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JCPSLP
Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology
Journal of Clinical Practice in Speech-Language Pathology
Text box C. “Issues” analysis for this case
1. Multiple ethical issues are involved
•
Autonomy of patients including aspects of informed
consent
•
Staff duty of care “Do no harm”
•
Staff ethic of care regarding the social and cultural
aspects of eating
•
Organisational legal advice based on the coroner’s
recommendations including risk assessment
•
Community service providers patient advocacy for
beneficence (quality of life) particularly for people
with long-term disabilities
2. The facts
•
Currently the hospital kitchen will not provide
“choke risk” food to a patient requiring a speech
pathology modified diet.
•
A speech pathology modified diet order can be
overridden by a written order by a consultant
medical officer.
•
Patients on modified diets who have capacity and
physical mobility can independently purchase and
consume “choke risk “foods from the hospital
public cafeteria.
•
Patients who are physically impaired but cognitively
able may request family members to provide
“choke risk” foods for them to consume even after
the risks have been explained.
•
Patients who do not have capacity to provide
informed consent may have a designated decision-
maker decide to provide “choke risk foods” to them
even after the risks have been explained.
•
Staff (medical and nursing) who disagree with
the current unwritten policy may privately provide
patients without family and physical capacity with
“choke risk food” independent of the hospital
supply.
•
Professional community-based carers may provide
“choke risk” foods to patients with or without
cognitive capacity.
3. Potential recommendations
•
As per legal advice, the hospital will not provide
“choke risk” food to patients.
•
Staff may refuse to feed patients at risk of choking
non-modified consistency food as a conscientious
objector.
•
Patients
with capacity
have the right to refuse
treatment including modified consistency diet
prescriptions and once they have been educated
and informed of the risks may choose not to
receive modified consistency diets.
•
For patients
without capacity
, their designated
decision-maker once informed of the risks can
organise and provide “choke risk” food to the
patient without the involvement of hospital staff.
4. Focus questions to understand the values and
duties
•
How do we respect the right of patients to choose
their treatments? How do we ensure substitute
decision-makers are acting in the best interest of
the client?
•
How do we ensure the safety of vulnerable patients
as an institution?
•
How do we protect the legal and ethical duties
of staff in acts that might lead to the preventable
death of a patient?
•
What are the values and principles that underpin
the organisation and how are they applied during
the development of the policy (e.g. respect,
compassion, patient-centred practice)?
5. Evaluate and Justify options
In the worked example the policy development
group including the speech pathology manager met
with key stakeholders to review the options and form
a consensus response. It was decided:
•
Hospitals were institutions designed to provide safe
treatment to patients. Staff had an ethical and legal
duty of care that “choke risk” foods would not be
provided to patients by the hospital.
•
If patients or their substitute decision-makers
sourced and provided “choke risk” food, after
being informed of the risks by a senior speech
pathologist or senior medical officer and educated
in methods to provide the desired items as safely
as possible, hospital staff would not prevent this
from occurring. Resuscitation status would be
discussed with the patient/substitute decision-
maker and documented by the medical team prior
to the provision of “choke risk” food.
•
The patient, family or designated decision-maker
will be asked to provide written confirmation of
these decisions.
•
For patients without physical or cognitive capacity
and no designated decision-maker, the matter
would be referred to the guardianship board for
advice and direction as this was likely to be a rare
occurrence.
6. Sustain and review the policy (plus reflection on
practice) and uptake
•
An education program to launch the new policy
was designed for medical, nursing, allied health
and kitchen staff by the policy team with the
speech pathologist taking a lead role.
•
Adverse incidents related to diet modified food and
choking episodes were to be reviewed quarterly by
the clinical leads on the policy development group
including the speech pathology manager, and
provided to the quality assurance committee.
•
The issue was to be added to the hospital risk
register and reviewed by the quality manager
quarterly. Trend data is required to be collected to
analyse the impact of the policy on patients as well
as counting adverse events or near misses.
•
The policy was to be reviewed by the policy
development team including the speech
pathologist initially after 12 months and there after
every 3 years.