Ethics: A Clinical Perspective for Therapists

This is an edited transcript of a live webinar. Review the course handouts for essential details required for a thorough understanding of course material.

 

Learning Outcomes

After this course, participants will be able to:

• List basic principles of ethics and their application to rehabilitation and physical therapy.
• Identify codes of ethics that govern discipline-specific therapy practice.
• Describe ethics in healthcare and professional licensing, including that which is considered unethical and/or unlawful by credentialing boards.
• Discuss procedures for analyzing ethical dilemmas in healthcare
• Analyze ethical dilemmas through case scenarios to illustrate how to apply a Code of Ethics to real-world issues.
• Identify ethical issues commonly experienced in healthcare settings.

Today we will go over some general ethics concepts and share a few ethical considerations for your work. I think I've seen it all until I realize I haven't. New scenarios always present themselves. With my experience, hopefully, I can impart some useful perspectives.

Principles of Ethics

Ethics play a crucial role in guiding our decisions about what is morally right and wrong, extending seamlessly from our personal lives into our professional conduct as physical therapists. Our choices in the professional realm are intricately tied to the unique context in which we practice. In this discussion, we will delve into fundamental principles of ethics. As we progress, we hope you will find alignment with these principles, affirming that your practices align seamlessly. However, you may also encounter situations that present ethical gray areas, prompting further consideration and reflection within your clinic or practice area.

Autonomy

Let's start with the basic ethical principles, beginning with autonomy. Autonomy refers to the moral right to make choices about one's own actions. In other words, it's the right to self-determination. For practitioners, respecting autonomy means refraining from interfering with patients' individual choices. We allow and enable patients to make their own choices. That said, we can still educate patients about risks, benefits, and consequences of choices without diminishing autonomy. 

In our approach to patient education, we prioritize providing information to empower individuals to make informed decisions regarding their therapy. However, it's essential to acknowledge that within the health and rehabilitation sector, our dedication to helping others can inadvertently overshadow the principle of respecting autonomy.

For instance, when a patient declines therapy, it's crucial to communicate the potential risks and benefits associated with their decision. However, persistent attempts to convince or pressure them could undermine their autonomy and demonstrate a lack of respect for their choices and preferences.

Maintaining a delicate balance between offering guidance and honoring an individual's autonomy is paramount. By providing comprehensive information and fostering open communication, we create an environment where patients can confidently exercise their autonomy in making choices about their care.

Nonmaleficence

This principle embraces the timeless guidance from the Hippocratic Oath - "do no harm." As healthcare practitioners, it reminds us that if we cannot provide direct assistance to our patients, we must, at the very least, ensure we do not cause harm or exacerbate their condition. When we examine harm, it's imperative to recognize its diverse manifestations, encompassing physical, psychological, social, mental, reputational, or even harm to one's liberty, property, and more.

The nuanced nature of harm leads us to question both the recipient and nature of the harm, especially when working with patients who may lack decision-making capacity, such as those with advanced dementia. Understanding harm in this context requires a delicate approach, considering differing interpretations and perspectives on what constitutes harm.

Furthermore, it's vital to acknowledge that our perception of harm may diverge from the patient's own assessment. For instance, we may believe that non-participation in physical therapy could result in harm to the patient, while the patient may not perceive it as detrimental. Hence, we must carefully consider whose perspective of harm we are referencing.

Beneficence

In alignment with nonmaleficence, we delve into the principle of beneficence, representing our duty to prevent harm and promote the greater good. This duty involves the act of removing harm and actively fostering positive outcomes. However, it's essential to recognize that this moral obligation has its limits, especially when our actions, aimed at benefitting the patient, may inadvertently cause harm to ourselves as healthcare providers. Balancing the pursuit of benefit with the preservation of our well-being is a critical aspect of this ethical consideration.

Beneficence in healthcare centers on promoting the patient's overall well-being. However, a crucial and complex aspect is navigating the potential disparity in perspectives regarding what constitutes the patient's "good" or best interest. As healthcare providers, we often have a professional understanding of what interventions may optimize a patient's health and quality of life.

