Time can be a challenging thing. We can only live in the present, but we understand that present through the past and the future. Decisions cannot exist in a time vacuum, where we are entirely focused on the decision itself and not the future complications that the decision will create. When we are making medical decisions with a patient, and discussing the realities of those decisions, we have to take into account what future those decisions create. Take, for example, a recent case.

Trach and Then What?

We recently had a patient in the ICU. The patient was a middle-aged woman suffering from respiratory distress. She has multiple additional medical complications and had to be intubated and put on the breathing machine. That was about two weeks ago, and the patient has not improved.

Now the medical team is discussing placement of a trach and PEG and would then likely need to be sent to a skilled nursing facility while the patient recovers. This situation is complicated due to the patient’s immigration status. The patient is undocumented, and the rest of her family lives out of the country. This is challenging the decision to place a trach because the medical team is asking, “Then what?”

Because of the patient’s undocumented status, finding placement for her is next to impossible. The patient does not have health insurance, but unlike a similar patient who is a citizen of this country, she does not have a path to insurance. While other patients could possibly go on Medicaid, this patient will likely never qualify and thus never establish insurance. The hospital is also a relatively small hospital, with only four ICU beds that are constantly full. Should this patient receive lifelong interventions only to stay in the hospital, occupying an ICU bed with little to no expectation of ever leaving?

The Full Situation

When we discuss concepts such as justice, we have to take into account the full situation and what justice means. Justice does not necessarily entitle every patient to receive everything possible, but rather that patients are treated fairly. How should a lack of a path to insurance, and thus a patient’s immigration status, impact the other principles, such as what is best for the patient and what the patient wants?

Unfortunately, one aspect of medical ethics, and all applied ethics, is that we are often tied down not by what is right, but rather by what is best. That can cause some troubling situations where the healthcare team knows what is right for the patient but is unable to deliver it fully because of additional restrictions. And with the current political climate, with limits and restrictions put upon those who qualify for resources, these situations—and the moral distress that comes with them—will only happen more often.