Treatment Candidacy and Ethical Decision-Making What does it mean to do the “right thing” for our patients? Does the right thing always exist? Is there possibly more than one right thing? What follows is not necessarily the right answers but a framework for asking the right questions, specifically when challenged with decision-making regarding treatment candidacy ... Features
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Features  |   March 01, 2004
Treatment Candidacy and Ethical Decision-Making
Author Notes
  • Paul R. Rao, is vice president of clinical services, quality improvement, and corporate compliance/privacy officer at the National Rehabilitation Hospital (NRH) in Washington, DC. He has been a member of the NRH Bioethics Committee since its inception. Contact him by e-mail at Paul.R.Rao@Medstar.Net.
    Paul R. Rao, is vice president of clinical services, quality improvement, and corporate compliance/privacy officer at the National Rehabilitation Hospital (NRH) in Washington, DC. He has been a member of the NRH Bioethics Committee since its inception. Contact him by e-mail at Paul.R.Rao@Medstar.Net.×
  • Jennifer E. Martin, is a senior speech-language pathologist at the National Rehabilitation Hospital. She has served on the NRH Ethics Committee for five years and has presented on the topic of ethics in rehabilitation in multiple formats and locations. Contact her by e-mail at Jennifer.E.Martin@Medstar.Net.
    Jennifer E. Martin, is a senior speech-language pathologist at the National Rehabilitation Hospital. She has served on the NRH Ethics Committee for five years and has presented on the topic of ethics in rehabilitation in multiple formats and locations. Contact her by e-mail at Jennifer.E.Martin@Medstar.Net.×
Article Information
Professional Issues & Training / Attention, Memory & Executive Functions / Features
Features   |   March 01, 2004
Treatment Candidacy and Ethical Decision-Making
The ASHA Leader, March 2004, Vol. 9, 1-21. doi:10.1044/leader.FTR2.09052004.1
The ASHA Leader, March 2004, Vol. 9, 1-21. doi:10.1044/leader.FTR2.09052004.1
What does it mean to do the “right thing” for our patients? Does the right thing always exist? Is there possibly more than one right thing?
What follows is not necessarily the right answers but a framework for asking the right questions, specifically when challenged with decision-making regarding treatment candidacy and/or termination.
Definitions
David Resnick, in Professional Ethics for Audiologists and Speech-Language Pathologists (1993, p. 2), defines professional ethics as a system of conduct that is painstakingly developed to guide the practice of a specific discipline. Fletcher et al., in Introduction to Clinical Ethics (1997, p. 10), defines ethics as the examination of morality, conduct, and social practices. According to the latter, principles guiding ethical decision-making in the medical field include: beneficence, or doing good for others; respect for patient autonomy, which protects and defends the informed choices of capable patients; nonmaleficence, or avoiding doing bad for others; and justice, fairness of access to health care and to issues of rationing at the bedside (p.12). Our ethical obligations toward our patients include respecting patient privacy and maintaining a process that protects confidentiality; communicating honestly about all aspects of diagnosis, treatment, and prognosis; determining whether the patient is capable of sharing in decision-making; and conducting an ethically valid process of informed consent throughout the relationship with the patient (p.12).
Ethical challenges arise when circumstances place two or more of the principles or obligations in conflict, and one has to choose the better of two good or the lesser of two undesirable actions.
When tackling complex ethical issues, the above principles and obligations are meant to guide us in the decision-making process. We need to ask questions such as: What outcome is best, or least detrimental, for the patient? How do we define what is best or least detrimental? Can the patient make decisions for him/herself? If not, who is the appropriate decision-maker? Is the decision-maker properly informed of the options and potential consequences? What impact will a course of action have on other patients, or on the system as a whole?
Case Study
A 59-year-old white female suffered a thalamic cerebrovascular accident with a resultant cognitive-communication impairment, characterized by severely reduced short-term memory, problem-solving, insight, and safety awareness. As a result of the stroke, the patient moved in with her daughter, who drove her to treatment and reported that the patient’s poor insight was having a significant impact on safety in the home setting. From the onset of her outpatient evaluation, the patient evidenced disinterest in and resistance to treatment, indicating that she didn’t see the need. Additionally, the patient would not allow the clinician to incorporate her daughter into the treatment, so no joint problem-solving regarding home safety or family training was possible. Despite the patient’s wishes to discontinue treatment, the daughter insisted that, as the appointed decision-maker, she wished her mother’s treatment to continue.
The SLP was thus presented with this quandary: “Who owns the decision, and what is best for the person served?”
Boyle (p. 74) states that:
“the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research suggested that capacity is determined by whether a patient can do the following:
  • understand information relevant to the decision

  • communicate with caregivers about the decision

  • reason about relative alternatives against a background of reasonably stable goals and values”

