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ACQ
Volume 12, Number 3 2010
ACQ
uiring knowledge in speech, language and hearing
So, in practice, there is discussion with the patient’s
decision-maker about the risks of not adhering to speech
pathology recommendations. After explanation, the decision-
maker usually understands the risks, and then helps to
persuade the patient to take the recommended modified
diet and thickened fluids. If not, we return to principle 2 “in
the patient’s best interests”. This produces more possible
scenarios:
1. If the patient is at the end stage of his illness (which is
often the case), then deeming him of “palliative” status
would allow him to consume whatever diet and fluid
he wishes. This may be considered to be in his “best
interests”. Even in this case, the decision-maker has to
agree with the palliative status, and all discussions and
actions would be fully documented. If the decision-maker
does not agree to palliative status, we would continue
to attempt to get the patient to accept modified diet and
fluid if possible.
2. In the case of the non-palliative patient, the speech
pathology recommendations are still in the patient’s
medical “best interest”, and would therefore be upheld.
In this case if the patient still refuses modified diet and
fluid, or the decision-maker allows the patient to drink
cups of tea (as a way of exercising the patient’s right to
self-determination), this would be documented in detail
to avoid liability on the part of the health authority, in the
event of the patient’s health status declining, or of these
actions causing the patient’s death.
Suze
Thank you, Deb and Melanie, for sharing your thoughts on
this very important aspect of ethical practice. We must be
mindful of the need to ensure that the people we work with
understand that they are partners in the therapeutic process.
They should be fully informed about the assessments and
interventions we offer them, and we need to make our
information, ourselves as clinicians, and our healthcare
environments as accessible as we can.
References
Berglund, C. (2004).
Ethics for health care
(2nd ed).
Melbourne, Oxford University Press.
Body, R., & McAllister, L. (2009).
Ethics in speech and
language therapy
. Chichester, Wiley-Blackwell.
Melanie
I try to consider several ethical principles in these cases:
1. Respect for human life and dignity.
2. Respect for individual’s right to self determination/
autonomy, which includes informed consent, disclosure
of information to the patient, duty of confidentiality.
3. Beneficence and non-maleficence, which includes
treatment that is in the patient’s best interest, evidence
based best treatment, and duty of care.
4. Justice, which includes fairness in allocation and use of
resources, and the greatest good for the greatest number
of people.
The right to autonomy (principle 2) can come into conflict
with treatment which is in the patient’s best interest (principle
3), as in the following example.
An 80-year-old gentleman who is on an inpatient ward
following a stroke has a swallowing disorder diagnosed by
the speech pathologist and requires a modified diet and
thickened fluid in order to avoid the risk of aspiration. He
has a background of cerebrovascular disease with a known
“Mini-Mental” (Folstein) score of 15 /30, consistent with a
moderate dementia (likely vascular dementia). He becomes
agitated on the ward, refusing to drink any thickened fluid,
and demanding a cup of tea. The speech pathologist
tries to explain the risks of aspiration to the patient but is
unsuccessful in persuading him from his position. Following
this, the psychiatrist is called to assess the patient’s
competence.
She deems the patient to be lacking in decision-making
competence. In this instance, since the patient lacks
competence, consideration needs to be made of:
•
what is in the patient’s best interest. This would be
to continue the speech pathology recommendations
of thickened fluid and a modified diet. If these
recommendations are not followed there may be a risk of
aspiration and subsequent death.
•
whether the patient has an “Advance Healthcare
Directive” (“Living Will”) on his file with a statement of
values in which he favours quality of life, and ability to eat
and drink what he chooses, over prolongation of life.
This is where the ethical principles above of 2 and 3
come into conflict, and the “Advance Healthcare Directive”
reflecting the patient’s wishes would have to be followed at
the expense of medically acting in the patient’s best interest.
However, the directive would be upheld only if the patient
had been sufficiently specific about what treatment he
would refuse. If there is no directive, other paths need to be
considered, including:
•
whether the patient (when competent) has nominated
someone to have “Power of Guardianship”. If he has then
that person will have the decision-making capacity on
behalf of the patient.
•
whether a family member is prepared to be a proxy
decision-maker. This is the commonest outcome, but can
be problematic.
A potentially difficult scenario may be the proxy decision-
maker. There may be conflict between family members
about who is to be the proxy decision-maker, and each
family member may have different ideas about what is in the
patient’s “best interest “– and each person has a right to self-
determination. I often have relatives saying things like: “But
he just loves his cup of tea, surely you can’t take that simple
pleasure away from him, when he has so little else in life”.
Deborah Hersh, PhD,
has over 20 years of clinical and research
experience in speech language pathology and has worked in the
UK and Australia. She has presented and published in the areas of
discharge practice, professional client relationships, clinical ethics,
group work for chronic aphasia and goal setting in therapy. She is a
Fellow of Speech Pathology Australia and a senior lecturer in speech
pathology at Edith Cowan University in Perth.
Melanie Breese
trained in the UK, and has over 25 years clinical
experience in adult neurology. She now specialises in older adult
mental health as senior clinician at North Metropolitan Area Health
Service (NMAHS), Perth, and in community-based conversational
groups, affiliated with ReConnect, Perth. She regularly presents to
both undergraduates and postgraduates.
Suze Leitão, PhD,
is the current chair of the Speech Pathology
Australia Ethics Board, works in private practice, and teaches clinical
science to undergraduate and Masters students at Curtin University.
She is a Fellow of Speech Pathology Australia and a senior lecturer
in speech pathology at Curtin University. She is interested in issues
around ethical clinical practice.