Ethical challenges for subacute providers.

As nursing facilities transition into developing subacute care programs, there are numerous considerations -- some obvious, some that are not quite as obvious and are difficult to predict. The obvious include, of course, the needs for subacute-oriented remodeling, construction, financing, staff, equipment and supplies. Less obvious, but just as important, are the attitudes, values and ethics that must be brought to bear on this new mission. Health care professionals accustomed to long-term care or acute care settings may find some adjustments are in order.

For instance, a subacute rehabilitation program will most likely see a younger patient with a shorter stay than that of a traditional nursing home resident. Long-term care staff will find their involvement with these patients to be more intense, with more emphasis upon timely discharge and return to independence. Staff coming from an acute care background find that patient involvement lasts longer, and that patients' families are often around and expressing their concerns. The patient's goals and family's goals can sometimes conflict concerning such issues as true functional capabilities or return to work. Staff members find that they will be called upon to mediate in such situations, providing all parties with the best information possible.

Issues of permanent disability or terminal illness will arise, a prime example being subacute programs focused on treating HIV/AIDS-related diseases. Staff will have to come to terms with the complications of managing such patients and learning to accept their different lifestyles -- and, occasionally, watching these younger patients die.

Administrators must attempt to hire staff based on flexibility of attitudes, as well as skills and technical capabilities. Just as some choose to work in a traditional nursing home with a slower pace and long-term personal involvements with residents and families, others enjoy the accelerated turnover of patients restored to relatively good health and the demands of the high technology involved. They feel more prepared to deal with the demands of families and the risks faced by younger patients.

While bioethics committees and education are not new to universities and large acute hospitals, they are of more recent advent in the long-term care setting. Skilled nursing facilities are finding them to be a welcome addition, particularly when adapting to subacute care, because the decisions are often complex and may require the skills and training of non-staff professionals and community members. Involvement of local clergy and legal professionals, along with other members of an ethics committee, can give your program an advantage. Ethics committee members are often a means of support and information that can provide direction towards answers to the tough questions that patients, their families, and subacute staff members may be grappling with.

This is one reason why ethics committee members can be helpful in developing policies and procedures for working through difficult cases. A recent example of this occurred in our area. A young man in his twenties was admitted to a subacute program after an extended stay in an acute facility. The patient had been involved in an unusual accident where a heavy object had fallen on him while he was walking down the street. His condition was terminal. The staff became very involved with the patient and wanted to do everything they could to make him better. The family, on the other hand, had become more and more distant, visiting less and showing less interest.

The staff was becoming increasingly agitated over the family's behavior, when the administrator called a meeting of the ethics committee for assistance. Two of the members of the ethics committee, a local minister and a psychologist, pointed out that the family's behavior was appropriate to the situation. The patient had been hospitalized for some time, and therefore the family had had an opportunity to begin to deal with the loss and had undergone counseling. The subacute care staff, on the other hand, had been confronted with the youngest terminal patient they had ever admitted and had not had a chance to deal with their feelings about loss.

The ethics committee members suggested that the staff had to work on its own feelings about the patient. At the suggestion of the ethics committee, the administrator introduced a weekly support group for the staff so that these and other issues could be addressed.

Not to be ignored is a side benefit of ethics committee participation by "lay members," i.e., it will help generate community interest and provide a positive perception of the facility's subacute program.

In short, a subacute program should be gone into with "open eyes and an open mind," realizing that the challenges encountered are not simply technical, but may present profound ethical considerations.