Yet, it's paramount to acknowledge and respect the individualized perspectives of each patient. What we might perceive as a beneficial treatment or intervention may be viewed differently by the patient based on their unique experiences, pain thresholds, fears, and personal circumstances. For instance, encouraging a patient to walk for their health may conflict with their personal experiences of pain and fear of falling, causing them to consider it against their best interest.

The essential approach lies in effective patient education, open dialogue, and collaborative decision-making. By providing comprehensive information about risks, benefits, and potential outcomes, we empower the patient to make informed choices aligned with their values and concerns. It's about finding a balance where we promote the patient's well-being while respecting their autonomy and individual perceptions of what is beneficial for them.

Justice

The principle of justice in healthcare is becoming increasingly significant as the demand for limited healthcare resources continues to rise. Justice emphasizes fair distribution of both burdens and benefits in society, aiming to provide individuals with their rightful due. In the realm of healthcare decision-making, this principle is pivotal in determining who should receive essential resources, examining if some individuals deserve these resources more than others, and identifying the stakeholders responsible for these allocation decisions.

However, achieving justice in healthcare is a complex challenge, as it involves addressing various contextual factors, including religious beliefs, professional ethics, legal frameworks, institutional policies, and more. The story of my mother's experience highlights the importance of advocating for fair and equitable distribution of healthcare resources, irrespective of personal connections or influential networks.

My mother just recently had back-to-back emergency surgeries and she's doing very well right now. She was in the intensive care unit and we were trying to get her into an inpatient rehab facility as opposed to a skilled nursing facility. I knew the case manager at that particular large teaching hospital. I was able to ask her what she would be able to do to get my mom whatever she needed.   We got what we wanted and we got what we asked for. Was that justice? No, not necessarily. I thought to myself, how do we fairly and equitably distribute resources such as discharge location and therapy, fairly and equitably? It shouldn't be necessary that you know someone to get what is needed.  I was a very strong advocate. What about those individuals who are receiving care, who don't have advocates in their family like me? 

It's crucial for healthcare professionals to uphold the principles of justice by advocating for all patients, particularly those without strong advocates. By doing so, we contribute to a system where healthcare decisions are made fairly and ethically, guided by the best interests of the patients and the community.

Informed consent

Informed consent is a fundamental ethical and legal principle in healthcare. It requires healthcare professionals to provide patients with comprehensive and easily understandable information about their proposed intervention strategies. This includes outlining the potential benefits, risks, potential risks, side effects, alternatives, and any other relevant details associated with the proposed course of action.

Informed consent is far more than just a checkbox to complete a procedure or evaluation. It embodies a vital opportunity for genuine communication and understanding between healthcare providers and their patients. It's about engaging in a meaningful conversation, ensuring that patients fully comprehend the proposed evaluation or treatment, its potential benefits, risks, alternatives, and what is expected from them throughout the process.

This process of obtaining informed consent should be conducted with care, empathy, and a genuine concern for the well-being and understanding of the patient. By taking the time to explain and address any concerns, questions, or uncertainties, we establish a foundation of trust and collaboration with the patient. This, in turn, enhances patient satisfaction, compliance, and overall outcomes.

Moreover, by approaching informed consent in this way, we uphold ethical principles, such as autonomy and beneficence, by respecting the patient's right to make informed decisions about their own healthcare. It's an opportunity to empower patients with knowledge and involve them in the decision-making process regarding their own health, promoting a sense of ownership and engagement in their care.

Veracity

Informed consent, an ethical cornerstone, hinges on the principle of veracity. Veracity dictates our duty to convey truth and integrity in all our patient communications. Let me pause momentarily to clarify that I will use patient, resident, and individual client interchangeably. Now, diving deeper into veracity, its significance becomes apparent as we delve into case examples later.

Confidentiality

Confidentiality, deeply rooted in the Hippocratic Oath, is paramount. The oath asserts, "Anything I see or hear of the life of men, whether in a professional capacity or otherwise, which should not be passed on to others, I will hold as professional secrets and not divulge them." Hence, we possess a duty, an obligation to restrict access to treatment-related information, maintaining a strict boundary of confidentiality between us and our patient.

