitate systematic reviews of this area as well as guide research and application to practice.

Application of Rehabilitation Ethics to a Selected Burn Patient Population’s Perspective

BACKGROUND

Flame injury confers significant physical and psychologic stress on burn patients. Because most patients and their surrogates lack an understanding of burn injury, and these injuries preclude the meaningful exercise of patient autonomy, informed consent is a challenge for physicians. To better promote patient autonomy, this project collected patient perspectives on the proper duties of patients and physicians after severe burn injury and throughout the recovery phases.

STUDY DESIGN

Ten survivors of severe burn injury were prospectively identified to represent different causes of injury, support systems, and socioeconomic backgrounds. Six persons participated (4 men, 2 women). Personal interviews with these individuals discussed their perspective and experience regarding physician and patient duties after severe burn injury as they relate to patient autonomy.

RESULTS

All participants thought that informed consent was unrealistic at the time of their injury, but that this capacity developed over time as their understanding and level of functioning improved. In addition, all believed that the burn physicians' role was to do whatever was medically best for their patients in an emergency situation, but that this duty included the physician educating the patient or surrogates about what these treatments entail.

CONCLUSIONS

Patient autonomy may be an unrealistic goal acutely for patients with severe burn injuries. Educational approaches to consent may facilitate patient autonomy, participation in decision making, and adherence to care plan over time. The ethical framework for this approach has been accepted in rehabilitation literature, but this is the first demonstration that relevant patient populations agree with this approach.

Just regionalisation: rehabilitating care for people with disabilities and chronic illnesses

BACKGROUND

Regionalised models of health care delivery have important implications for people with disabilities and chronic illnesses yet the ethical issues surrounding disability and regionalisation have not yet been explored. Although there is ethics-related research into disability and chronic illness, studies of regionalisation experiences, and research directed at improving health systems for these patient populations, to our knowledge these streams of research have not been brought together. Using the Canadian province of Ontario as a case study, we address this gap by examining the ethics of regionalisation and the implications for people with disabilities and chronic illnesses. The critical success factors we provide have broad applicability for guiding and/or evaluating new and existing regionalised health care strategies.

DISCUSSION

Ontario is in the process of implementing fourteen Local Health Integration Networks (LHINs). The implementation of the LHINs provides a rare opportunity to address systematically the unmet diverse care needs of people with disabilities and chronic illnesses. The core of this paper provides a series of composite case vignettes illustrating integration opportunities relevant to these populations, namely: (i) rehabilitation and services for people with disabilities; (ii) chronic illness and cancer care; (iii) senior's health; (iv) community support services; (v) children's health; (vi) health promotion; and (vii) mental health and addiction services. For each vignette, we interpret the governing principles developed by the LHINs - equitable access based on patient need, preserving patient choice, responsiveness to local population health needs, shared accountability and patient-centred care - and describe how they apply. We then offer critical success factors to guide the LHINs in upholding these principles in response to the needs of people with disabilities and chronic illnesses.

SUMMARY

This paper aims to bridge an important gap in the literature by examining the ethics of a new regionalisation strategy with a focus on the implications for people with disabilities and chronic illnesses across multiple sites of care. While Ontario is used as a case study to contextualize our discussion, the issues we identify, the ethical principles we apply, and the critical success factors we provide have broader applicability for guiding and evaluating the development of - or revisions to - a regionalised health care strategy.