Having examined the case from the perspective of the patient’s capacity, the SLP judged that the patient’s reasoning and judgment were impaired resulting in her inability to appreciate the benefits of treatment and that the daughter was in fact the appropriate decision-maker. Treatment thus continued for a number of sessions despite the patient’s objections. The treatment was not terribly successful as the patient was neither engaged nor invested in it. No clear evidence of improvement was documented.
The SLP found herself conflicted between the principles of beneficence, patient autonomy, justice, and the ASHA ethical principle I. G. (“Individuals shall evaluate the effectiveness of services and of products dispensed and shall provide services or dispense products only when benefits can reasonably be expected”; ASHA, 2003). One wants to do what is best for patients (beneficence) while allowing them to make their own decisions (patient autonomy) to the extent that they can. However, one cannot provide treatment without objective evidence that it is beneficial. The obvious, age-old dictum of “You can bring a horse to water…” is a critical variable in treatment. The issue of justice also plays a role in that providing treatment to a poor candidate takes potentially beneficial resources away from other patients.
The patient’s wishes did end up overriding the daughter’s in this case. The daughter had felt so strongly about the continuance of treatment and her role as decision-maker that she put it in writing via a letter to the treating clinician. The patient saw the letter on the clinician’s table and was so angry and upset that she vowed not to return. Given some encouragement by the SLP, the patient did agree to allow the clinician to engage in conversation with the daughter. The three jointly agreed that treatment was not beneficial, and the clinician was able to give some functional home-based suggestions for facilitating cognitive communication.
Ethics and Frequency of Services
Recently, several cases have presented themselves at our institution illustrating the ethical dilemma posed when clinicians are asked to provide treatment at a higher frequency than was deemed clinically appropriate at the time of evaluation or throughout the treatment regime. Within both our inpatient and outpatient systems, we have encountered numerous situations in which wealthy patients and/or their families develop high-and perhaps unrealistic-expectations, resulting in requesting an increase in the frequency, intensity, and/or duration of treatment, contrary to the recommendation of the treatment team. A request for a different level of care is often met with resistance by the team, which is accustomed to providing one level of care to all patients based on individual need. The team may need to explain to the family the apparent disparity in frequency of treatment among patients based on a variety of factors, such as diagnosis(es), presence of comorbidities, and prognostic factors.
For some patients or families, this is difficult to accept. It is not uncommon in our outpatient system for a patient/family to request a private arrangement with the primary clinician, or any SLP who is willing and available, for additional home-based services to be provided above and beyond what the outpatient system has recommended and/or provided, with the idea that “more is better.” This is an awkward request, especially if the optimal frequency is questionable, and/or the frequency/duration provided within the system is dictated by insurance vs. the clinician’s professional opinion. There’s a temptation to justify the additional services, as they may benefit and likely won’t harm the patient and definitely will benefit the clinician, as such an arrangement provides supplemental income.
The ethical concepts at play in such situations include justice, patient autonomy, and beneficence. We want to respect a patient/family request, yet such a request may misallocate limited resources that are seriously constrained under managed care and prospective payment systems. In addition, we are required to justify treatment decisions and engage the patient and family in that decision-making process by providing education and counseling regarding treatment candidacy, efficacy, and outcomes. In essence, the ability to pay for increased frequency or duration of treatment does not necessarily trigger a more intense regime. Again, the ASHA Code of Ethics principle I. G. indicates that we need to responsibly provide treatment only when benefit is expected.
In conclusion, both the organization and the individual may well be tempted to approve treatment requested by a patient or family member that hasn’t been clinically indicated. When insurance does pay for physician-prescribed clinical intervention for a patient with obvious deficits that is supported by the family as proxy decision-makers, it appears that treatment would be indicated. When the organization or private practitioner does not have to abide by compliance constraints or reimbursement requirements, an out-of-pocket solution to the dilemma seems like a win-win arrangement for the patient and the provider. However, implicit in all of the above, the underlying principle to guide us in decision-making is beneficence, doing good for our patients and abiding by ASHA’s Code of Ethics. When the gray area of determining what is right prevails, consider the principles we have outlined. And though there may not be a black-and-white answer, the asking of the questions will hopefully keep our consciences alert to guide our actions and make the best choices we can for our patients.
References and Resources
American Speech-Language-Hearing Association. (2003). Code of ethics (revised). ASHA Supplement, 23, 13–75.
American Speech-Language-Hearing Association. (2003). Code of ethics (revised). ASHA Supplement, 23, 13–75.×
Boyle, R. J. (1997). Determining patients’ capacity to share in decision making. In Fletcher, J., Lombardo, P., Marshall, M., & Miller, F. (Eds.), Introduction to clinical ethics (2nd ed., pp. 71–88.). Frederick, MD: University Publishing Group, Inc.
Boyle, R. J. (1997). Determining patients’ capacity to share in decision making. In Fletcher, J., Lombardo, P., Marshall, M., & Miller, F. (Eds.), Introduction to clinical ethics (2nd ed., pp. 71–88.). Frederick, MD: University Publishing Group, Inc.×
Fletcher, J. C., Miller, F. G., & Spencer, E. M. (1997). Clinical ethics: History, content and resources. In Fletcher, J., Lombardo, P., Marshall, M., & Miller, F. (Eds.), Introduction to clinical ethics (2nded., pp. 3–20). Frederick, MD: University Publishing Group, Inc.
Fletcher, J. C., Miller, F. G., & Spencer, E. M. (1997). Clinical ethics: History, content and resources. In Fletcher, J., Lombardo, P., Marshall, M., & Miller, F. (Eds.), Introduction to clinical ethics (2nded., pp. 3–20). Frederick, MD: University Publishing Group, Inc.×
Lubinski, R., & Frattali, C. (2001). Professional issues in speech-language pathology (2nd ed.). San Diego, CA: Singular.
Lubinski, R., & Frattali, C. (2001). Professional issues in speech-language pathology (2nd ed.). San Diego, CA: Singular.×
Resnick, D. M. (1993). Professional ethics for audiologists and speech-language pathologists. San Diego, CA: Singular.
Resnick, D. M. (1993). Professional ethics for audiologists and speech-language pathologists. San Diego, CA: Singular.×
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March 2004
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