Respect for autonomy: issues in neurological rehabilitation

Disorders of Consciousness Rehabilitation: Ethical Dimensions and Epistemic Dilemmas

Patients with disorders of consciousness who survive to discharge following severe acute brain injury may face profoundly complex medical, ethical, and psychosocial challenges during their courses of recovery and rehabilitation. Although issues encountered in caring for such patients during acute hospitalization have received substantial attention, ethical challenges that may arise in subacute and chronic phases have been underexplored. Shedding light on these issues, this article explores the landscape of normative issues in the course of treating and facilitating access to care for persons with disorders of consciousness during rehabilitation and examines potential implications for patients, clinicians, family members, and society.

[The Autonomy of Patients in Inpatient Medical Rehabilitation - Aspects of Endangerment and Preservation]

PURPOSE

The aim of the study is to identify aspects within inpatient medical rehabilitation that may endanger or preserve the autonomy of patients.

METHODS

A scoping review was carried out on the basis of the current state of scientific knowledge. The methodological approach was based on the specifications of the Joanna Briggs Institute. The research and generation of findings were logged according to the PRISMA-ScR checklist.

RESULTS

The final study inclusion comprises 39 empirical and normative-theoretical contributions. Autonomy-threatening aspects were assigned to the following domains: Rehabilitation system, rehabilitation clinics, staff, patients and third parties. Aspects potentially preserving the autonomy of patients included the following domains: Rehabilitation clinics, staff, concepts and forms of expression as well as instruments.

CONCLUSION

A large number of heterogeneous aspects can endanger, but can also preserve or promote the autonomy of patients during their stay in inpatient medical rehabilitation. These are located throughout in the entire rehabilitation process and concern the structural, organizational and personal level. The autonomy of patients should not only be treated as an outcome of rehabilitation, but also as a requirement for structures and actors during the rehabilitation stay.

A phenomenological exploration of source isolation in patients infected with multi-drug resistant organisms

BACKGROUND

The physical isolation of patients colonised or infected with multi-drug resistant organisms is a requirement in hospitals considering the risk of infecting other patients, healthcare workers and visitors. However, how these patients experience isolation in the current environment is not fully understood from the literature.

AIMS

To explore and interpret the lived experience of the source isolation in patients infected with MDROs within an Australian setting.

DESIGN

Hermeneutic phenomenology was utilised as the philosophical framework.

METHODS

Unstructured in-depth face to face interviews were conducted with 20 patients infected with multi-drug resistant organisms who were physically isolated. Data was collected from February-2018 to January-2019 at two large teaching hospitals in the Sydney metropolitan area. The interviews were recorded, transcribed verbatim, analysed using thematic analysis by three researchers, and then subsequently interpreted, drawing insights from the relevant phenomenological notions.

RESULTS

Three key findings emerged from the study as: Living in a changed space - developed from the participants' struggle to cope with being physically confined to a room that made them feel imprisoned. Living in a changed body - emerged from the participants who described their bodies as 'different' because of bacteria that conventional medicine could not destroy permanently but kept relapsing. Striving to survive - developed from participants who spoke about means of enduring some unfavourable experiences.

CONCLUSION

The essence of the lived experience of the phenomenon of source isolation from the perspectives of patients who become infected with MDROs emerged as Being-in-a-changed-world.

IMPACT

While source isolation is an important procedure for preventing and controlling transmissible infection; it often results in adverse psychological experiences. An understanding of this finding from the patients' perspectives is essential for nurses and other healthcare workers involved in their care to maintain a balance between infection control isolation and psychological needs.

Experiences of inpatient rehabilitation from the perspective of persons with acquired brain injury

BACKGROUND

Perspectives of individuals with acquired brain injury (ABI) regarding inpatient rehabilitation experiences can inform patient-centered care; however, these voices are under-represented in the literature.

PURPOSE

To explore the experiences, needs, and preferences of patients from an ABI inpatient rehabilitation program in Ontario.

