Abstract

In this paper, an attempt has been made to describe and evaluate priority-setting decision-making as to which patients are to be moved out to accommodate new patients in the emergency department of a community hospital. The identity of the hospital and related people are not disclosed. Data collection and analysis was by means of modified thematic analysis of documents, interviews with participants and direct observation of emergency department surge meetings. The priority-setting decision was evaluated against the four conditions of Daniels and Sabin’s (2002) “Accountability for Reasonableness” (A4R): relevance, publicity, appeal/revision and enforcement/leadership. The study revealed that the severity of a patient’s medical condition/need was the main driver for a priority-setting decision during surge situations. The hospital had policies in place to guide decision-making. These decisions and reasons were usually explained to the healthcare team but seldom to patients and families. The existing hospital surge policy was not known to all stakeholders. No formal process of appeals/revision existed and appeals usually involved informal negotiations. Although the relevance condition has been met to an extent, the enforcement condition in this case is not met because the condition of publicity is not fulfilled and the condition of revision is only partially met. The author believes that bioethics is a key component of high-quality health care and that organisational ethics is a domain of bioethics inquiry and practice. This bioethics study has been able to identify good practices and potential opportunities for quality improvement of healthcare in the organisation.

The key lesson of this study is not only the specific findings obtained here but also the realisation that combining a case study approach with the ethical framework of A4R can be useful to identify good practices and opportunities (Mielke et al. 2003), in order to improve the fairness of priority-setting in surge situations.

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