JCPSLP Vol 17 Supplement 1 2015

JCPSLP

Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology

Journal of Clinical Practice in Speech-Language Pathology

Ethics and dysphagia management

A reflection on ethical policy

development

A case example of a hospital patient with dysphagia

Helen Smith and Christina Wilson

KEYWORDS

CHOKE RISK

DYSPHAGIA

ETHICS

POLICY

DEVELOPMENT

POLICY

IMPLEMENTATION

Helen Smith (top)

and Christina

Wilson

called enduring power of attorney (medical treatment),

enduring power of attorney for personal and health matters,

medical agent or medical power of attorney.

Patients can write down their wishes in a document that

is called an advance care directive (ACD). If a patient has

an ACD, and it relates to the current decision, then it is

considered legally binding. Substitute decision-makers are

obliged to adhere to the ACD as they are obligated to make

decisions they believe the patient would have made. While

ACDs usually record decisions about refusing life-sustaining

treatments, they are not limited to end-of-life decisions and

can be used to support patient choices in their medical

care. This “ethical” conversation presents a case whose

significant issues are around choices in eating and drinking.

Organisations are obliged to translate legal frameworks into

the development of appropriate policies at an organisational

level to deal with the needs of all stakeholder groups,

respect the values and culture of the organisation and the

individual patients who come in contact with it.

Institutional policies developed to support/manage

patients’ options around safe eating and drinking, if patients

are at risk of choking (given choking can lead to multiple

medical problems and even death), must cover patients

who have decision-making capacity, an informal or formal

substitute decision-maker and/or an advance care directive

in place. It is important that staff and family are aware of the

role and responsibilities, and the legalities around substitute

decision-making and ACDs including the right to refuse

medical treatments. Generally if an ACD exists it should be

used as the basis for the decision.

Speech pathologists bring a unique contribution and

perspective to interdisciplinary decision-making affecting

clients with communication and swallowing disorders. A

speech pathologist, in their role as a manager or as clinical

lead in a policy working party, can use the principles

outlined in the SPA Code of Ethics as a useful reference for

reflecting on potential benefits and harms for patients, the

impact policy may have on autonomy and informed choices

for patients, issues of fairness and access to care, and

finally the impact any policy may have on the professional

integrity of individual clinicians and the profession as a

whole. The Speech Pathology Australia Code of Ethics

may be a useful reference when working with colleagues to

ensure a shared understanding of the ethical issues being

discussed.

In this discussion we will use a hypothetical case

example to illustrate the use of a process to assist ethical

The Speech Pathology Australia Code of

Ethics challenges speech pathologists to

incorporate ethical practice into all aspects

of their professional roles. Policy

development and implementation may be

part of a speech pathologist’s role particularly

in institutional settings. This article illustrates,

using a case example of a gentleman with

dysphagia, a number of models which may

assist speech pathologists and their

colleagues to reflect ethically during policy

development, implementation and

sustenance processes.

n this issue’s “ethical reflection” we wish to consider

tools that may assist speech pathologists in facilitating

ethical policy development and implementation. The

Speech Pathology Australia Code of Ethics (SPA, 2010)

challenges speech pathologists to provide quality services

not only to individuals but also to communities and service

providers. According to the Code of Ethics, one of the

ways speech pathologists meet ethical responsibilities is

by contributing to the development of employers’ policies

and procedures that relate to the provision of high-quality,

efficient and effective services. Policy development and

implementation have the potential to impact not just on

individual clients but on whole organisations and client

groups (Frolic, Drolet, Bryanton, Caron, Cupido, Flaherty,

Fung and McCall, 2012) and therefore are critical to speech

pathologists’ professional roles. A conundrum for clinicians

can be that some policies, while legally sound, are ethically

problematic.

In Australia, the legal framework governing decision-

making when patients no longer have capacity, such as

when they may be close to the end of life, is impacted by

different state, territory and federal laws. This can lead to

drastically different outcomes for patients depending on the

jurisdiction in which they live. Terminology also differs from

state to state

. Substitute decision-makers and advance

care directives are used only when patients no longer have

capacity to make their own informed decisions. Substitute

decision-makers may include immediate family members,

carers or guardians. Formal substitute decision-makers,

nominated and legally endorsed by the patient, may be