Ethical Issues in Medical Rehabilitation: The Dilemma of Who to Admit : American Journal of Physical Medicine & Rehabilitation

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Literature Reviews

Ethical Issues in Medical Rehabilitation

The Dilemma of Who to Admit

Friedman, Alan MD; Friedman, Basil MD; Lutzky, Lena MD; Friedman, Elisha; Strous, Rael D. MD; Treger, Iuly PhD

Author Information
American Journal of Physical Medicine & Rehabilitation: December 2022 - Volume 101 - Issue 12 - p 1168-1174
doi: 10.1097/PHM.0000000000001971

Abstract

Medical rehabilitation services, as defined by the American Academy of Physical Medicine and Rehabilitation and adopted by the American Medical Association, are “a coordinated multidisciplinary approach to disability under a qualified physician who directs a plan of management for one or more of the categories of chronic disabling diseases or injuries, specifying realistic goals for maximum recovery.”1 However, how does one decide to whom to provide this care in a world of not unlimited resources? In this review of rehabilitation department admission criteria, we provide an overview of general principles as well as practical medical criteria and applied triage protocol. The intention of the study was to evaluate and describe specific resource allocation principles and any specific ethnical concerns in modern rehabilitation hospital practice of relevance to these allocation principles.

METHODS

Search strategies were based on the objectives for the study. The following terms were included in the search: rehabilitation, admission criteria, and ethics (including combinations of these terms). A systemic search was conducted in six sources (MEDLINE/PubMed, Google Scholar, ScienceDirect, Cochrane Library, LILACS, Embase) in accordance with preferred reporting items for systematic reviews and meta-analyses statement guidelines.2 Searches were limited to English language articles with no date restriction, reflecting all available data. (The LILACS database is not English but returned no results.) The final search was performed on February 11, 2021. Search strategies used for most of the databases (MEDLINE/PubMed, Google Scholar, ScienceDirect, Cochrane Library, LILACS) followed the MEDLINE/PubMed model. We used three search terms (“rehabilitation,” “admission criteria,” and “ethics”) combined with the Boolean operator AND. In an attempt to capture more results, searches were also done using the term “admission” in lieu of admission criteria. The MEDLINE/PubMed, Cochrane, and Science Direct databases followed this model. In the LILACS database, the search terms were inserted without a Boolean as suggested in the online tutorial. When searching Google Scholar, the three search terms were placed in quotation marks and separated by a Boolean operator “AND.” Google Scholar then suggested further terms of which “rehabilitation centers selection of patients” was appropriate and was used. The EMBASE database uses a more unique search method. The search terms were also used as “explosion” terms and terms in addition to the basic word search.

Data deduplication was conducted with a manual search in Microsoft Word. Full articles were obtained for any abstracts judged eligible for inclusion, and their relevance was assessed. One reviewer screened and assessed searches for eligibility. This study conforms to all preferred reporting items for systematic reviews and meta-analyses guidelines and reports the required information accordingly (see Supplementary Checklist, Supplemental Digital Content 1, https://links.lww.com/PHM/B518). Construction of the algorithm occurred actively over time. Upon opening the department, we initially adopted a trial period of accepting patients on a first-come first-served basis. After a few months, once the initial demand and patient population were clearer, there was a meeting between the senior physicians in the (rehabilitation) department, heads of the southern district of the medical fund/s, and the heads of other acute departments (neurology, orthopedics, surgery, and internal medicine). Together, we developed the most optimal system to service the catchment population in the most professional and ethical way. We updated the algorithm over time to address changing realities as they occurred.

Information regarding “The Soroka University Medical Center Experience” was collected from 2015 to 2020. There is one electronic medical system for the public health system, which includes the hospital and health fund district. We obtained the data obtained from this medical records system.

RESULTS

Database searching plus additional records gleaned from alternate sources (included references) resulted in 14 articles that met the desired criteria (Fig. 1).

F1
FIGURE 1:
Preferred reporting items for systematic reviews and meta-analyses flow diagram of literature search and selection process.

