Discontinuation of Home Health Care Services: Making Ethical Decisions

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By Elizabeth E. Hogue, Esq.

Patients who are initially appropriate for home health services, may, over time, no longer meet the criteria for receipt of care from agency staff. For example, the clinical condition of patients may become so complex that they cannot be treated properly at home.

Likewise, the availability of reliable primary caregivers may change. The patient’s spouse who cares for the patient may become too ill to participate in the patient’s care any longer. Suppliers may conclude that patients they are serving really need nursing home placement which they may flatly reject.

Under these circumstances, staff may, however, have concerns about termination of ser-vices that they express in terms of ethics. They may, for example, acknowledge that it is legal to terminate services, but say that they are not certain that discontinuation is “ethical.”

It is important, therefore, to address ethical concerns about termination of services. One of the most common dilemmas faced by staff members occurs when patients refuse transfer to a nursing home. It is also important, therefore, to thoroughly examine the ethical dimensions of this common problem.

A careful review of this issue from an ethical point of view should include examination of three principles:

Autonomy,

Justice, and

Beneficence/Non-beneficence.

Autonomy generally means that patients make choices and act upon them (Beauchamp, Tom L. and Childress, James L.; Principles of Bioethics, Oxford University Press, 1980.).

The primary mechanism for ensuring patients’ autonomy is through the use of a process of informed consent. Patients are given information about treatment alternatives upon which they base their choices. This ethical principle requires health care providers to honor patients’ choices, including decisions to refuse treatment.

Bioethicists recognize the right of patients to refuse treatment in the form of nursing home placement. Patients have an absolute right to stay at home and staff must honor their choices in order to be “ethical.”

But does the patient’s decision to refuse treatment mean that staff should continue to arrange for and/or provide care in inappropriate settings? Must staff members help patients refuse treatment by continuing to provide care at home?

The principles of justice and beneficence/non-beneficence may provide some insight into the answer to this crucial question.

Justice means that every patient receives his or her due. Individuals are entitled to justice. According to the principle of so-called distributive justice, justice must also be applied on a community-wide basis (Id.). So a key question is: What is "just" in the case of patients who refuse nursing home placement for both individuals and the community?

Patients who are inappropriate for home care often gobble up providers' resources. When patients who need continuous care receive only intermittent services, staff almost always end up trying to “take up the slack” by going well beyond the proverbial “extra mile.”

Although ethical issues are sometimes characterized as matters of patients’ rights, it is important to recognize that ethical principles apply to everyone, including staff members, involved in the care of patients. Do staff members receive their just due when they are asked to care for patients who are inappropriate for home care and perhaps at great risk of injury as a result? In terms of distributive justice, is it fair to other patients to lavish attention on patients who are inappropriate for home care, so that others may not receive adequate attention?

When viewed from this perspective, staff may conclude that it is not just to continue to arrange for/provide services to patients who refuse nursing home care.

Another dimension of justice is also relevant. Justice implies that patients are entitled to their due in the sense of appropriate care. When companies assist patients who remain at an inappropriate level of care, and patients are denied justice in this form, they may not be acting in a manner consistent with ethical principles.

Beneficence/non-beneficence must also be examined in view of this dilemma. Beneficence means that staff members act to do good for patients. Non-beneficence is a more passive principle that basically requires staff to do no harm (Id.).

What action should providers take when patients refuse treatment in the form of nursing home placement? Both justice and beneficence may dictate that patients take action to secure appropriate treatment in a nursing home. Thus, although practitioners tend to conclude that “some care is better than no care,” this mindset may be ethically unsound. The principle of non-beneficence may dictate discontinuation of services in order to avoid enabling patients to remain in inappropriate settings.

Consideration of ethical issues always involves balancing ethical principles of various participants’ points of view. Certainly there are no easy answers to ethical questions in home care. Providers, however, must be careful to engage in ethical decision making, as opposed to operating from their “guts,” when a situation just feels wrong. When providers engage in a process of ethical decision-making, they may conclude that they are acting ethically when refusing to arrange for or discontinuing services to patients who are no longer appropriate for home care.

(To obtain more information about ethical issues in home care and hospice in a book entitled Ethics, send a check for $30.00, including shipping and handling, to Elizabeth E. Hogue at the above address.)

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