METHODS

Using an interpretive description approach, we interviewed 12 participants and analyzed the transcripts inductively to generate themes.

FINDINGS

We identified three major themes: (1) Life Rerouted - participants felt their lives diverted due to ABI, with rehabilitation seen as a way to return to pre-injury life, (2) Autonomy within Rehab highlighted the perceived importance of personal autonomy in decision-making within rehabilitation, and (3) Life (and Recovery) Go On reflected an ongoing recovery process after discharge - leading to mixed emotions. An overall message, "re-establishing personal identity is important to the recovery process," reflected theories of biographical disruption and relational autonomy.

IMPLICATIONS

Our findings provide a patient perspective for clinicians and administrators to consider. We found that ABI was significantly disruptive to personal identity - resulting in tensions in autonomy while attempting to reclaim a sense of identity. We suggest counseling services and strategies supporting post-injury adjustment, along with ways for rehabilitation professionals to enhance patient autonomy where possible.Implications for rehabilitationSustaining an ABI can significantly disrupt personal identity and sense of autonomy - especially as persons occupy the role of "patient" while in inpatient rehabilitation.Psychological support is recommended to address the impacts of ABI on patients' sense of identity, as well as on family members.Strategies of support might include, providing formal psychotherapy, as well as creating opportunities for patients and family members to discuss the changes they are experiencing, and to establish their personal narratives (e.g., through writing or art) or peer mentorship programs between discharged and current patients.Clinicians can enhance patient autonomy by increasing opportunities for communication with patients about choice; educating patients and family members on the rehabilitation team's decision-making process, and other methods that increase communication and provide consistent up-to-date information to patients and their family members.

Is independence enough? Rehabilitation should include autonomy and social engagement to achieve quality of life

PURPOSE

This discussion paper argues that holding independence as the central goal for rehabilitation has limitations that hinder successful outcomes. It shows why autonomy and social engagement should also serve as goals of rehabilitation, in order to achieve quality of life and effective functioning.

METHODS

The paper reviews problems arising from the over-emphasis on independence in rehabilitation. Although independence is a valuable goal on some tasks, it is sometimes not possible or desirable and is best complimented by autonomy and social engagement. Autonomy recognises that enacting some goals requires the support of other people. Autonomy is thus linked to social engagement (connectivity) in the workplace and personal relationships. The paper applies this framework to motor and cognitive disabilities.

RESULTS

The inclusion of autonomy and social engagement as goals for rehabilitation addresses the limitations of independence and can serve the unifying aim of enhancing the person's quality of life. These goals apply equally to motor disabilities and the cognitive and behavioural effects of injuries which affect personal and work relationships.

CONCLUSIONS

Rehabilitation is likely to be more effective if it aims at a combination of independence, autonomy and social engagement, in service of the goal of a good quality of life.

Interdisciplinary Collaborative Goal Planning in a Post-Acute Neurological Setting: A Qualitative Study

The aim of this qualitative study was to explore the use of interdisciplinary collaborative goal planning from the perspective of patients, their relatives and professional staff. Eighteen patients and their relatives who had been involved in collaborative goal planning were interviewed individually after the patient was discharged from the ward of a neurological rehabilitation hospital. The members of the interdisciplinary team responsible for implementing the goal planning process were also interviewed.

The findings showed that the majority of the patients and their relatives valued highly the opportunity to become actively involved in their care and discussed the impact of this on motivation, perceptions of control and freedom in decision making. The professional staff also identified benefits, which included giving clarification and direction to treatment and further opportunities for patient-centred practice. Challenges emerged as well, including the question of how to implement collaborative goal planning with people with severe language or cognitive impairment, those with poor insight or those in low awareness states. Further consideration of the issues raised is recommended as a means to promote patient-centred care.