Ethics of Resource Allocation in Rehabilitation Services

Ethical dilemmas—including the question of allocation of resources—are not novel. All societies need to and do limit access to medical care on some level. According to Daniels and Sabin,3 “we lack consensus on principles for allocating resources and, in the absence of such a consensus, we must rely on a fair decision-making process for setting limits on health care.” As Rajput and Bekes4 proclaim, “as the knowledge of medicine, technology, and science continues to grow, the challenges of regulation, policy, and ethical issues in the hospital setting and elsewhere in the health care system will occupy physicians for some time to come.” How to establish such processes and how to allocate medical resources in general include ethical dilemmas as to whom to provide services.5,6 When investigating ethical decision making, Hughes and Griffiths7 recorded doctors’ discussions and concluded that age, lifestyle, and wider social structural factors seem to influence outcomes. Vincent8 reported “interesting differences between what a physician actually does and what he or she believes should be done.” Physical medicine and rehabilitation (PM&R) is no exception,9,10 and as the field has matured so has the discussion on allocation of resources and ethical issues.

It is clear that when it comes to allocation of resources, there are several guiding principles from an ethical perspective. These include consideration of value of life, equality of all individuals, transparency, consistency, equity in access, fair distribution, greatest good to the greatest number, preserving societal humanity, compassion to all patients, and promoting public trust. Caplan et al.9 stated that “the goals of rehabilitation are to restore patients to optimal self-sufficiency and functional performance.” Although these are all important ethical values, they may at times conflict with each other. For example, while “value of life” is indeed important, it may at times be at odds with the principle of “greatest good to the greatest number” or utilitarian good.

We, therefore, set out to define what practical tenets are particularly important and crucial in determining the critical allocation of resources regarding rehabilitation in a real-life setting. This is with respect to a rehabilitation unit in a general hospital located in a developed country with limited medical resources in peripheral areas of the country. Specifically, we attempted to assess what ethical criteria are used to admit patients to a general rehabilitation ward. There have been attempts to establish admission criteria for cerebral vascular accident patients,11–13 but these are usually not based on ethical criteria. The focus tends to be on presumed prognosis, medical stability, discharge location, and (anticipated) length of stay. Nevertheless, as Ilett et al.14 showed “there may be variations in practice in selection for rehabilitation leading to inequities of access.” Furthermore, those criteria assist in accepting one stroke patient over another. They do not address the issue of whom to accept when faced with limited space (or resources) and patients with different diagnoses such as seen in a general rehabilitation department. Practice guidelines for both, stroke and hip fracture management, already exist and recommend that rehabilitation services be provided as part of the acute and postacute treatment to minimize loss of function and prevent disability15–17 but again do not address ethical considerations or on what basis to accept a stroke patient over a brain injury patient for example.

The Experience of Other International Centers

To understand what issues confound and challenge physiatrists when considering admission to the rehabilitation ward, it is important to consider the experience of others and how similar centers address and manage the dilemma. A Hastings Center report on Ethical and Policy Issues in 1987 stated that until recently, ethical issues in the field of medical rehabilitation had received little attention. They point out that the challenge is sometimes greater in PM&R as it is a medical specialty lacking an age, organ, technology, or appendage to define it. Rehabilitation doctors must treat the whole person rather than discrete physical, emotional, or sensory dysfunctions. In addition, as opposed to other specialties (especially inpatient departments), a distinctive aspect of rehabilitation is that practitioners choose the patients and once a referral has been made it is usually the physiatrist who screens the patient for rehabilitation. This places rehabilitation physicians squarely in the middle of the admission decision and the moral issues it raises. In addition, because family members play an important role in the treatment of a rehabilitative patient, the role—and possible rights—of family members is more prominent.9

When looking at which patients in acute stroke units were referred for rehabilitation, Lynch et al.18 found that the decision to refer for rehabilitation was not made purely on the patient’s needs. Treating clinicians tended to refer patients whom they thought would be accepted by the rehabilitation service. Some staff were concerned that referring all patients with stroke-related deficits to rehabilitation would be “unfavorable” with rehabilitation providers. Overall, only a small percentage of stroke patients were even referred for a rehabilitation evaluation.18,19

Haas20,21 addressed various dilemmas and inequities involved with whom to admit. She noted that perhaps resources should not be expended upon patients who will not benefit from treatment. “Selection criteria vary; discrepant standards may be invoked from one patient to the next. Program-oriented centers may give preference to patients with specific diagnoses, thus excluding equally deserving persons with different disabilities,” as well as issues that can influence the decision to admit a patient to the rehabilitation department: prognosis, ability to pay, age, vocation, and disposition issues. They recommended that guidelines delineating standards for admission be established.20,21

Blackmer22 observed that the final decision is ultimately made subjectively by the physiatrist, regardless of whether criteria exist. There is a fine line between beneficence and justice, and doctors must also remember that not all patients want rehabilitation.

