Rehabilitation as “destination triage”: a critical examination of discharge planning
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PURPOSE: In this paper we examine how the intersection of various social and political influences shapes discharge planning and rehabilitation practices in ways that may not meet the espoused aims of rehabilitation programs or the preferences of older adults and their families. METHODS: Taking a critical bioethics perspective, we used microethnographic case study methods to examine discharge-planning processes in a well-established older adult inpatient rehabilitation setting in Canada. The data included observations of discharge-planning family conferences and semi-structured interviews conducted with older adults facing discharge, their family members and rehabilitation professionals involved in discharge planning. RESULTS: From the time of admission, a contextual push to focus on discharge superseded program aims of providing interventions to increase older adults' functional capabilities. Professionals' primary commitment to safety limited consideration of discharge options and resulted in costly and potentially unnecessary recommendations for 24-hour care. The resulting "rehabilitation" stay was more akin to an extended process of "destination triage" biased towards the promotion of physical safety than optimizing functioning. CONCLUSIONS: The resulting reduction of rehabilitation into "destination triage" has significant social, financial and occupational implications for older adults and their families, and broader implications for healthcare services and overarching healthcare systems. Implications for Rehabilitation Current trends promoting consideration of discharge planning from the point of admission and prioritizing physical safety are shifting the focus of rehabilitation away from interventions to maximize recovery of function, which are the stated aims of rehabilitation. Such practices furthermore promote assessments to determine prognosis early in the rehabilitation stay when accurate prognosis is difficult, which can lead to overly conservative recommendations for discharge from rehabilitation services, thus further negating the impact of rehabilitation. Further work is required to examine the social, occupational and functional implications of superseding rehabilitation interventions to maximize capabilities with practices that prioritize safety over quality of life for older adults and their family members.
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