Ethical conflicts in home care. Patient autonomy and physician advocacy

To identify whether and how family physicians practising home care resolve ethical dilemmas in clinical management of homebound patients and to examine whether the self-reported, theoretical ethical positions of these physicians match their actual patient management.

Cross-sectional survey.

Quebec community-based home care program.

Quebec family physicians actively involved in community-based home care: 85 men and 65 women.

Physician level of agreement with theoretical ethical statements about autonomy, caregiver needs, and resource allocation; management options chosen for a clinical case vignette; and mechanisms used for resolving conflicts.

There were 209 respondents to the 279 questionnaires sent (75%). Of these, 59 who were not currently involved in home care were excluded, leaving 150 participants. Most (83.3%) physicians surveyed agreed with the ethical principle of patient autonomy; 88.7% agreed that the interests of family caregivers are important in decisions regarding patients, and 72.0% agreed that limiting home care services is reasonable in the context of limited resources. In managing a patient, 65.3% of physicians thought the patient should be placed in a nursing home against her wishes because of "danger to self," while 82.7% felt she should be placed if the caregiver is "exhausted." Three quarters of physicians did not limit or decrease home care services, despite noncompliance.

Family physicians practising community-based home care in Quebec have practical views on various ethical principles guiding home care practice. Except in the area of limiting or discontinuing home care services, their ethical framework is reflected in a case vignette of patient management.