In a lecture to the American Academy of Physical Medicine and Rehabilitation, Strax23 stressed the need for ethical criteria in decision making so as not to discriminate against less powerful or affluent populations. However, he offered no suggestions as how to accomplish this.

Hakkennes et al.24 attempted to identify patient-related factors related to stroke rehabilitation decisions and outcome. Although age was found to be independently associated with discharge to rehabilitation, it was one of the lowest ranked items in importance in the rehabilitation assessor decision-making process. Despite their statement that best practice guidelines are that all patients after acute stroke receive care in a specialized stroke unit, they warn that acceptance of patients who do not benefit from inpatient rehabilitation could be considered a misuse of healthcare resources. In conclusion, the authors stated that there is a considerable variation in practice with regard to inpatient rehabilitation admissions after stroke.24,25

The Australian Stroke Coalition Rehabilitation Working Group established that all acute stroke patients must be referred to rehabilitation unless they meet one of four exceptions ([1] return to premorbid function: full recovery in all aspects including physical, emotional, psychological, and cognitive; [2] death is imminent—in which case they should be referred for palliative care; [3] the patient is in a coma and/or is unresponsive; [4] the patient declines rehabilitation).26 Although these are meant as clinical guidelines, they can also serve as ethical baselines for admission.

Kennedy et al.27 surveyed key factors involved in decision making when selecting patients for rehabilitation after stroke and to examine the level of agreement among physician assessors regarding admission to rehabilitation. The most influential clinical factors listed were prognosis, social support, anticipated discharge destination, age, and anticipated length of stay. All respondents agreed that prognosis was a key factor. The outcomes of this study were mixed. In some cases, high levels of agreement were demonstrated, for example, prognosis was the key factor for selection for rehabilitation. Low levels of agreement for some of the case scenarios were associated with divergent views about prognosis in the case examples. The authors advise that when assessing patients for rehabilitation, a balance should be maintained between those who will clearly benefit and those who may not benefit.27

Kirshblum et al.28 and Kirschner et al.29 addressed challenges inherent in caring for VIPs, defined as “high profile individuals who have celebrity status in the fields of business, government, education, entertainment and/or sports.” Unique to these patients is not only the decision-making process in whether to admit them but also that their presence often impacts the other patients already in the ward. The team of experts counseled that even in these cases, “all patients, including VIPs, must meet the same criteria for admission based upon their diagnosis and impairments, prognosis and ability to both participate in and benefit from the rehabilitation program.” It helps neither the VIP patient nor the physicians or facility if they are not appropriate rehabilitation candidates. Furthermore, they stressed the importance of not changing usual hospital practice—including the physician in charge of care. The lead physician “should be the clinician who has the most expertise in this particular diagnosis.” Other ethical challenges with such patients include the need for police protection, addressing the media on their care/providing status updates, and avoiding subspecialized and fragmented care.28,29 They recommend following Guzman’s nine principles of caring for VIPs, which include some of the above plus avoiding “VIP syndrome” and perhaps most important—the need to “communicate communicate communicate.”30,31

