About two weeks ago, a 23 year old patient of mine was in a motor vehicle accident and sustained multiple fractures as a result of the accident. She sustained fractures to her right clavicle, C2 – C3, L5 and a fracture to her left ischium (this was an unstable fracture).
She had arrived with a Philadelphia cervical collar on from the hospital she was referred from but whenever I saw her she was wearing it incorrectly as she kept removing it and either did not always put it back on, or when she did, she did so incorrectly. After I explained the dangers of doing this and showed her how to put the collar on correctly, there was an improvement in her compliance but she was still not fully compliant.
According to the Dr, she was allowed to mobilise but with partial weight bearing on her left lower limb due to the pelvic fracture. In order to get her mobile, I taught her how to mobilise using 2 elbow crutches, it took a while before she understood how to only put partial weight through her left lower limb, she needed constant reminding about how to do it, so left feeling uneasy about whether I could trust that she would do it properly or not.
The next day I taught her how to walk with a walking frame instead, as she seemed more stable and managed to put partial weight through her left lower limb a lot better with the walking frame than she could with the crutches. The patient reported that she felt a lot better and safer using the frame than she did with the crutches.
I was in a bit of a dilemma, as we had many crutches available but that was the last walking frame the department had. The hospital needed to order more walking frames and my patient was being discharged the next day.
I was struggling to make a decision between whether I should issue the crutches and hope for the best after I educated the family and re-iterated what I had already said to my patient about the dangers and precautions of her condition, or if I should issue the last walking frame, knowing my patient would be better off in terms of recovery and preventing further complications but then we would have no other walking frame to assess and mobilise patients in the ward.
I felt like I was being almost negligent if I had to issue the crutches, knowing the risks of her compliance and safety but if I issued the walking frame, my patient would benefit but it would be unfair to all the other patients after her, until we received more walking frames.
According to (Katz, 2015) one of the ways to allocate scarce resources is to ration the resources rationally; in this way you look at whichever patient or situation is priority and they are the ones who will get the resource. This suggestion could work for my patient, as her condition was quite serious and it would help her to be safe and not putting her full weight on her affected side would greatly aid her healing and not contribute to future complications. Another suggestion made by (Katz, 2015) is to not ration at all (i.e. everybody gets the resources) but this would not work in my patient’s situation nor be very likely to work in the government medical facilities in South Africa, as a lot of the time there is scarcity of resources and there are just not enough e.g. walking frames at the hospital for everybody who needs it to take home and for it to make mobilising a bit easier and safer for them. In this case, the seriousness of the condition of the patient would need to take priority in order to utilise the very few walking aids available in the best possible way.
Establishing who is high priority, can be determined by the following; patient need and preference, potential benefit, safety, quality of life gained, impact on quality and care givers, clinical effectiveness (Ginsburg et al, 2011).
My patient matches all of those criteria in terms of whether she should have been allocated the walking frame or not, as she is safer mobilising with a walking frame, she preferred it, it will benefit her recovery process so in that way it is also clinically effective, she is able to be more independent therefore there is quality of life gained and it will be a bit led demanding on her caregiver as she will be mobile and a bit more independent than being in a wheelchair and will need less supervision compared to mobilising with elbow crutches as her compliance was a bit less with the crutches compared to the walking frame.
Despite her meeting all the criteria, one is still left with the thought of; what if somebody with the same or worse fractures is admitted to the hospital a day after she is discharged, then we will not have a walking frame to assist that patient with or a CVA patient who really needs the walking frame, by them rather lying in bed to be safe and not risk falling (with CVA) or weight bearing too soon (with fractures) is then detrimental to their recovery and progress.
These are the thoughts I was left with even after issuing my patient with the walking frame; I know it was in her best interest to receive a walking frame but what if patients arrive the next day who may possibly need it more than she did, or just as much as she did.
According to (Constitution of the Republic of South Africa, 1996) everyone has the right to access to health care services, most South African citizens (more so in the urban areas) do have access and do utilise it but they do not always get the best possible care, due to factors like inadequate resources especially in our government heath care facilities, which then affects the quality of health care they receive. By just having access is not enough, these health care facilities need access to/ need to be supplied with the necessities in order to provide the health care people are entitled to receive.
According to a document issued by the department of health, regarding assistive devices in South Africa (Standardisation of provision of assistive devices in South Africa,2016), it states that budgets should be allocated at a regional and provincial level. Despite this being the intention and that there is a budget available, I don’t think that the budget allocated to each province and each health care institution, matches the amount of patients each institution caters to. The document also states that the health care facility should be able to issue patients with assistive devices or contract it out but this particular hospital I worked at, did not even have enough walking frames to contract out/lend to a patient, as there simply was not enough available.
Either there is not enough money in the allocated budget or the hospital does not order enough assistive devices ahead of time, as there was a surplus of rollators but not enough walking frames. It could on the other hand, also be the person ordering the devices that estimates the demand of assistive devices incorrectly.
This is an ongoing issue with many contributing factors that I think may unfortunately be an issue in our government health care facilities for quite some time in the future.
