According to Markkula Center for Applied Ethics (2010), ethics is defined based on well-founded standards of right and wrong that prescribe what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues. Personal and religious beliefs, as well as sociological factors, affect the ethical treatment of patients. This discussion of ethics can be broken down across all settings, but how does the conversation relate directly to speech-language pathologists within the skilled nursing facility?
Making ethical decisions in skilled nursing and medical settings can be challenging. The stress of maintaining productivity combined with limited work time and mounting documentation can affect the quality and quantity of services provided. The therapist can be placed in a precarious situation when the possibility of losing their license looms. When these stresses begin to pile up, some issues may arise, and an ethics consultation may be requested for situations including (Sutter Health, 2014):
- Advance directives
- Surrogate decision making
- Refusal of treatment
- Conflicts with caregivers
- Foregoing life-sustaining treatment
- Do Not Attempt Resuscitation (DNAR) orders
- Other issues perceived as ethical problems
Let’s take a look at some situations that are considered a violation of the American Speech-Language Hearing (ASHA) Code of Ethics and how you can work to prevent or remedy them:
Sue has seen over 15 patients during her work shift at the SNF. She has treatment encounter notes and progress notes due. Completing this documentation during her work shift will significantly reduce her productivity below 85%. In order to maintain her standard productivity percentage for the week, Sue clocks out to complete her documentation.
Principle of Ethics I- Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner. Rule of Ethics- (q) Individuals shall maintain timely records and accurately record and bill for services provided and products dispensed and shall not misrepresent services provided, products dispensed, or research and scholarly activities conducted.
Don’t clock out!! Documentation time is still productive time that warrants pay. If documentation is extending your workday, meet with your manager/supervisor to assist with improving your daily efficiency. Some suggestions include providing time one day a week to conquer lagging documentation.
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My employer wants me to see a patient for dysphagia because family members are demanding daily treatment. This patient has severe dementia, is not safe for any PO diet, and requires suctioning. Swallow initiation is reflexive, and the patient has difficulty managing their own secretions. The family has been educated on the risks of aspiration. My supervisor is insisting I continue seeing the patient.
Principle of Ethics I- Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner. Rule of Ethics- (m) Individuals who hold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served.
Education and documentation are important in situations like this. An interdisciplinary meeting with the nursing staff, physician, and other professionals involved with this patient keeps everyone accountable for this patient’s quality of life, and you can make a decision as a treatment team. The physician can then discuss options with the family.
Jane is an excellent Speech Pathologist and co-worker. She mentions she is going through a divorce and her finances are going to her legal fees. She has not saved enough to renew her license and continues to practice until she can get the money to renew.
Principle of Ethics IV-Individuals shall uphold the dignity and autonomy of the professions, maintain collaborative and harmonious interprofessional and intraprofessional relationships, and accept the professions' self-imposed standards. Rule of Ethics- (d) Individuals shall not engage in dishonesty, negligence, fraud, deceit, or misrepresentation. (r) Individuals shall comply with local, state, and federal laws and regulations applicable to professional practice, research ethics, and the responsible conduct of research.
Speak to your employer as they may be able to offer financial hardship assistance programs to help cover emergency costs. Financial difficulties can be especially challenging, but we cannot let them cloud our ability to make ethical decisions.
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When you think you’re faced with an ethical dilemma in this setting, consider the following:
Is my action legal? Does my action comply with our values and the code? Is my action honest? Do my actions appear appropriate to others? Would I be proud to tell my family or friends about my action? Would I like to see my action published on the front page of the newspaper (or in our case, The ASHA Leader)?
In addition to ASHA’s Code of Ethics, each state provides its own Code of Ethics and professional conduct guidelines. Refer to your state of practice on these standards. Additionally, Gray Matter Therapy, a website started by SLP Rachel Wynn, provides an extensive resource on SNF ethics, as well as other topics pertaining to working in the SNF setting. Other organizations that support ethical, evidence-based treatment include the Health Care Compliance Association and the National Association for Healthcare Quality.
Speech-Language Pathologists are often faced with challenges while working in skilled nursing facilities which place them at risk for clinical burnout or, worse, at risk for sanctions, censure, and total loss of professional licensure. This can lead to sub-par treatment practices, low morale, and overall professional dissatisfaction in this setting. Clinicians should be vigilant in identifying potentially challenging ethical situations and have an experienced mentor to assist in the identification of hazardous situations if need be. It is of best practice to frequently review ASHA’s, your professional state organization’s, and your state’s codes of ethics.
- American Speech Language Hearing Association (2016) Code of Ethics; https://www.asha.org/Code-of-Ethics/#sec1.5
- American Speech Language Hearing Association. States Code of Ethics. https://www.asha.org/practice/ethics/state-codes-of-ethics/
- Cutter, M and Polovoy, C (2014) Under Pressure. The ASHA Leader. https://doi.org/10.1044/leader.FTR1.19062014.36
- Friedman, V (2016) The Health Files: Ethics. Rehab Insider. http://rehab-insider.advanceweb.com/the-health-files-ethics/
- Sutter Health. (2014) What are Ethical Dilemmas? Alta Bates Ethical Committee. http://www.altabatessummit.org/patientsandvisitors/ethicaldilemma.html
- Valasquez, M. et al (2010) What is Ethics? Markkula Center for Applied Ethics at Santa Clara University. https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/what-is-ethics/