The Soroka Experience

The Department of PM&R at the Soroka University Medical Center was established 6 yrs ago. The department consists of 20 beds with a catchment area similar to half of the state of New Jersey. The number of annual referrals to rehabilitation reflects the regional activity and is presented in Table 1. We service a diverse socioeconomic population, ranging from nomadic Bedouins to professors and high-tech professionals. The department is a general rehabilitation unit, caring for patients with all diagnoses, including stroke, spinal cord injury, brain injury (including traumatic brain injury, encephalopathy, anoxia), multiple sclerosis, orthopedic surgeries (including amputations), post-COVID survivors, neuropathies, myopathies, and trauma. The unit is unique for a number of reasons: We are located within a tertiary-level acute care hospital, which is the only level 1 trauma center in the same, largely rural, catchment area. That this area is often an active war zone because of the conflict in the nearby Gaza region only adds to the need for a rehabilitation ward. This places further premium upon our beds for two reasons: being located in the rural periphery makes us the primary choice for most families, because they do not have to travel to the center of the country to visit their family member during a protracted rehabilitation stay. The second reason is that sicker patients are less likely to be able to be transferred to other facilities and need to stay in our facility, as all medical services are readily available if necessary. We have had particular success in rehabilitating patients with psychiatric illness, specifically patients with schizophrenia, who traditionally do not do well with psychiatric rehabilitation,32 and active, complicated oncology patients. We developed a program with the hematology and oncology departments to accept patients who are receiving chemotherapy but are too weak to receive further intervention. These patients are admitted to the department and provided rehabilitation services until they are strong enough to continue their cancer treatment.

TABLE 1 - Clalit HMO southern region—number of patients referred to inpatient and outpatient rehabilitation 2014–2020
Year Inpatient Rehabilitation Outpatient Rehabilitation
2014 868 484
2015 866 500
2016 1538 531
2017 1575 620
2018 1742 675
2019 1770 778
2020 1686 771

These factors lead to a high demand for relatively few beds, and almost immediately, we encountered a dilemma as to whom to extend these beds. Whether to admit patients who would only require relatively short rehabilitation stays, thereby enabling us to treat the highest number of patients or to admit those who may or may not be “successfully” rehabilitated, but in any event that would occupy a precious bed for an extended time. If some combination of the two, which seemed intuitive, how to determine that mix? Furthermore, as ours is a general rehabilitation ward, should one diagnosis take precedence over another (e.g., should we admit a paraplegic patient over a car accident victim)?

In the United States, one of the challenges for determining admission criteria revolves around government regulation and rules as it relates to Medicare. Raj and Pugh33 reviewed the development of the Centers for Medicare and Medicaid Services policies as it relates to reimbursement for rehabilitation care, including capitation plans, the “75% Rule” and subsequent modifications. The driving force behind these decisions is reimbursement. Essentially, the Centers for Medicare and Medicaid Services makes the decisions by virtue of controlling the purse strings. In Israel, the decision is simpler. Medical rehabilitation is part of the mandatory state-subsidized health care provided to all citizens.34 Israel’s health services are mandated by the national Health Insurance Law and are managed by the Health Maintenance Organizations (HMOs). Rehabilitation services exist in inpatient rehabilitation facilities or as outpatients, but subacute rehabilitation or long-term care hospitals do not exist. Although there is financial pressure on the HMOs to lower their costs by transferring patients quickly to rehabilitation, the doctors decide where patients receive rehabilitation not the HMO. However, because there are not enough beds, especially in our region, it magnifies the importance of “whom to admit.” With time, because of the growth in the demand for rehabilitation, the problem will be exacerbated (Fig. 2).

F2
FIGURE 2:
Inpatient and outpatient rehabilitation demand in the South Region of Israel (Clalit HMO).

This was the impetus for beginning the literature search, and not surprisingly, we discovered that we were not the first to entertain at least some of these questions. Unfortunately, review of the current literature reveals that there is no consensus regarding what criteria should be used to admit patients to a general PM&R ward. This may be due to no lack of available rehabilitation beds in any catchment area and/or no need to ration them.

