Ethical enigmas for physical medicine and rehabilitation in the post acute continuum of care

As medical rehabilitation occurs in an increasingly diverse set of locations, new and different challenges to the ethical care of patients are emerging. With care being delivered in hospitals, outpatient facilities, nursing facilities, other community settings, and the home, the traditional safeguards for ethical considerations may not suffice. At the same time, the type of care offered by rehabilitation professionals is broadening. Primary care, acute illness management, and even end of life care all fall within the practice spectrum of physiatrists and other rehabilitation professionals, along with the traditional rehabilitation services. Ethical conundrums may occur within a given care setting, but more important, and in addition, at the interfaces between settings. Typical issues that are confronted include decisions regarding medical and economic criteria for admission to programs, scope of treatment during service provision, and decision-making for discontinuation of care. Frequently, ethical considerations are sited when disputes occur between professional team members, patients and family members. Methods to resolve these dilemmas include the existence of structured methods to recognize and deal with them that cross the full continuum. It is important to provide mechanisms for debate and discussion, and ethical consultation and advice, regardless of a care delivery site.