JCPSLP Vol 17 Supplement 1 2015_lores

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. 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. This article was originally published as: Hersh, D., Breese, M., & Leitão, S. (2010). Communicatively accessible healthcare environments: Ethics and informed consent. ACQuiring Knolwedge in Speech, Language, and Hearing , 12 (2), 127–128.

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”. 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

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JCPSLP Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology

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