• Rosalind Abdool, Michael Szego, Daniel Buchman, Leah Justason, Sally Bean, Ann Heesters, Hannah Kaufman, Bob Parke, Frank Wagner, and Jennifer Gibson.
• Centre for Clinical Ethics, Canada; Hôtel-Dieu Grace Healthcare, Canada; Joint Centre for Bioethics, University of Toronto, Canada; Department of Philosophy, University of Waterloo, Canada rabdool@uwaterloo.ca.
• Nurs Ethics. 2016 Nov 1; 23 (7): 770-783.

BackgroundIn Ontario, Canada, patients who lack decision-making capacity and have no family or friends to act as substitute decision-makers currently rely on the Office of the Public Guardian and Trustee to consent to long-term care (nursing home) placement, but they have no legal representative for other placement decisions.ObjectivesWe highlight the current gap in legislation for difficult transition cases involving unrepresented patients and provide a novel framework for who ought to assist with making these decisions and how these decisions ought to be made.Research DesignThis paper considers models advanced by Volpe and Steinman with regard to who ought to make placement decisions for unrepresented patients, as well as current ethical models for analyzing how these decisions should be made.Participants And Research ContextWe describe an anonymized healthcare transition case to illustrate the fact that there is no legally recognized decision-maker for placement destinations other than long-term care facilities and to show how this impacts all stakeholders.Ethical ConsiderationsThe case provided is an anonymized vignette representing a typical transition case involving an unrepresented patient.FindingsAs a result of a gap in provincial legislation, healthcare providers usually determine the appropriate placement destination without a clear framework to guide the process and this can cause significant moral distress.DiscussionWe argue for a team decision-making approach in the short term, and a legislative change in the long-term, to respect the patient voice, evaluate benefit and risk, enhance collaboration between healthcare providers and patients, and promote social justice. We believe that our approach, which draws upon the strengths of interprofessional teams, will be of interest to all who are concerned with the welfare and ethical treatment of the patients for whom they care.ConclusionsOne of the main strengths of our recommendation is that it provides all members of the healthcare team (including nurses, social workers, therapists, and others) an increased opportunity to advocate on behalf of unrepresented patients.© The Author(s) 2015.

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