Background: Autonomy is a central concept in both bioethics and rehabilitation. Bioethics has emphasized autonomy as self-governance and its application in treatment decision-making. In addition to discussing decisional autonomy, rehabilitation also focuses on autonomy as functional independence. In practice, responding to patients with diminished autonomy is an important component of rehabilitation care, but also gives rise to tensions and challenges. Our objective was to better understand the complex and distinctive ways that autonomy is understood and upheld in the context of (...) rehabilitation care by reviewing how autonomy is discussed in the rehabilitation literature. Methods: We conducted a scoping review addressing issues of autonomy in the context of mental and physical rehabilitation. Our process followed three sequential steps. We extracted and analyzed bibliometric information. We then examined how autonomy was defined and conceptualized. Finally, we examined how the articles discussed the roles of rehabilitation health professionals in responding to patient autonomy. Findings: The articles include 16 empirical reports, 17 case studies and 30 theoretical papers. The most common conceptual accounts of autonomy drew upon principlism, rights-based and legal analyses, and relational/social approaches. We identified four broad approaches for responding to patient autonomy: supporting, promoting, respecting and advocating. Conclusion: This review helps clarify some of the ambiguities and conceptual distinctions underlying discussions and practices related to autonomy in rehabilitation. It also draws attention to a wide range of activities that health professionals can undertake with the goal of supporting, promoting, respecting and advocating for patient autonomy in rehabilitation care. (shrink)

Background: Autonomy is a central concept in both bioethics and rehabilitation. Bioethics has emphasized autonomy as self-governance and its application in treatment decision-making. In addition to discussing decisional autonomy, rehabilitation also focuses on autonomy as functional independence. In practice, responding to patients with diminished autonomy is an important component of rehabilitation care, but also gives rise to tensions and challenges. Our objective was to better understand the complex and distinctive ways that autonomy is understood and upheld in the context of (...) rehabilitation care by reviewing how autonomy is discussed in the rehabilitation literature. Methods: We conducted a scoping review addressing issues of autonomy in the context of mental and physical rehabilitation. Our process followed three sequential steps. We extracted and analyzed bibliometric information. We then examined how autonomy was defined and conceptualized. Finally, we examined how the articles discussed the roles of rehabilitation health professionals in responding to patient autonomy. Findings: The articles include 16 empirical reports, 17 case studies and 30 theoretical papers. The most common conceptual accounts of autonomy drew upon principlism, rights-based and legal analyses, and relational/social approaches. We identified four broad approaches for responding to patient autonomy: supporting, promoting, respecting and advocating. Conclusion: This review helps clarify some of the ambiguities and conceptual distinctions underlying discussions and practices related to autonomy in rehabilitation. It also draws attention to a wide range of activities that health professionals can undertake with the goal of supporting, promoting, respecting and advocating for patient autonomy in rehabilitation care. (shrink)

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments (n=98; proportion of participation was (...) 99%) conducted in 2015 across publicly funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector. (shrink)

In the context of long waiting time to access rehabilitation services, a large majority of settings use referral prioritization to help manage waiting lists. Prioritization practices vary greatly between settings and there is little consensus on how best to prioritize referrals. This paper describes the prioritization processes for physiotherapy services in Québec and its potential implications in terms of equity in access to services. This is a secondary analysis of a survey of outpatient physiotherapy departments conducted in 2015 across publicly (...) funded hospitals in Québec. In many settings, persons with acute orthopaedic conditions were prioritized while chronic conditions were given a lower priority. There were 72 different combinations of prioritization criteria used in outpatient physiotherapy departments. Variability was also observed in the type of personnel involved in the prioritization process, the number of priority levels used to rank the referrals and the source of information used to prioritize referrals. These results highlight potential issues regarding equity in access to physiotherapy services: the prioritization of persons with acute conditions to the detriment of those with chronic conditions, the lack of consensus on a fair prioritization process and the importance to adequately assess patients’ needs for treatment. Further research and interventions on prioritization criteria and processes are needed to ensure equitable access to physiotherapy services, especially in the public sector. (shrink)

Many physiotherapists are reluctant to treat a client with bone metastases, as treatment indications are not clearly defined. The paradigmatic case presented here, and a review of the literature, allow us to highlight some ethical and clinical issues in physiotherapy care at the end of life, particularly for patients with bone metastases. The objective of this article is not to create an ethical decision making model but rather to serve as additional guidance to existing decision models in rehabilitation. This guidance (...) is based on principlism and is specific to the oncology clients in palliative care. The proposed principles, without being exhaustive, are beneficence, non-maleficence, respect for autonomy and justice. With a review of clinical indications and precautions, the article also helps to clarify both the theoretical and the evidence-based risks. These principles provide avenues for reflection to guide the management of these patients. The physiotherapist will then be able to conduct a critical analysis, in collaboration with the interdisciplinary team, whose goal is to respect the client’s right to appropriate care at the right time and that is based on clinical need. (shrink)

With the world's population aging, hospitals are facing pressure to adequately meet the needs of a growing number of frail older patients. For this population, comorbidities combined with a limited ability to face stressful situations contribute to frailty whereby a small injury or illness can lead to significant loss of function. It is widely recognized that hospitalized older patients are more vulnerable to physical or cognitive functional decline and require increased assistance in activities of daily living (Creditor 1993; Sager et (...) al. 1996; Mahoney, Sager, and Jalaluddin 1998; Kortebein et al. 2008; English and PaddonJones 2010; Covinsky, Pierluissi, and Johnston 2011; Zisberg et al. 2011;... (shrink)

Many health care professionals (HCPs) are understandably reluctant to treat patients in environments infested with bedbugs, in part due to the risk of themselves becoming bedbug vectors to their own homes and workplaces. However, bedbugs are increasingly widespread in care settings, such as nursing homes, as well as in private homes visited by HCPs, leading to increased questions of how health care organizations and their staff ought to respond. This situation is associated with a range of ethical considerations including the (...) duty of care, stigmatization, vulnerability, confidentiality, risks for third parties, and professional autonomy. In this article, we analyze these issues using a case study approach. We consider how patients whose living environments are infested with bedbugs can receive care in the community setting in a manner that supports their well-being, is consistent with fairness in care provision, and takes into account risks for HCPs and third parties. We also discuss limits and obstacles to the provision of care in these situations. (shrink)