Decision Algorithm

Through necessity, we developed our own internal criteria (Fig. 3, Table 2). The ultimate criterion is who can benefit the most from our services. Regardless of diagnosis, if we feel that a certain patient is likely to benefit the most from our facility as opposed to other options (community outpatient care, subacute-type inpatient or inpatient in other areas of the country), we will accept that patient to our department—even in lieu of a patient with a more classic rehabilitation diagnosis. Thus, when having to choose between two or more such patients, we take ward optimization and if necessary “first come, first served” principles into consideration (although these are also part of the initial decision). An example of this decision tree is our large Bedouin population. Their nomadic lifestyle provides less opportunity for community-based rehabilitation or for the family to travel a few hours by car daily to visit a patient in the center of the country. As a result, we often admit Bedouin patients whom otherwise would have been referred to other options. Similarly, we may accept a patient with an expected prolonged inpatient rehabilitation hospitalization specifically to spare the family a long daily ride. We filter those who are able to benefit from less intensive rehabilitation facilities as well as those who require care in a specialized unit (e.g., severe spinal cord or traumatic brain injury patients). This allows us to best triage the up to 20 daily requests for admission. On the other hand, we accept patients who would not necessarily fit our typical population. We do not have an upper or lower age limit—having accepted patients aged 14–88 yrs. We admit patients who, by strict decision algorithms, would be referred to geriatric rehabilitation (less intensive, perhaps only one discipline) but were active before their injury/medical event. Others who because of medical diagnosis or other factors have been declined for admission by several other facilities come to our unit.

F3
FIGURE 3:
General rehabilitation decision algorithm.
TABLE 2 - Local algorithm for admission priority to the Soroka rehabilitation department
Admission Decision Component High Priority Low Priority
Medical status and need for intensive medical follow-up by other specialties Stable medical situation with continuous need for immediately available medical treatment and follow-up Stable medical situation with no need for special medical treatment or follow-up
Rehabilitation status and need for specialized professional care Patients with “general” rehabilitation problems, e.g., stroke, amputees, multi trauma, deconditioning Patients with spinal cord injury or severe traumatic brain injury (As there are specialized units in other facilities)
Functional status and need for interdisciplinary professional intensive rehabilitation program Intensive interdisciplinary rehabilitation program is essential for patient’s functional improvement Patient can improve with one discipline and less intensive treatment program
Social status and family’s ability to travel long distances to support the patient in another facility Low socioeconomic level, weak family support, and inability to travel long distances High socioeconomic level, strong family support, and ability to travel long distances

DISCUSSION

There is no consensus in the literature as to whom to admit to a rehabilitation unit. Both, Blackman and the Hastings Center report, touch upon a crucial element in the discussion—the fact that in contrast to other disciplines, physiatrists actively choose whom to admit. These decisions are not made on purely clinical criteria (i.e., the patient requires a ventilator). In our department, the decision of whom to admit is made by one of the senior physicians, but the ultimate timing of when the patient is admitted is made in consultation with the head nurse.

Although rife with recommendations for admission criteria for specific diagnoses (strokes, hip replacement, etc.), the literature is sparse on guiding principles, and no one has addressed a cross-diagnostic decision approach. Some of the suggested criteria—such as prognosis29—are not transferrable to our unit as described previously regarding our catchment area and population. Other variables identified by Kennedy et al.27 and Haas,21 anticipated length of stay, ability to pay, and disposition issues, are not issues in our socialized-medicine milieu. As mentioned, age has very little to do with our decisions other than those younger patients who have fewer other options.

Ultimately, although numerous selection criteria abound, they are clinical not ethical decisions. There remain no ethical criteria that cross-diagnostic boundaries. Haas21 is correct in saying that “discrepant standards may be invoked from one patient to the next.” Because there is no criterion standard, we developed our own approach that attempts to ethically accommodate everyone as best as possible. We do not make admissions dependent on diagnosis or social factors but rather a combination of diagnosis, social factors, and, most of all, whether this specific patient can benefit the most from our department. In this manner perhaps, it may be stated that rehabilitation is not a typical medical specialty, all decisions and treatments are multidisciplinary and multifactorial, but to minimize systemic or facility-based admission biases, more standardized criteria may indeed be necessary.

Study Limitations

These results reflect the findings in a single ward in a single medical district. They may not represent the reality in other facilities. In addition, facility is based on a socialized medicine system, and the decision algorithm may not be applicable to other medical systems. The numbers collected are small as ours is a small department. A large facility may not encounter the same restrictions and limitations.

CONCLUSIONS

This review highlights a number of important ethical issues in modern rehabilitation hospital practice, resource allocation principles, and rehabilitation selection criteria. These may assist clinicians in improving selection procedures and standardizing access to inpatient rehabilitation. Further high-quality empirical research studies and reviews of ethical admission practice with regard to rehabilitation acceptance are required.

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Keywords:

Rehabilitation; Ethics; Admission Criteria

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