Rebecca Brashler

Ethics, Family Caregivers, and Stroke

Abstract Even though stroke caregivers provide valuable care to loved ones, often sacrificing their own life goals and sometimes their health, they are frequently viewed by stroke professionals as irritants or problems. Medical training and medical bioethics literature focus almost exclusively on the physician–patient relationship, which leaves family members with uncertain standing. A family-centered approach allows providers to acknowledge and respect caregivers’ needs without sacrificing patients’ interests or authority.

Moral Distress in Rehabilitation Professionals: Results From a Hospital Ethics Survey

Moral distress in the rehabilitation setting was examined in a follow‐up survey. The survey had 3 goals: (1) to systematically and anonymously gather data about the ethical issues that employees struggle with in their daily work; (2) to raise the visibility of the hospital‐based ethics program and resources available to employees; and (3) to prioritize and focus the direction of the programs educational seminars, quality improvement projects, and ethics consultation.

Your Opinion Please, Doctor: Is Your Patient Unable to Work in Any Capacity?

T D ore often than not, when asked to fill out a disability form on behalf of a patient, I feel onflicted. As a rehabilitation specialist, I am trained to get my patients back to full lives—and ivelihoods—to the greatest degree possible. My mantra has always been to preserve and aintain function. I cringe regarding the inevitable question I will be asked: “Is the patient nable to work in any capacity?” And, as I examine this question, I wonder whether I truly elieve whether a patient is ever unable to work (barring the extreme examples of severe brain njury and permanent unconsciousness). I think of Stephen Hawking, the famous physicist with myotrophic lateral sclerosis (ie, Lou Gehrig disease), who is still a prolific scientist, or my patient ith severe athetoid cerebral palsy who works full time in an office by using an augmentative ommunication system, the patient with high quadriplegia who is a physician, or the university eacher with postpolio syndrome who uses nocturnal ventilation. They all require extensive ersonal assistance services to navigate their lives; they all require health insurance and durable edical equipment. They also are all motivated individuals who have surmounted the chalenges required to stay gainfully employed. My thoughts then wander to the patients who were never gainfully employed before their isability and who lack basic social and vocational skills; those who just do not want the assle of negotiating the multiple barriers to return to some form of work; or those who fear he loss of benefits for personal assistance services, health care, and durable medical quipment. What if someone theoretically could work 20 hours a week at a fast-food estaurant but was used to working as a high-level executive with executive compensation efore his or her brain injury? What if she or he simply does not want to do this sort of work, ven if it is theoretically possible? However, I also ask myself, if disability benefits were not et up for people with extensive disabilities from quadriplegia, strokes, and brain injury, hen for whom were they set up? And what of the person who has chronic low back pain after a work injury and claims to e unable to work? It is distressing enough for me to officially “disable” a patient with severe ermanent neurological deficits, but how do I (or even should I) incorporate the subjectivity f chronic pain into this disability equation? Borrowing from my medical colleagues’ ernacular, these are people who represent adult failure to thrive. Yet, treating these types of omplex biopsychosocial problems is for what physiatrists are best known. I feel caught in a conundrum. I want to convey to my patients my belief in possibilities, y desire to help them pursue their dreams and their full potential. I feel angst almost every ime I sign the form indicating permanent disability, even when the disability occurred years go, and even when gainful employment never occurred, despite vocational services. Yet, I m always cognizant of the psychosocial circumstances of my patients’ lives—the multiple arriers (eg, physical, transportation, attitudinal) and the fact that personal assistant services re expensive and provided by the state only if a patient is impoverished. I know that ithout these benefits my patients may lose their safety nets. The physiatrist is often a critical (although not exclusive) arbiter for such decisions. I elieve the conflict I experience is one of dual agency—one being my fiduciary responsiility to the patient (eg, to advocate for my patient’s best interest, which the patient nevitably helps to define), the second being my fiduciary responsibility to society (eg, to be truthful and conscientious steward of communal resources). This conflict is exposed no atter the nature any individual patient’s underlying pathological condition (eg, back pain r spinal cord injury) and is universally accentuated by an array of external forces. D C

