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164 ACQ Volume 11, Number 3 2009 ACQuiring knowledge in speech, language and hearing
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.
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 Unpublished Masters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
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.
2.
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.