References
Constitution of The Republic of South Africa, Act 108 of 1996, Chapter 2, section 27
Ginsburg, J.,Kline,M.,Doherty,R.,Neubauer,R.,McLean,R.,&Arora,V., et al. (2011).How can our nation conserve and distribute health care resources effectively and efficiently (pp. 1-3). Philadelphia: American College of Physicians.
Katz, D. (2015, July 8). There are only 3 ways to allocate health care resources. Retrieved March 3, 2019, from KevinMD.com: https://www.kevinmd.com/blog/2015/07/there-are-only-3-ways-to-allocate-health-care-resources.html
Standardisation of provision of assistive devices in South Africa. (2016). Retrieved March 20, 2019 from http://uhambofoundation.org.za/new_wp/wp-content/uploads/2016/06/standardisation_of_provision_of_assistive_devices_in_south_.pdf
3 thoughts on “Just allocation of assistive devices”
Dear Zara. Thank you for giving me the opportunity to read your writing piece.
I like how the topic you chose is something most of us experience at some point in the government hospital settings and it is definitely relatable. It is certainly an ethical dilemma that occurs often.
I personally think you made the right decision because the patient is still young and has her whole life ahead of her and you do not know whether the next patient who will need a walking frame will be admitted the next day or in the next few months. I like how although you had different options and perspectives on the situation but at the end of the day, you did what was best for that patient. I do agree that sometimes it is hard to decide in that moment because you do not know if there will be a patient a couple of hours later or the next day who will need it more than your patient. Sometimes you have to think of a “risk vs benefit” mindset and go with your instinct (or maybe put yourself in that persons shoes) – this is something i had to do at my block as well because the hospital has the same situation with limited walking aids. Despite feeling conflicted, how did you feel afterwards as a physiotherapist knowing that although you gave the last walking frame to the patient, you also made her life easier? Were there any new admitted patients who needed the walking frame in that same week as well?
You could also mention in your writing piece some of the bill of rights and disability rights that are stated in the links that are applicable to this situation and back up why you did what you did. You can possibly focus on the values of dignity, equality and freedom – the link is: https://www.westerncape.gov.za/legislation/bill-rights-chapter-2-constitution-republic-south-africa#9 and https://www.hhrguide.org/2014/03/21/disability-and-human-rights/
These can help you to justify why you thought giving the last walking frame to the patient was the best option and how it could benefit her in the future. The links can also add to your references which could make your writing piece seem “stronger”
In addition – in the 4th paragraph line 2. it should be “managed” and in line 4 of that paragraph it should be “than”
All the best for your final piece. Good work and keep it up.
Erin
Hi Zara. thank you for sharing your writing with me, I enjoyed reading your piece of work. I liked how you chose this specific topic as it is very relevant to us as physiotherapists, despite not having a personal experience with such a dilemma, I am sure to be faced with something similar in my future as a physiotherapist.
I like how you shared and explained your conflicted situation and why each option could be the “right” choice either for your patient or future patients. As therapists we want the best for our patients and we want to ensure that they are safe and given the best chance of full recovery to regain functional activities. Theretofore I can relate to you and how conflicted you may have been feeling.
Your reference to the allocation of scarce sources is a fair way of approaching the dilemma however this is not always easy as how do you prioritize the patients when you have no idea of what patient and their condition could walk into physio in the future. As you mentioned they may be worse off than your patient today. Consider researching some reasons or problems behind the scarce supply of assistive devices in some of the government hospitals, clinics and health care facilities in South Africa.
There is no clear answer of what to do in a situation like this as we cannot see into the future but only try prioritize a patient’s condition and current need for assistance. This is however subjective and comes down to the therapist. This is therefore a common ethical dilemma among health professionals. Consider reflecting on how you felt after you gave the walking frame to this patient?
Review paragraph 4, line 1 “managed to put” instead of “manage putting”
Your writing was easy to follow and flowed well between paragraphs. I hope my comments will be helpful and can guide you in ways to strengthen your writing piece. Well done, keep up the good work.
Hey Zara. I really enjoyed your piece of writing as I’ve had a very similar experience not too long ago. It’s a really grey moral and ethical dilemma where I feel there is no real right or wrong in this situation as you just want what is best for all your patients. The just allocation of resources will always be a challenge in the developing world.
I thought your topic as well as your writing was really good. It was easy to follow and you explained the circumstances very well. I could almost see myself standing there watching you in real life.
You stated that even though this patient required a walking frame, you didn’t know if someone else would need it more tomorrow. You did well to look at the literature to say this is what they say you should do. However, in a South African context, I think that you could potentially look at what the bill of rights says about health and access to health.
Also, look at the potential consequences if you were to deny this patient her walking frame. If she did fall, what will be the consequences for the hospital/staff who didn’t issue her with the correct device even though there was 1 available? You could also look at potential reasons for why there isn’t enough equipment available at the hospitals, taking into account the current economic situation in SA and the amount of people who are dependent on government help for medical care as well as general welfare.
However, I think you did assess the situation well and you did an amazing job to write about it. Well done.