JCPSLP Vol 17 Supplement 1 2015_lores

Text box C. “Issues” analysis for this case

decision-makers are acting in the best interest of the client? • How do we ensure the safety of vulnerable patients as an institution? • How do we protect the legal and ethical duties of staff in acts that might lead to the preventable death of a patient? • What are the values and principles that underpin the organisation and how are they applied during the development of the policy (e.g. respect, compassion, patient-centred practice)? 5. Evaluate and Justify options In the worked example the policy development group including the speech pathology manager met with key stakeholders to review the options and form a consensus response. It was decided: • Hospitals were institutions designed to provide safe treatment to patients. Staff had an ethical and legal duty of care that “choke risk” foods would not be provided to patients by the hospital. • If patients or their substitute decision-makers sourced and provided “choke risk” food, after being informed of the risks by a senior speech pathologist or senior medical officer and educated in methods to provide the desired items as safely as possible, hospital staff would not prevent this from occurring. Resuscitation status would be discussed with the patient/substitute decision- maker and documented by the medical team prior to the provision of “choke risk” food. • The patient, family or designated decision-maker will be asked to provide written confirmation of these decisions. • For patients without physical or cognitive capacity and no designated decision-maker, the matter would be referred to the guardianship board for advice and direction as this was likely to be a rare occurrence. 6. Sustain and review the policy (plus reflection on practice) and uptake • An education program to launch the new policy was designed for medical, nursing, allied health and kitchen staff by the policy team with the speech pathologist taking a lead role. • Adverse incidents related to diet modified food and choking episodes were to be reviewed quarterly by the clinical leads on the policy development group including the speech pathology manager, and provided to the quality assurance committee. • The issue was to be added to the hospital risk register and reviewed by the quality manager quarterly. Trend data is required to be collected to analyse the impact of the policy on patients as well as counting adverse events or near misses. • The policy was to be reviewed by the policy development team including the speech pathologist initially after 12 months and there after every 3 years.

1. Multiple ethical issues are involved • Autonomy of patients including aspects of informed consent • Staff duty of care “Do no harm” • Staff ethic of care regarding the social and cultural aspects of eating • Organisational legal advice based on the coroner’s recommendations including risk assessment • Community service providers patient advocacy for beneficence (quality of life) particularly for people with long-term disabilities 2. The facts • Currently the hospital kitchen will not provide “choke risk” food to a patient requiring a speech pathology modified diet. • A speech pathology modified diet order can be overridden by a written order by a consultant medical officer. • Patients on modified diets who have capacity and physical mobility can independently purchase and consume “choke risk “foods from the hospital public cafeteria. • Patients who are physically impaired but cognitively able may request family members to provide “choke risk” foods for them to consume even after the risks have been explained. • Patients who do not have capacity to provide informed consent may have a designated decision- maker decide to provide “choke risk foods” to them even after the risks have been explained. • Staff (medical and nursing) who disagree with the current unwritten policy may privately provide patients without family and physical capacity with “choke risk food” independent of the hospital supply. • Professional community-based carers may provide “choke risk” foods to patients with or without cognitive capacity. 3. Potential recommendations • As per legal advice, the hospital will not provide “choke risk” food to patients. • Staff may refuse to feed patients at risk of choking non-modified consistency food as a conscientious objector. • Patients with capacity have the right to refuse treatment including modified consistency diet prescriptions and once they have been educated and informed of the risks may choose not to receive modified consistency diets. • For patients without capacity , their designated decision-maker once informed of the risks can organise and provide “choke risk” food to the patient without the involvement of hospital staff. 4. Focus questions to understand the values and duties • How do we respect the right of patients to choose their treatments? How do we ensure substitute

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

Journal of Clinical Practice in Speech-Language Pathology