Ethical Conflicts in the Vocational Rehabilitation of Stroke Survivors

Abstract

David G. is a 53-year-old right-handed man with a medical history significant for hypertension and coronary artery disease who collapses at home one morning while shaving. His wife finds him unresponsive immediately after the event and calls EMS. He is transported to the emergency department of a nearby hospital, which is a major academic medical center. Initial work-up in the emergency department finds that Mr. G has suffered a hemorrhagic stroke involving the right parietal region. His blood pressure, which is 210/98 on admission, is stabilized, and he is admitted to the neurologic ICU for further observation. Further work-up fails to reveal an aneurysm, arteriovenous malformation, or other anatomic etiology of the stroke. Mrs. G tells her husband’s nurses that she has been worried about him lately because of his refusal to take his blood pressure medication. His event is felt to be a hemorrhagic stroke secondary to untreated hypertension. Over the next 2 weeks, Mr. G’s neurologic status improves. He is awake, alert, and oriented to place, his family members, and his general situation. He responds to simple motor commands with his right upper and lower extremities, but he exhibits some left hemineglect, impulsivity, and decreased awareness of his deficits and safety concerns with mobility. His motor exam, which has improved since admission, now shows greater-than-gravity strength of the left upper extremity but increased resting tone and flexor synergy on purposeful movement. After a 3-week inpatient rehabilitation stay and 6 weeks of outpatient therapy, Mr. G and his wife report that he is doing well at home and requires minimal or moderate assistance for activities of daily living. He is walking household distances independently with a small-based quad cane but requires occasional cueing and reminders about safety. He is less impulsive in general than earlier in his rehabilitation course, but he still lacks insight and judgment with regard to his deficits and their functional implications. Prior to his discharge from outpatient therapy, Mr. G and his wife met with a vocational rehabilitation counselor to dis-