JCPSLP Vol 21 No 1 2019

Table 1. Case example of principles-based decision-making protocol

The facts (Describe and define the issue/dilemma)

What are the facts? Michelle has been employed as a communication intermediary to assess and advise on June’s communication as it pertains to the justice process. However, as an experienced SLP she has observed signs that June may have dysphagia and is aware of the potentially serious risks if this is not adequately managed.

How did she learn about them? Michelle observed June coughing while drinking tea during the communication assessment.

Who is involved? Michelle, June, and June’s care staff.

What are the client-related factors? June is at risk of aspiration (and subsequent aspiration pneumonia) if she has dysphagia that has not been recognised or managed. What are the external considerations? Michelle does not want to act outside of her role of intermediary as that is the role in which she was employed in this case. Does she need any other facts or information? Michelle is unsure whether June has previously been assessed for dysphagia and has made a decision to accept the risks and continue normal intake, whether the care staff in the nursing home have had any training in spotting the signs of dysphagia, and whether there is an SLP who visits the home who may be better placed to comment on observed swallowing difficulties of residents. List possible actions that could be considered at this early stage Michelle considers that there are several different actions she could take: • She could stay within her role of intermediary and ignore the possible dysphagia; • She could assess June’s swallowing skills in order to provide more accurate information to her care staff; • She could offer to provide dysphagia awareness training for the staff; • She could mention to care staff that June may benefit from a dysphagia assessment. Which ethical principles apply? If so, in what way? Michelle is troubled by the desire to do good (beneficence) for June and minimise any harm (non-maleficence) by alerting June and her staff to her possible dysphagia. She considers June’s autonomy and right to make an informed decision about what she eats/drinks, but is unsure whether June is aware of the risks if she does have dysphagia. Michelle is also aware that June is likely to need support to understand the information and express her wishes if required to participate in a decision-making process regarding dysphagia management. Michelle is keen to maintain her professional integrity as a communication intermediary, and stay within that role in which she is employed in this case, however she also feels she needs to maintain her professional integrity as an SLP by raising her concerns regarding June’s possible dysphagia. Which duties, obligations or rules are not being met? If so, in what way? Michelle has been employed in this case as a communication intermediary with clear professional boundaries and is bound by the code of conduct which she signed when she took the role. Although she recalls firm guidance during her intermediary training that intermediaries should not comment on anything outside of communication relating to the justice processes, she cannot find anything specifically discussing this in the code of conduct. She feels that by ignoring the observed signs of dysphagia, she is not following the standards of practice expected for a speech- language pathologist. What and where is the conflict? Michelle believes that in this case there is a conflict between the expectations and boundaries of her role as a communication intermediary and her knowledge/experience as an SLP. She feels this has led to potential conflict between doing good and not doing harm, and consideration of June’s ability to make autonomous decisions. What is her decision? Michelle decides to speak with the manager of the nursing home. Although Michelle will not be mentioning the possible dysphagia in her intermediary report (as it is not relevant to the police or court proceedings), she does document it (and her subsequent actions) in her notes, and informs both the referrer and her employing agency so that she has been transparent in her actions. How will she evaluate and reflect on this process and its outcome? Although Michelle is likely to have ongoing contact with June during the investigative and trial processes, she will not follow-up regarding her possible dysphagia. Michelle feels comfortable that she has alerted the nursing home to June’s possible swallowing difficulties and that it is now their responsibility to act on this, so Michelle can now focus on her role as a communication intermediary.

Is there a problem that requires action (early planning)?

The problem (mapping to the Code of Ethics)

Proposed decision

Evaluation and reflection plan

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JCPSLP Volume 21, Number 1 2019

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