From Persuasion to Coercion: Responding to the Reluctant Patient in Rehabilitation

Early mobilization of patients while in hospital has been demonstrated to provide better outcomes for patients and use fewer resources. Physical therapy-based rehabilitation is central to achieving those goals. Successful rehabilitation requires that patient's and therapist's goals align, and this is commonly the case. However, occasionally, physical therapists will come across patients who are competent but reluctant to mobilize. This situation leaves the physical therapist in an ethical quandary: either accept the patient's right to refuse proposed treatment or utilize other strategies to encourage the patient to adhere to treatment. Practically, physical therapists will use a range of treatment pressures, including persuasion, offering incentives, inducements, possibly threatening or coercing, and even explicitly overriding the patient's wishes (compulsion). Deciding which treatment pressure is ethically acceptable involves the physical therapist balancing his or her therapeutic view of what is in a patient's best interests against the therapist's ethical responsibility to respect patient autonomy. This article evaluates some common strategies used by physical therapists to influence, persuade, or perhaps pressure patients to adhere to rehabilitation. The work of Szmukler and Appelbaum is utilized in analyzing treatment pressures. The authors conclude that there is a spectrum of treatment pressures, with some (persuasion and incentives) being more acceptable than others (threats and compulsion). As physical therapists balance health system pressures for rapid turnover of beds with obligations to benefit patients within limited reimbursement models, while respecting the patients' autonomy, they must be mindful of the effects of treatment pressure on patient care.

Actual Interaction and Client Centeredness in Home Care

The purpose of this study is to explore client-nurse interaction from a client perspective with respect to client-centered care. A grounded theory study was conducted with Dutch clients who were chronically ill and receiving home care. Data were collected by focus interviews with 8 client informants, participatory observations with 45 clients, and semistructured interviews with 6 clients. The core category actual interaction was identified. Six patterns of actual interaction were distinguished. Changes in actual interaction could be related to changes in desired participation by the client and in allowed client participation by the professional. From the client's perspective, client-centeredness means congruence between desired and allowed participation. Congruence was experienced with consent, dialogue, and consuming. Congruence is not necessarily synonymous with promoting patient participation or with doing as the client wants. Ongoing attentiveness, responsiveness, promotion of client autonomy, and being a critical caregiver are recommended.

Understanding through experience: information, experience and understanding in clinical rehabilitation practice

PURPOSE

According to ethical theories of patient autonomy, patients need information and understanding to make their own, autonomous choices. The aim of this article is to describe strategies used by clinical rehabilitation teams to develop patients' understanding and promote their autonomy.

METHOD

Individual semi-structured interviews were conducted with the patient, the nurse, the physiotherapist and the physician of three institution based rehabilitation teams. Analytic procedures described by Strauss and Corbin were applied, identifying categories by their properties and dimensions.

RESULTS

The analysis revealed how practitioners recognized that patients needed experience with practical challenges in order to understand their clinical conditions properly. Practitioners disclosed information related to the individual patient's experience with his or her clinical condition. In order to make information relevant to the individual patient's experience of possibilities and limitations, information was disclosed in discussions of these experiences, rather than in abstract verbal explanations. Patients needed to understand their situation to make autonomous choices for their future lives.

CONCLUSIONS

In clinical rehabilitation, patients and practitioners agree that adequate understanding cannot be achieved by verbal information alone, and that patients need to experience essential aspects of their physical possibilities and limitations.

IMPLICATIONS FOR REHABILITATION

Patients need an adequate understanding of their injuries or diseases to be able to make autonomous choices. In clinical rehabilitation teams, practical and bodily experiences are recognized as crucial for patients to develop such understanding. Rehabilitation practitioners may effectively enhance a patient's understanding and autonomy by disclosing information as part of discussions of the patient's own experiences.

Whose decision is it anyway? How clinicians support decision-making participation after acquired brain injury

PURPOSE

To raise professional awareness of factors that may influence the support offered by clinicians to people with acquired brain injury (ABI), and to consider the potential implications of these factors in terms of post-injury rehabilitation and living.

