JCPSLP Vol 21 No 1 2019

well as for his profession, by highlighting how he, as a SLP, could assist with assessing mental capacity and modifying the consent procedures. When considering how he might proceed, Tom reflects on the questions suggested as a reasoning framework within a casuistry approach from the SPA Ethics Education Package (2014): What are the most important issues in this case? • What is the client’s diagnosis and prognosis? • Are there quality of life issues to consider? • Has the client expressed a strong preference for or against an intervention? • What is the nature of the ethical issue or dilemma

Michelle finds the process of problem-solving and drawing on the Principles-Based Decision Making Protocol helps her manage her ethical unease and provides her with a plan to follow. When she speaks to Glenn, the manager of the nursing home, he tells her that he was unaware that June may have swallowing difficulties and thanks Michelle for alerting him to this. He assures her that he will mention it to the GP who regularly visits the home, and ask for a referral to a local SLP for further assessment. Scenario 2 Tom is the first SLP in his state working in a youth detention centre. He has started working with Dale, a 16-year-old with moderate intellectual disability and severe receptive and expressive language difficulties. Tom hears that Dale was recommended to receive some invasive medical treatment soon, but has been deemed to lack capacity to consent to this intervention. Tom understands that people’s capacity to make decisions on specific matters requires an ability to understand and retain the information and express their answer. He wonders whether Dale would have been able to participate more effectively in the decision-making process had his communication needs been supported, but knows that the staff in the detention centre do not routinely involve speech- language pathology in consent procedures. He is unsure whether to raise concerns about this, and find ways to support Dale’s communication in the consent procedures, or to say nothing as the centre staff have well-established ways of operating and he does not want to rock the boat. SLPs value clinical and professional experience as a guide for ethical reasoning, and often draw on clinical experience to identify and resolve ethical conflict or guide ethical practice. This approach to reasoning is termed “casuistry” or case-based learning. The first step incorporates a comprehensive understanding of the case and key ethical issues at stake, with consideration of the relevant communication/swallowing information, client preferences, quality-of-life issues, and the overall health care context. The next step involves searching for relevant cases which may relate to the current case and inform our deliberations, our decision-making and our practice. These may be drawn from the SLP’s experience or that of their peers, from clinical guidelines or position statements, from the research literature, and/or advice from experts in the area. Finally, SLPs compare and contrast details regarding the current case with these sources of information to facilitate decision-making, carefully considering any individual factors pertinent to the current case which may affect the course of action selected. Tom realises that by suggesting that different practices may have enabled Dale to participate in the decision-making process, he could be perceived as challenging the status quo, and this might not be well- received by staff who may have followed the same procedures for many years. As a new member of the multidisciplinary team at the centre, and the first SLP to be employed there, he feels it is important to establish strong, positive working relationships with the other staff, and is worried he might be seen as a trouble-maker if he challenges the current practice. However, Tom believes that he has an ethical obligation to advocate for his client and his right to make an independent autonomous decision, as

(with reference to the Code of Ethics)? Have I managed a case like this before? • How did I approach previous cases? • Is there empirical evidence to inform case management? • What were the outcomes in other cases?

• If I haven’t managed a case like this before, are there any similar professional cases or resources I should investigate? How similar are the cases? • How closely do the features of my current case match previous cases? • Are there new or distinguishing features about this case? • What are the reasons for maintaining or changing my response to this dilemma? Tom draws broadly on this framework and begins by collating the background information he has on Dale. The referral states that Dale has a moderate intellectual disability and so Tom is aware that he is likely to require additional supports to understand the decision about whether or not to accept medical intervention. Tom has spent several hours with Dale, both informally (e.g., playing basketball with him in the yard), and in individual speech-pathology sessions during which he has developed good rapport and gained an initial understanding of strategies that support Dale’s ability to understand information and express himself. Tom reflects on how he might approach the matter with centre staff, and what he might suggest as possible alternative methods to establish mental capacity and gain informed consent, given Dale’s communication strengths and weaknesses. While Tom has only recently begun work in this context, he has previously worked for an organisation that supported people with disabilities and, when he first qualified, on a stroke ward. He reflects on the approaches he used to gain consent in these cases and contexts, using modified forms with images and simple English. He searches for literature about the complexity of assessing mental capacity and the need to make reasonable adjustments to ensure information is presented in a way that an individual is most likely to understand, retain, and process, and to enable them to express a decision (Jayes, Palmer & Enderby, 2016). He then reads articles about suggested methods for adapting consent procedures when recruiting people with communication difficulties in research, such as the use of total communication strategies and staged delivery of information (Jayes & Palmer, 2014) and Talking Mats TM (Cameron & Murphy, 2006), which take into account the individual’s communication abilities. He is also interested in articles discussing the use of Talking

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JCPSLP Volume 21, Number 1 2019

Journal of Clinical Practice in Speech-Language Pathology