Time to Make a Call? The Ethics of Mandatory Reporting

Over 50 years ago, the first U.S. laws were passed regarding the mandatory reporting of suspected child abuse and neglect. During the ensuing decades, other laws have emerged that delineate the role of the physician in protecting his or her patients as well as the public. In theory, the reporting by clinicians who become aware of concerns plays a critical role in decreasing harms; however, in practice, various tensions exist, including the limits of our observations, the veracity of information received, and perhaps an underlying ambivalence about privacy and the role of the doctor. This column grapples with the ethical issues of mandatory reporting. Why might we be reluctant to report suspected abuse or neglect, someone who is unsafe to drive, or a colleague who is impaired? At the core of the concerns about reporting is the relationshipdthat between doctor and patient, doctor and family members, and between colleagues. Many also express distrust in systems or worry about what will be done with the information that is provided to the authorities. In the first essay, Rebecca Brashler, LCSW, Director of Global Patient Services at the Rehabilitation Institute of Chicago and a colleague in the Rehabilitation Institute of Chicago’s Donnelley Ethics Program, discusses the

Should Health Care Professionals Google Patients or Family Members

For this issue, I have invited Rebecca Brashler, LCSW, an ethics consultant and director of Care Management and Family Support Services at the Rehabilitation Institute of Chicago, to share an interesting ethics case that recently was brought to the Rehabilitation Institute of Chicago consultation service. Without a doubt, the use of the Internet for e-mail and social networking has raised novel issues for professional practice. By recognizing the allure as well as the potential pitfalls of such practices, many institutions and professional organizations have begun to develop guidelines and policies for their use. Ms Brashler raises a related, but slightly distinct, concern: the use of the Internet by health care professionals seeking personal information about patients and their family members. Ms Brashler lays out the parameters of the case, the issues raised, and the discussion ensued. I have invited Matthew K. Wynia, MD, MPH, FACP, the director of The Institute for Ethics, and Bette-Jane Crigger, PhD, the director of Ethics Policy, the American Medical Association, to provide the first commentary. The second commentary is by Anita Halvorsen, FACHE, MBA, MS, CCC-SLP, vice president at Schwab Rehabilitation Hospital in Chicago. In addition to her current leadership role in hospital administration, Ms Halvorsen has extensive prior experience in hospital corporate compliance. Finally, Ms Brashler provides some closing comments about how she came to see the issue after consulting on the particular case. As always, please do feel free to write in and provide your thoughts and comments!

Feeding Tubes: Three Perspectives

Abstract Percutaneous endoscopic gastrostomy tubes, or PEG tubes, look innocuous enough—narrow, plastic, pliable tubes, that when inserted into the stomach protrude approximately 3 to 5 inches and can be attached to a bag of liquid food. How can something so seemingly straightforward create so much controversy and evoke such intense emotion? It seems that part of the answer lies in the fact that nobody sees the same thing when they look at a feeding tube. This article will present three different views of gastrostomy tubes and challenge practitioners to think beyond traditional models.

Ethical Challenges of Caring for VIPs in the Rehabilitation Setting

Much has been written about the particular challenges of caring for VIP (very important person) atients in health care. The recent tragic death of Michael Jackson highlights how serious errors n medical judgment and deviations in standards of care seem more likely to occur with high tatus, influential, and wealthy patients. Hospital staff often express angst about observed nequities in treatment between 2 patients who have the same medical conditions but markedly ifferent social status. How do we reconcile this differential treatment in light of expressed rofessional values of caring for all patients? Are the words of the Declaration of Geneva merely spirational, that is, to “not permit considerations of age, disease or disability, creed, ethnic rigin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any ther factor to intervene between my duty and my patient”? The media pose another set of challenges for health care providers in caring for high-profile atients. For people who live in the public eye, the media’s desire for information can be nsatiable. Yet, patients have a fundamental right to privacy. Trying to ensure that right and rotect from leakage of information when health care institutions literally have hundreds of mployees who have potential access to patient information is daunting. Legitimate questions bout whether there are limits to the right to privacy have also been raised when the patient, such s an elected official, has a fiduciary interest to the public.