METHOD

A review of the literature was conducted to identify factors that determine how clinicians provide support and influence opportunities for individuals with ABI to participate in decision making across the rehabilitation continuum. Clinical case studies are used to highlight two specific issues: (1) hidden assumptions on the part of the practitioner, and (2) perceptions of risk operating in clinical practice.

RESULTS

There are a range of factors which may influence the decision-making support provided by clinicians and, ultimately, shape lifetime outcomes for individuals with ABI. A multidimensional framework may assist clinicians to identify relevant factors and consider their potential implications including those that influence how clinicians involved in supporting decision making approach this task.

CONCLUSIONS

Participation in decision making is an undisputed human right and central to the provision of person-centred care. Further research is required to understand how clinical practice can maximise both opportunities and support for increased decision-making participation by individuals with ABI.

IMPLICATIONS FOR REHABILITATION

There is an increasing focus on the rights of all individuals to be supported to participate in decision making about their life. A number of changes associated with ABI mean that individuals with ABI will require support with decision making. Clinicians have a critical role in providing this support over the course of the rehabilitation continuum. Clinicians need to be aware of the range of factors that may influence the decision-making support they provide. A multidimensional framework may be used by clinicians to identify influences on the decision-making support they provide.

Physiotherapists in emergency departments: responsibilities, accountability and education

Emergency physiotherapy roles have evolved within the UK and are increasingly being adopted in Australia in response to a need for greater workforce flexibility and improved service provision to meet growing patient demand. This paper discusses the need for the physiotherapy profession to develop evidence-based regulatory, ethical and educative frameworks to keep pace with the changing clinical environment and service delivery in emergency departments. Definitions of Emergency Physiotherapy as either advanced practice or extended scope of practice are identified, and the implications for both regulation of practice and education are highlighted. Suggestions for education in areas of clinical skills, ethical understanding and legal and professional knowledge are highlighted as important areas to support physiotherapists moving into this area of practice.

Rehabilitation settings after joint replacement: an application of multiattribute preference elicitation

While advances in medical treatment and technologies have the potential to improve the delivery of health care, their use typically involves making multiple, complex decisions. Patients and their medical providers may share in the decision-making processes and balance a variety of criteria and/or attributes in the pursuit of improved health. This necessitates a stronger understanding of the role of human behavior in health care processes and presents a timely opportunity to use decision analysis tools to contribute to this important aspect of health care operations. This article reports on the application of multiattribute preference elicitation to identify postsurgical rehabilitation setting options for elective hip and knee replacement patients and their discharge planning team prior to placement in these settings. These preferences are analyzed to identify trends in emphases across patients and the discharge planning team, including a comparison with actual outcomes to determine the extent of congruence with each other, an important component of patient-centered care. Variances are identified in what patients and the discharge planning team expected and what actually happened. Reasons for these variances are discussed.

Ethics in goal planning for rehabilitation: a utilitarian perspective

Background: Past debate on ethics in goal planning for rehabilitation has tended to focus on tensions that can arise between ethical principles; in particular the principles of autonomy and beneficence. When setting goals, clinicians tend to prioritize the wishes of patients, justifying this from the perspective of maximizing patient autonomy. This is tempered by consideration of what is `realistic' and what the pursuit of `unrealistic goals' might be on patient well-being.

Rationale: In this paper it is argued that clinicians also have an ethical obligation to take into account the resource implications of goal planning. Utilitarianism provides one perspective on addressing such issues. A utilitarian approach to goal planning would necessitate a focus on maximizing the benefits of rehabilitation to the whole community served when negotiating goals with individual patients.

Critique: Clinicians may, however, have a number of concerns about utilitarianism. One assumption is that the quality of life of people with severe disability will be judged as being intrinsically low, and therefore valued less from a utilitarian perspective. A second assumption is that for people with severe disability the large effort expended in rehabilitation to achieve small gains cannot possibly repay itself in a utilitarian equation, specifically in financial terms. Evidence from the literature however has demonstrated that in fact both of these assumptions are probably false.

