title: Difficult healthcare transitions: Ethical analysis and policy recommendations for unrepresented patients.
abstract: BACKGROUND
  In Ontario, Canada, patients who lack decision-making capacity and have no family or friends to act as substitute decision-makers currently rely on the Office of the Public Guardian and Trustee to consent to long-term care (nursing home) placement, but they have no legal representative for other placement decisions.
  
  
  OBJECTIVE
  We highlight the current gap in legislation for difficult transition cases involving unrepresented patients and provide a novel framework for who ought to assist with making these decisions and how these decisions ought to be made.
  
  
  METHODS
  This paper considers models advanced by Volpe and Steinman with regard to who ought to make placement decisions for unrepresented patients, as well as current ethical models for analyzing how these decisions should be made.
  
  
  METHODS
  We describe an anonymized healthcare transition case to illustrate the fact that there is no legally recognized decision-maker for placement destinations other than long-term care facilities and to show how this impacts all stakeholders.
  
  
  METHODS
  The case provided is an anonymized vignette representing a typical transition case involving an unrepresented patient.
  
  
  RESULTS
  As a result of a gap in provincial legislation, healthcare providers usually determine the appropriate placement destination without a clear framework to guide the process and this can cause significant moral distress.
  
  
  CONCLUSIONS
  We argue for a team decision-making approach in the short term, and a legislative change in the long-term, to respect the patient voice, evaluate benefit and risk, enhance collaboration between healthcare providers and patients, and promote social justice. We believe that our approach, which draws upon the strengths of interprofessional teams, will be of interest to all who are concerned with the welfare and ethical treatment of the patients for whom they care.
  
  
  CONCLUSIONS
  One of the main strengths of our recommendation is that it provides all members of the healthcare team (including nurses, social workers, therapists, and others) an increased opportunity to advocate on behalf of unrepresented patients.
authors.affiliation: Centre for Clinical Ethics, Canada; Hôtel-Dieu Grace Healthcare, Canada; Joint Centre for Bioethics, University of Toronto, Canada; Department of Philosophy, University of Waterloo, Canada rabdool@uwaterloo.ca.
authors.forename: Rosalind
authors.initials: R
authors.lastname: Abdool
authors.affiliation: Centre for Clinical Ethics, Canada; Department of Family and Community Medicine, University of Toronto, Canada; Joint Centre for Bioethics, University of Toronto, Canada michael.szego@utoronto.ca.
authors.forename: Michael
authors.initials: M
authors.lastname: Szego
authors.affiliation: University Health Network, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
authors.forename: Daniel
authors.initials: D
authors.lastname: Buchman
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
authors.forename: Leah
authors.initials: L
authors.lastname: Justason
authors.affiliation: Sunnybrook Health Sciences Centre, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
authors.forename: Sally
authors.initials: S
authors.lastname: Bean
authors.affiliation: University Health Network, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
authors.forename: Ann
authors.initials: A
authors.lastname: Heesters
authors.affiliation: Department of Family and Community Medicine, University of Toronto, Canada.
authors.forename: Hannah
authors.initials: H
authors.lastname: Kaufman
authors.affiliation: Humber River Hospital, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
authors.forename: Bob
authors.initials: B
authors.lastname: Parke
authors.affiliation: Department of Family and Community Medicine, University of Toronto, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
authors.forename: Frank
authors.initials: F
authors.lastname: Wagner
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Canada; Joint Centre for Bioethics, University of Toronto, Canada.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Gibson
mesh_terms: D000368:Aged; D000544:Alzheimer Disease / Q000523:psychology; D003657:Decision Making / Q000941:ethics*; D005260:Female; D006291:Health Policy / Q000331:legislation & jurisprudence; D006801:Humans; D007258:Informed Consent / Q000941:ethics*; D008134:Long-Term Care / Q000941:ethics / Q000331:legislation & jurisprudence; D009864:Ontario; D010360:Patient Transfer / Q000941:ethics* / Q000331:legislation & jurisprudence; D019727:Proxy; D011788:Quality of Life
keywords: Bioethics; ethics; healthcare transitions; placement; unrepresented patients