JCPSLP Vol 17 Supplement 1 2015_lores

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JCPSLP Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology 59
reflection on policy formulation and analysis of the potential
impact of the policy.
The impact of policy
While acknowledging policy development may be a small
part of many speech pathologists’ roles, the potential
impact of a policy or policy change may be broad. Within a
hospital context Frolic et al. (2012) suggests policies and
policy changes may impact at least six distinct stakeholder
groups. Applying Frolic’s groups to a current Australian
hospital system these groups may include:
1. the hospital as an institution and possibly the local
health network more broadly;
2. the patients and families who may (or may not) receive
care;
3. staff, students and volunteers at the hospital;
4. other government, non-government and volunteer
service providers in the region;
Text box A. The case
The patient
Currently on the medical ward there is a frail, elderly
patient of Italian heritage with multiple medical problems
who is doing quite poorly. Through clinical assessment
and a modified barium swallow study, he has been
diagnosed by a speech pathologist as being at risk of
choking. The team has recommended a highly modified
diet that he finds unappetising and boring.
The patient has said he has had enough of life. He
has capacity and he wants to eat food that he enjoys.
There are also strong cultural and social norms,
particularly for his generation, about the healing power
of food and his wife is very upset that she can no longer
feed him particular foods as she feels this is a role she
can play in his healing.
The patient and his family want him to be able to eat
some of the foods they bring from home that he has
loved over the years. The patient and the family are all
prepared to take the risk of him choking as they feel his
quality of life is suffering; he is unhappy, depressed and
losing weight.
The rule
Currently the unwritten hospital rule is that dysphagic
patients who are at risk of choking are not provided with
or fed “choke risk” foods by the hospital during their
inpatient stay.
There has been conflict between staff members and
patients and families over this “rule.” It is felt a clear
written policy would decrease conflict around this issue
and clarify what procedures to follow in the event of any
team managing a patient who has been diagnosed as
being at risk of choking.
The differing perspectives
• Some staff support the approach of not providing
food to patients who are at risk of choking, in order
to not harm (potentially kill) patients.
• Some staff believe patients’ autonomy should be
respected and patients should be provided with
the food they (or their designated decision-makers)
request as long as they are informed of the risk.
• Some staff are distressed at the thought of providing
or feeding a patient with food they might choke on
as they have observed a person choking to death.
Text box B. Who are the stakeholders impacted on
by this case?
1. The hospital as an institution and possibly the
local health network more broadly
Another hospital within the local area network recently
had a coroner’s case concerning a patient choking to
death. The coroner’s findings were very clear
regarding the need to follow the speech pathologist’s
diet modifications and recommendations (when
choking due to dysphagia was identified as a risk to
patients). Consistent policies across the network are
therefore essential.
2. The patients and families who may (or may not)
receive care
• Patients: Malnutrition is often an issue for hospital
inpatients and many patients have very clear food
preferences.
• Families: Many hospital patients come from
multicultural backgrounds for which the provision
of food and particular foods is a cultural indicator
of “care”. Family members, trusted friends or
carers who may hold an enduring power of
attorney (medical treatment act) or an advance
care directive from the patient are integral to the
decision-making processes that will occur in
relation to policy and procedures.
• Delegated decision-makers: Many dysphagic
patients in hospital also have an element of
cognitive impairment and therefore enduring power
of attorney (medical treatment act) or care directives
or delegated decision-makers may be involved.
3. Staff, students and volunteers at the hospital
• Consultants often want their patients to “just
eat more”. When patients lose weight, they lose
muscle tone, stamina and capacity to undertake
daily self-care activities.
• Nurses who have seen patients choke,
sometimes to death, do not want to be forced to
feed a patient at risk. Other nurses think patients
should be able to eat whatever they like.
• Kitchen staff who deliver food and drinks from the
kitchen do not want to provide food that could
potentially “kill” someone.
• Students and new graduates of all disciplines
want a clear policy to follow, particularly in
sensitive cases. Accurate and detailed policy and
procedures inform the staff as to what to do and
how to document this.
4. Other government, non-government and
volunteer service providers in the region
If the hospital/local area health network introduces a
“no choke” risk policy, this may impact on disability
service providers providing institutional care, local
nursing homes, hospices, rehabilitation organisations
and individual carers at home.
5. The local community that relies on the hospital/
health network for care
Advocates for people with disabilities would stress
the importance of autonomy and clients’ rights to the
least restrictive intervention possible, particularly in
the community.
6. Related agencies such as social services
Community members fund health services through
taxes. They are invested in health services improving
patients’ health status efficiently and effectively, and
safely.
The office for the public advocate may provide
guardianship advice.
Solicitors from the public trustees’ office may
provide legal advice (particularly given previous
coroners’ findings).