Conclusion: Rehabilitation professionals should not be hesitant to consider utilitarianism as an ethical framework for rehabilitation. In fact, rehabilitation may well gain if people were to use this approach.

Supporting stroke patients' autonomy during rehabilitation

In a qualitative study, 22 stroke patients undergoing rehabilitation in three nursing homes were interviewed about constraints on and improvements in their autonomy and about approaches of health professionals regarding autonomy. The data were analysed using grounded theory, with a particular focus on the process of regaining autonomy. An approach by the health professionals that was responsive to changes in the patients' autonomy was found to be helpful for restoration of their autonomy. Two patterns in health professionals' approach appeared to be facilitatory: (1) from full support on admission through moderate support and supervision, to reduced supervision at discharge; and (2) from paternalism on admission through partial paternalism (regarding treatment) to shared decision making at discharge. The approach experienced by the patients did not always match their desires regarding their autonomy. Support and supervision were reduced over time, but paternalism was often continued too long. Additionally, the patients experienced a lack of information. Tailoring interventions to patients' progress in autonomy would stimulate their active participation in rehabilitation and in decision making, and would improve patients' preparation for autonomous living after discharge.

Autonomy in stroke rehabilitation: the perceptions of care providers in nursing homes

Twenty-seven health care providers from three nursing homes were interviewed about the autonomy of stroke patients in rehabilitation wards. Data were analysed using the grounded theory method for concept development recommended by Strauss and Corbin. The core category 'changing autonomy' was developed, which identifies the process of stroke patients regaining their autonomy (dimensions: self-determination, independence and self-care), and the factors affecting this process (conditions (i.e. circumstances) and strategies of patients; strategies of care providers and families; and the nursing home). Teamwork on increasing patient autonomy is recommended, which can be stimulated by multidisciplinary guidelines and education, and by co-ordination of the process of changing autonomy.

Patient autonomy during rehabilitation: the experiences of stroke patients in nursing homes

This article describes the results of a grounded theory study among stroke patients (N=17, aged 50-85) in rehabilitation wards in nursing homes. Patient autonomy (dimensions: self-determination, independence and self-care) increases during rehabilitation due to patient factors (conditions and strategies of patient) and environmental factors (nursing home and strategies of health professionals and family). During rehabilitation patients are in a state of transition regarding autonomy: patients need support to enhance autonomy, gradually regain autonomy, and thereby need less support. Although facilitating environmental factors were discovered, patients also experienced constraining factors regarding patient autonomy. Health professionals should give more attention to self-determination and independence; the nursing home should offer stroke patients more opportunities to do familiar activities autonomously.

The development of a handicap assessment questionnaire: the Impact on Participation and Autonomy (IPA)

OBJECTIVE

To report on the feasibility and psychometric properties in terms of homogeneity and construct validity of a newly developed handicap questionnaire focusing on person-perceived handicaps: the Impact on Participation and Autonomy (IPA).

DESIGN

Cross-sectional. SETTING, subjects and outcome measure: One hundred consecutive individuals from the outpatient clinic of the department of rehabilitation of an academic hospital administered the new questionnaire IPA.

RESULTS

The results show good homogeneity and construct validity of the IPA. Factor analysis showed that the scale consists of four factors, explaining 68% of the total variance: social relationships, autonomy in self-care, mobility and leisure, and family role. Homogeneity of the four subscales was considered good, Cronbach's alpha ranged from 0.84 (family role) to 0.87 (social relationships). Feasibility in terms of the number of missing values and administration time needed was satisfactory.

CONCLUSION

The first results suggest that the IPA promises to be a useful handicap questionnaire. Further research is needed to establish test-retest reliability, convergent validity and responsiveness to change.