Recently, ethicists Peter Allatt and Bob Parke shared their concerns over Ontario’s More Beds, Better Care Act. While some of the issues they highlight are indeed concerning, the broader argument lacks some perspective.
The rushed nature of this legislation, and avoidance of opportunity for debate, do highlight ethical concerns in terms of fair (or even good) process. Further, the fact that our current bed shortage owes more to government-imposed constraints on three- and four-bedroom wards than on patients (and families) refusing admission to long-term care (LTC) homes is indeed accurate (and yet there are no calls for an explanation as to why the prohibition on three- and four-bed rooms continues to be in place despite the fact patients waiting for these beds remain primarily in hospitals in four-bed ward rooms?)
Alternative Level of Care days in hospitals were a significant problem prior to COVID, which merited different ways of thinking. The problem is now worse than just the number of available beds in either LTC or hospitals because staffing has drastically changed since the beginning of COVID – specifically, Personal Support Workers (PSWs) are leaving LTC homes (often in favor of agencies) and the field as well. From a policy perspective, there are obvious lessons to be drawn from this– that new LTC beds are required, but more importantly, that there must be significant investment in the training and compensation of PSWs to care for our aging population.
All this aside, the issues raised by the More Beds, Better Care Act should not be considered controversial.
The main claim concerns the ability for clinicians and administrators to make decisions on behalf of patients without their expressed consent. While this at first seems antithetical to ethical commitments, we need to step back to consider the bigger picture. Consent isn’t required for a variety of activities in health care, and for good reason. If you are in a car accident, your admission to hospital does not require consent. Yes, the treatment provided does, but the mere fact of being placed in a hospital bed does not require consent because there is really no alternative. Likewise, patients identified as needing ALC don’t have a choice in the matter about requiring that level of care. It is a simple (and sometimes tragic) fact of illness, disease and aging that some individuals simply don’t have a choice about things such as their ability to ambulate or the cognitive function to live independently.
All this aside, the issues raised by the More Beds, Better Care Act should not be considered controversial.
So, when should choice be a requirement? It’s not immediately obvious that the decision of where one calls home temporarily, while waiting for their preferred choice, ought to require consent – especially in a publicly funded system that shares the burdens of limited health-care resources.
That the consent-related concern of charging a patient for using a publicly funded resource – a hospital bed, when by definition that resource isn’t required – is an act of coercion draws an erroneous connection between the circumstance (a hospital stay is not publicly insured if it is not required), and the need for a patient to choose an LTC residence to call home.
In fact, patients could well decide not to go to LTC, but instead pay for private care in their own homes and it wouldn’t matter to the hospital. The hospital is not interested in which choice patients make, but rather that they make a choice that aligns with their needs. That choice may be limited by circumstance, but then that is the reality of illness, disease and aging – they all reduce choice in some form.
The focus on a $400/day bill for patients who don’t accept an available LTC bed misdirects our attention from what those dollars are meant to compensate for. In a health system of limited resources, each occupied acute care bed is one less bed for another patient experiencing a trauma, a mental-health crisis or who otherwise can’t be cared for in any other environment (including an individual experiencing an acute decline who is ultimately destined for LTC). And so, the cost of operating that bed, for someone who by definition doesn’t need that level of care is your tax dollars being mis-spent Further to that, the $400 figure is a drastic underestimate of what is actually spent to keep that bed operating (by most hospital’s accounting, an acute care bed costs somewhere between $1,500-$2,000 per day to operate.) When compared to the roughly $1,800 per month for a basic bed in LTC, the difference is staggering and could contribute toward the needed funding of PSWs. There is no other sphere of public spending where it would be considered appropriate to spend 30 times the necessary cost (whether that be to build a bridge or compensate teachers).
In our current circumstance, is the More Beds, Better Care Act going to make a significant dent in our ALC numbers? Probably not. But that isn’t because the concept of quickly moving patients out of situations whose resources are misaligned to patient need is a bad – or unethical – idea.
In fact, Nova Scotia has had an almost identical policy since 2015 with little moral outrage.
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Your comment that those moved to a LTC facility not of their choice but is only temporary, is a fallacy. Once in a LTC bed, that individual’s priority is significantly lower and will superseded by future higher priorities of individuals awaiting placement still in ALC hospital beds, in retirement homes or still residing in their own homes but who require complete hands-on care. As a consequence the chance of an individual moving to a LTC home of their choice after initial placement is negligible.