The JCB's Working Group on Difficult Transitions

By: Rosalind Abdool, Centre for Clinical Ethics / Hôtel-Dieu Grace Hospital


The University of Toronto Joint Centre for Bioethics' working group on Difficult Transitions has recently had their manuscript accepted to Nursing Ethics. The working group members consist of Rosalind Abdool and Michael Szego as the co-leads on the project, and co-authors: Sally Bean, Daniel Buchman, Jennifer Gibson, Ann Heesters, Leah Justason, Hannah Kaufman, Bob Parke, and Frank Wagner. The article is titled: "Difficult healthcare transition decisions for unrepresented patients: An ethical case analysis and policy recommendation".


The working group first came together following several clinical ethics cases involving complex discharges. We observed that these cases involved a patient population with the following characteristics: 1) lacking capacity to make placement and treatment decisions and 2) lacking family or friends involved in their care. When no family member or power of attorney for personal care exists (or if they exist but are unable or unwilling to act as decision-makers) the Public Guardian and Trustee (PG&T) takes on the role of substitute decision maker. The PG&T will provide informed consent for treatment decisions and for placement decisions to long-term care, but unfortunately not for other placement locations, including retirement and group homes for example.


Patients lacking family or friends advocating on their behalf are often called unrepresented patients. In addition, unrepresented patients typically have complex co-morbidities and finding an appropriate placement that takes into consideration their needs, as well as ensuring that they and others are safe, require careful time and consideration. In the manuscript, we argue that the current legislation in Ontario leaves healthcare providers in the position of acting as an incapable patient’s substitute decision maker for all discharge destinations other than long-term care. Since consent is not required for discharge destinations other than long-term care, healthcare providers decide both the type and location of discharge destinations for unrepresented patients.


Healthcare providers were requesting ethics consultations because they were not comfortable making discharge decisions for unrepresented patients. They identified a lack of guidance for determining an appropriate placement location for each unique unrepresented patient. Hence, healthcare providers can face moral distress without a framework for this kind of decision-making and unrepresented patients can be placed without ensuring due diligence is completed in each situation. We considered several models and offered a novel team decision-making approach. The approach includes bringing together all stakeholders as valuable members of the decision process. In this manuscript, a discussion of the types of principles that should be considered in this process may be assistance to healthcare providers to make the most patient-centered decision and to provide the best patient care possible.


Ultimately, we argue for a team decision-making approach in the short term, and a legislative change in the long-term, with the aim of respecting patient voice, evaluating benefit and risk, enhancing collaboration between healthcare providers and patients, and promoting social justice.



Working Group:

Corresponding Author:
Rosalind Abdool, Centre for Clinical Ethics / Hôtel-Dieu Grace Hospital, 30 The Queensway Toronto Ontario M6R 1B5 Canada.


Corresponding Author:
Michael Szego, Centre for Clinical Ethics / St. Joseph's Health Centre, 30 The Queensway Toronto Ontario M6R 1B5 Canada.


Rosalind Abdool
Centre for Clinical Ethics / Hôtel-Dieu Grace Hospital, Windsor, Canada


Michael Szego
Centre for Clinical Ethics / St. Joseph's Health Centre, Toronto, Canada


Daniel Buchman
University Health Network, Toronto, Canada


Leah Justason
Joint Centre for Bioethics (Health Policy), University of Toronto, Canada


Sally Bean
Sunnybrook Health Sciences Centre, Toronto, Canada


Ann Heesters
University Health Network (Toronto Rehab), Toronto, Canada


Hannah Kaufman
Independent Practice, Kingston, Canada


Bob Parke
Humber River Regional Hospital, Toronto, Canada


Frank Wagner
Toronto-Central Community Care Access Centre, Toronto, Canada


Jennifer Gibson
University of Toronto Joint Centre for Bioethics, Toronto, Canada