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recommendations. It’s counter-productive to adopt a ‘do what I say if you want to receive a service’ approach. We need to be careful about the value judgements we place on terms such as ‘risk’ versus ‘comfort’ feeding.” Katherine summarised the tone of the discussion when she concluded: Sometimes we need to feel comfortable with not being in control and not being the expert about that person. Different approaches are taken in different places and it’s important to understand legal issues but don’t get stuck on them. We can navigate a more client-centred pathway. Katherine also acknowledged that decision-making with clients at end of life was a complex process and she provided recommendations for facilitating skill development in palliative practice. Such recommendations included: incorporation of palliative holistic approaches in professional preparation programs; clinical supervision to learn how to manage difficult conversations; opportunities to work with medicolegal departments to manage legal concerns; and access to individual psychosocial support for professionals to manage cognitive dissonance if clients’ personal values conflict with those of the health professional (e.g., workplace employee assistance/counselling programs). Katherine also incorporated the Code of Ethics into her decision-making, to respond in a way that reflected professional values. Nonetheless, both clinicians clearly identified: It’s challenging work but there is so much value in this work. You can have an enormous impact on a person’s end of life. It’s an enormous privilege to bring some positives to the experience and take away the fear. The approaches described by Katherine and Robyn certainly seem to reflect the Speech Pathology Australia’s ethical principles of beneficence and non-maleficence (i.e., to do good and do no harm) and uphold the values of respect and care espoused in the Speech Pathology Australia (2010) Code of Ethics. Further reading on this topic Speech Pathology Australia Code of Ethics Speech Pathology Australia. (2010). Code of ethics . Melbourne: Speech Pathology Association of Australia Limited. Retrieved 8 July 2018 from https://www. speechpathologyaustralia.org.au/SPAweb/Members/Ethics/ spaweb/Members/Ethics/Ethics.aspx?hkey=5c5556d0- 327f-4d06-8e89-fd1a638e543a Ethics Education Package and the new online SPA Continuing Professional Development Live Ethics online learning modules Speech Pathology Australia. (2014). Ethics education package . Melbourne: Speech Pathology Association of Australia Ltd. Retrieved 8 July 2018 from https://www. speechpathologyaustralia.org.au/SPAweb/Members/Ethics/ spaweb/Members/Ethics/Ethics.aspx?hkey=5c5556d0- 327f-4d06-8e89-fd1a638e543a Speech Pathology Australia. (2018) Ethics in professional and clinical practice . Retrieved 17 June 2018 from: https:// www.cpdlive.com/speechpath/seminars4/7576/9178/ Ethics-in-Professional-and-Clinical-Practice.html&Display__ this=Y Speech Pathology Australia. (2018) Enhancing ethical practice: Avoiding snakes and building ladders . Retrieved

talk with the family and Padraig about how he could be eating more kilojoules, in addition to monitoring for refeeding syndrome if need be. What would you see as a positive outcome in this case? Katherine described “the recipe for success” as: doing something that will help Padraig to achieve his goal. A plan that is flexible and responsive, maintains the therapeutic relationship as an ongoing process – depending upon where he is at and where the family is at. A plan that meets his goals as they, the goals, may change. Robyn identified the importance of situating Padraig and his goals in the context of his family and the need for good communication between the family members. She also identified that there needed to be “careful exploration and identification of the deep or real desire of Padraig which may actually be about caring for his family. Helping the family safely deal with his death and how they will manage without him.” Identifying Padraig’s goals, ensuring he has the information he needs for these to be at least somewhat realistic, and working towards his goals, minimising distress and maximising quality of life would be a positive outcome. Would your recommendations for/ management of Padraig change (or ethical considerations change) if other factors were different, e.g., his age, diagnosis, family responsibilities? Katherine and Robyn agreed that both recommendations for management and also ethical considerations may change, although many of the processes would be similar. Katherine reflected: Yes, and no. The process would be the same and you may involve a proxy decision-maker if Padraig were no longer able to make his own decisions, but really, it’s about what’s medically and clinically appropriate. For example, there is not much evidence that older people with dementia have improved outcomes with enteral feeding. But the overall well-being for the individual is the key consideration. Robyn agreed with Katherine, and added that consideration of supported accommodation for Padraig may need to be considered if his family were not in a position to assist with his care. What do you see as your ethical responsibilities in end of life decision- making, within your professional role? Both clinicians highlighted effective education, communication and inclusive practices: 1. Informed decision-making: “Our biggest value is in providing information, so good assessments, what may or not be helpful, how we’re going to manage with the tools that we have. Providing the information in an open, honest transparent way and sensitive to cultural preferences. Giving support and advocating.” 2. Appropriate communication: “Helping communication between the client and the team because we often have 1-hour discussions, not 10-minute interactions – we are ‘user friendly’ for clients.” 3. Inclusive care: “It’s important to keep the door open, even if clients don’t seem to agree with our

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JCPSLP Volume 20, Number 3 2018

Journal of Clinical Practice in Speech-Language Pathology