Due to unexpected structural repairs, and a decrease in LHIN funding for the next fiscal year, your organization must ‘find’ $500,000 in savings in order to balance the annual budget. The operational team is looking to the Board for guidance. How do you decide?

Things to consider:

Guiding principles at your organization – Guidance from your Ethics framework?

Mission, Vision, Values

Cornerstone programs – Can any be decreased, moved, or cut?

Possible criteria for allocation

Medical need

Medical benefit

Clinical efficacy/effectiveness

Cost-effectiveness

Practice guidelines and health care policies

Will the organization be transparent and accountable in their decisions?

Will you engage staff, patients, and the community in the decisions?

The situation:

Current occupancy at an acute care hospital is 125%. Specifically, volume includes:

18 “Unfunded beds” that have been opened, including some located in hallways,

15 admitted patients who are currently residing in the emergency department (in rooms and hallways),

5 surgical patients waiting for OR,

1 patient with hip fracture that has been waiting for a bed for 2 days,

3 patients who are due to return from another hospital since care needs have decreased,

34 ALC patients (22 confirmed waiting for long-term care, and 4 others pending)

Anticipated capacity includes:

2 discharges from the medicine unit

1 discharge from surgery

2 CCU beds if the organization can transfer 2 elsewhere

Compounding issues:

Some of the overcapacity is additional hallway spaces on the inpatient units

1 medical patient on surgical floor approached and advised will be moving to a hallway space to make room for another patient with higher needs, however, she has indicated she will sign herself out Against Medical Advice. Her bloodwork demonstrates critical issues.

Staff shortages abound, and many patients are arriving to emergency with failure to cope / failure to thrive.

There are no crisis beds available to divert avoidable admissions for non-acute care reasons, and patients/families are refusing retirement homes and remaining in hospital to wait for LTC.

There has been a reduction in CCAC services and increase in wait listing.

There are some available beds at two hospitals within 40 minutes of this particular organization, but patients are reluctant to consent to be transferred/admitted there.

What are some of the potential ethical issues in this scenario?

Limited access to limited inpatient resources: Who decides who will receive the resource, and how is this determined? Is it fair?

Do patients have a right to refuse transfer within the hospital? For example, can they refuse to be moved into a hallway?

Patients signing out AMA when still needing care: is this a failure to provide due care, or simply the right of a capable patient to do so?

ALC Management: How can patients who do not require acute care be transferred to an appropriate care setting, or more appropriately managed, when waitlists exist?

You have recently been speaking to your nursing colleagues about Mr. Goodwin, a patient from the community to comes to hospital once per week to receive a nurse-administered medication. You have been wondering whether it is appropriate to keep treating Mr. Goodwin in hospital, given that he would be eligible for community care support to have his medication administered in the home. The reason that he has continued to come to hospital to receive this medication is that it is not covered by any Ministry of Health program, and the hospital absorbs the cost for Mr. Goodwin at each treatment. You are not sure whether this is an appropriate use of resources since there are significant wait times for other procedures, and cost savings initiatives are being pursued in all other departments.

What are some of the ethical issues in this case?

Why was the decision made to treat Mr. Goodwin in hospital in the first place?

Can the hospital cover the cost of similar medications for other patients, or are there concerns of justice/fairness?

How are decisions regarding prioritization made organizationally? Are there agreed upon frameworks or ethical principles that are used?

As in any organization, there are often occasions when staff numbers are less than optimal due to sickness, vacation, etc. On those occasions, personal care for clients is the priority and homemaking/housekeeping tasks may be reduced/postponed. At your organization, you notice that it seems as though the homemaking tasks are most often cancelled are for those clients who staff know will not complain.

What are some of the ethical issues in this case?

While it seems that personal care services still get completed, do staff absences risk failing duties to colleagues or clients if they are not able to be filled?

How should you determine which tasks are not fulfilled, and for whom?

One of your clients recently returned home from hospital with increased care needs. She is unwilling to assist with self-management and expects staff to respond to the higher care needs as she requests. Currently there has been no reassessment for increased financial support to pay for additional hours of service.

What are some of the ethical issues in this case?

How can we balance the increasing needs of individual clients against zero financial increases?

Client care needs are decided following a formal assessment process and cannot/should not be adjusted without re-assessment. Can you appropriately meet this client’s needs, and ensure limited resources are used appropriately, without such an assessment?