Home is where the heart is…the challenges of discharge

planning with people who have dementia.

Zoe Ellis

Rachel Wilson

Background

Physiotherapist and Occupational Therapist Secure GEM ward Multidisciplinary team

Aim

Ethical frameworks Case study Personal perspectives Positive solutions

Case Study – ‘Noel’

68 yr old male Fall - fractured hip Past medical history Life history

Discharge planning

Early planning Home Residential care

Guardianship

OCCUPATIONALTHERAPIST

PHYSIOSOCIALWORK

DOCTOR.NURSES

NOEL

GP

DAUGHTER

CASE MANAGER

HOSPITAL TEAM

Discharge Planning

NEUROPSYCHOLOGIST

Case Manager

Identified risks Residential care Guardianship

Daughter

‘he would die in residential care’ Discharge home Community services Independent spirit

General Practitioner

Decision making Guardianship Residential care

Noel’s Perspective

Home No services Independent life

Team perspective

OCCUPATIONALTHERAPISTPHYSIO

SOCIALWORK

DOCTORNURSES

NEUROPSYCHOLOGIST

Where to from here?

Will it be possible to respect Noel’s wish to return home?

Ethical concepts

Ethical dilemma

‘…(when) acting on one moral conviction means behaving contrary to another or when adhering to one value means abandoning another.’(Bluemenfield & Lowel 1987)

Autonomy

‘Individual choice or freedom to follow one’s own will’ (Beauchamp & Childress 1995)

Beneficence

‘Health care professionals ‘do good’ in their decisions regarding actions towards patients’(Beauchamp & Childress, 1994)

‘…entails not only preventing harm but also actively promoting the health and welfare of the patient’(Cummings & Cockerham, 1997)

Paternalism

‘…health care professionals assert their own risk-benefit analysis over that of the patient and families in the belief that they are protecting the best interests of the patient’(Cummings & Cockerham, 1997)

Competence

Complex issue Application to Noel’s case Guardian

Assessment process

Hospital and community based assessments Strengths and weaknesses Risk versus safety

Noel’s Journey

Discharge home Support services

Personal perspectives

Positive solutions

‘What does safety mean to this person in the context of their life?’

Compromise Patient autonomy Team work

Conclusion

References

Beauchamp, T. & Childress, J. (1994). Principles of biomedical ethics (4th edition). New York:Oxford University Press.

Bluemenfield, S. & Lowel,J.I. (1987). A template for analysing ethical dilemmas in discharge planning. Health and Social Work, 12,47-56.

Cummings, S. & Cockerham, C. (1997). Ethical Dilemmas in discharge planning for patients with Alzheimer’s disease. Health & Social work, 22(2),101-108

OT Australia (2001), Australian Association of Occupational Therapists, Code of Ethics.

Reamer, F.G (1983). The concept of paternalism in social work. Social Service Review, 6,254-271