JCPSLP Vol 17 Supplement 1 2015_lores

66 / 80

64 JCPSLP Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology Journal of Clinical Practice in Speech-Language Pathology
References
Hoffer, L. J. (2006). Tube feeding in advanced dementia: the
metabolic perspective. British Medical Journal, 333, 1214–1215.
Meier, D. E., Ahronheim, J. C., Morris, J., Baskin-Lyons, S. &
Morrison, R. S. (2001). High short-term mortality in hospitalized
patients with advanced dementia: lack of benefit of tube
feeding. Archives of Internal Medicine, 161, 594–599.
Mitchell, K., Kerridge, I., & Lovatt, T. (1996). Bioethics
and clinical ethics for health care professionals (2nd
Edition). Wentworth Falls: Social Science Press.
Smith, H. B. (2007). Learning professional ethical
practice: The speech pathology experience. Unpublished
Masters thesis, Flinders University, SA.
Speech Pathology Australia. (2000). Code of ethics.
Melbourne: Author.
Trobec, I., Herbst, M., & Žvanut, B. (2009). Differentiating
between rights-based and relational ethical approaches.
Nursing Ethics, 16(3), 283-291.
Waldrop, D.P., & Kirkendall, A. (2009) Comfort Measures:
A Qualitative Study of Nursing Home-Based End-of-Life
Care. Journal of Palliative Medicine, 12(8), 719-724.
Acknowledgements
Christine Haling for providing an up to date list of relevant
legislation by state.
family or a medical power of attorney to reinforce Anna’s
advanced directive means the treating team have to
consider even more strongly what Anna would want.
Role of guardianship boards
In Max’s case he has a right to treatment that will be effective
despite his age and cognitive capacity. This may involve the
treating team providing best practice medical management
for his pneumonia and referring to a speech pathologist for
advice on swallowing management. However, a doctor is
not obligated to provide futile treatment, and in Max’s case
best practice evidence might suggest insertion of a PEG to
be futile (Meier, Ahronheim, Morris, Baskin-Lyons &
Morrison, 2001), even placing him at greater risk of
aspiration (Hoffer, 2006). If the team wishes to consider
consent for a PEG as a non-urgent surgical treatment, a
substitute decision-maker would be required.4
Further ethical considerations for the
speech pathologist
Justice
In all three cases it is important for speech pathologists to
consider the principle of justice, that is, fairness and equity
of access to services for John, Anne and Max. This may
involve ensuring John is not discriminated against due to
his longstanding mental health issues. For Anna it may be
advocating against treatment she would not want. It might be
ensuring Max receives reasonable treatment for a reversible
medical condition but does not receive futile treatment.
Beneficence/non-maleficence
The principle of beneficence/non-maleficence or “to do
good” is also relevant in the cases of John and Max. John
has a potentially reversible dysphagia and communication
impairment, but needs nutrition, hydration and access to
medications while he is receiving treatment for lymphoma.
In John’s case a PEG, which he may find less irritating than
a NGT, may be better tolerated. Similarly, by assessing
Max’s swallowing we may be able to show beneficence by
being able to provide him with oral intake he is able to
tolerate comfortably. By highlighting the complications and
risks of PEGs in individuals such as Max with end stage
dementia, we may also prevent doing harm through the
potentially unnecessary placement of a feeding tube.
Duties to clients
When considering our duties to clients we may contribute
to discussions with substitute decision-makers by providing
information that meaningfully informs the decision-making
process. Such information may include for example, the risks
and benefits of NGT or PEG tubes, or the meaning of “comfort”
oral intake, that is oral intake which may be aspirated but is
still provided for patient centered symptom management and
family care in individuals receiving palliative care (Waldrop
and Kirkendall, 2009). It may be information provided in
conjunction with other members of a treating team such as
gastroenterologists, dieticians and physicians.
Conclusion
In this column we have highlighted the many and varied
deliberations a treating team may undertake when determining
the placement of feeding tubes to provide non-oral
nutrition, hydration and medication. As has been discussed,
many ethical and legal issues need to be considered by the
treating team when contemplating substituted informed
consent. Speech pathologists have a vital role to play in
these deliberations and are well placed to positively
influence the decisions that are made and the actions
undertaken. Our clients will clearly benefit from our ability to
discuss these issues in an open and informed manner with
other team members and the relevant decision-makers.
Helen Smith is a member-elected member of the Speech Pathology
Australia Ethics Board. Helen has a longstanding interest in ethics
both professionally and personally, having sat on community and
hospital ethics boards and undertaken study in the field of biomedical
ethics. Helen has been involved in teaching ethics to both
undergraduate and postgraduate speech pathology students at
Flinders University since 2000 and her Masters research
investigated how student speech pathologists learn ethical
practice. Noel Muller is a consumer representative on the Speech
Pathology Australia Ethics Board. Noel has been an active
executive member of a consumer advisory group for a number of
years and has represented consumer rights/issues in numerous
areas including housing, disability, respite, aged care, suicide
prevention, and forensic mental health. Noel is currently the
president of Queensland Voice for Mental Health – a state-wide
consumer and carer body that provides the Queensland
government with policy advice regarding mental health initiatives
from a consumer and carer perspective.
Correspondence to:
Marie Atherton
Senior Advisor Professional Issues
Speech Pathology Australia
Level 2, 11–19 Bank Place
Melbourne Vic. 3000
email:
1. www.agpn.com.au/site/index.cfm?display=4207
2. http://www.mhca.org.au/documents/Definitionsofmentalhealth.pdf
3. For more information on a state-by-state basis see the
following: Consent to Medical Treatment and Palliative Care Act
1995, SA; Health Act 1911, WA; Natural Death Act 1988, NT;
Medical Treatment Act 1988 ,Vic; Medical Treatment – Health
Directions Act 2006, ACT; Health Services Act 1960, Tas;
Consent to Medical Treatment – Patient Information 2004, NSW.
4. The appropriate “substitute decision-maker” will vary from state
to state – it may be a member of the Guardianship Board or
other authority.
This article was originally published as: Smith, H., & Muller,
N. (2009). To tube or not to tube: Who can ethically answer
that question? ACQuiring Knowledge in Speech, Language,
and Hearing, 11 (3), 163–164.