JCPSLP Vol 17 Supplement 1 2015_lores

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 Unpublished Masters thesis, Flinders University, SA.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. 1. www.agpn.com.au/site/index.cfm?display=4207 2. http://www.mhca.org.au/documents/Definitionsofmentalhealth.pdf 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. 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.

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 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.

Correspondence to: Marie Atherton Senior Advisor Professional Issues

Speech Pathology Australia Level 2, 11–19 Bank Place Melbourne Vic. 3000 email: matherton@speechpathologyaustralia.org.au

This article was originally published as: Smith, H., & Muller, N. (2009). To tube or not to tube: Who can ethically answer that question? ACQuiring Knowledge in Speech, Language, and Hearing , 11 (3), 163–164.

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

Journal of Clinical Practice in Speech-Language Pathology