Yet, it's crucial to step back and acknowledge exceptions grounded in justice and beneficence. Certain laws mandate breaching confidentiality to protect citizens, such as reporting child abuse or elder abuse in specific states. We function as mandated reporters, adhering to distinct timeframes, notably in cases of elder abuse. Nevertheless, upholding confidentiality remains vital.

Allow me to elaborate. In my role as an occupational therapist, patients often confide personal details during daily activities. Perhaps a past trauma or a family-related matter. If it doesn't necessitate reporting, I frequently express gratitude for their openness. I ask, "May I have your permission to share this with the healthcare team? It will aid in devising the best plan of care and course of action for you." While not obligatory, seeking this permission cultivates trust and reinforces the patient's faith in us as practitioners. Confidentiality, once again, emerges as an immensely significant principle.

Fidelity

Fidelity, closely intertwined with confidentiality, embodies our moral duty to uphold promises and fulfill commitments made to individuals.

Patients rightly expect us to honor both explicit and implicit promises. The explicit promises, such as scheduled appointments like, "We'll meet you at 9:30 for your physical therapy session," are clear commitments. Simultaneously, implicit promises, rooted in regulations like HIPAA and confidentiality, assure patients that we will preserve the privacy of shared information and provide the services prescribed by the physician.

Continuing to explore fidelity, we recognize five crucial expectations that patients reasonably hold regarding healthcare contexts. These expectations encompass:

1. Treating them with fundamental respect and dignity,
2. Demonstrating competence and capability in performing our professional duties (a topic we'll delve into shortly),
3. Adhering to a professional code of ethics,
4. Following organizational policies, procedures, applicable laws, and licensure regulations,
5. Honoring any agreements made with the patient or client.

Duty

This underscores the obligations we hold toward others within society. Often, these duties stem from the nature of relationships between parties. In the context of therapy, initiating a patient-therapist relationship entails specific duties toward the patient. These encompass obligations to deliver a defined standard of care and maintain confidentiality, among other responsibilities. Establishing and upholding these obligations forms the foundation of ethical practice and professional conduct within the healthcare domain.

Rights

We will now discuss rights to a certain extent. Rights pertain to the ability to exercise a moral entitlement to either perform an action or refrain from doing so. In the realm of healthcare, a variety of rights come into play. The Patient's Bill of Rights, introduced some time ago, stands as a fundamental document. Additionally, individual healthcare facilities or communities may adopt their own Bill of Rights, outlining specific rights within their organizational context.

These rights encompass various aspects, including the right to health insurance irrespective of preexisting conditions—an evolving right. Federal statutes also delineate specific patient rights concerning privacy, such as the Health Insurance Portability and Accountability Act (HIPAA). Moreover, different states may have their unique Bill of Rights. Hence, it is crucial for us to understand and adhere to these rights as mandated by our respective organizations and regions of practice.

Paternalism

While not a distinct ethical principle, paternalism is a significant concept to address. Paternalism occurs when an individual, often a healthcare provider, disregards a person's autonomy and substitutes their own beliefs, opinions, or judgments for the judgment of the individual involved, typically a patient. They may act without obtaining informed consent or going against the patient's wishes under the pretext of seeking to benefit the patient.

In cases of paternalism, individuals rationalize their actions by asserting that they acted in the person's best interest. This often happens when someone believes they know better or what's best for the person in question without adequately considering the desires and wishes of the patient. Paternalism is sometimes observed in healthcare, particularly when dealing with families, such as in end-of-life care, where family members may have differing opinions on the care plan compared to the patient. In long-term care settings, involving the family in decision-making instead of the patient can also be a form of paternalism, especially in cases of dementia where the patient's capacity to make decisions may be intact.

Recognizing and addressing paternalism is crucial in promoting patient-centered care and upholding the principle of autonomy. Respecting and honoring a patient's wishes and involving them in decision-making processes is essential to provide care that aligns with their values, preferences, and autonomy. 

Physical Therapy Code of Ethics

Professional Ethics

Professional ethics incorporates the values, principles, and morals into professional decision-making within our respective professions. Without this guidance, we risk falling into pitfalls that can cause harm to ourselves, others, and society at large.

An insightful perspective shared by a friend emphasizes the importance of intuition, that gut feeling, as a guide for ethical decisions. However, it's crucial to recognize that not everyone possesses the same intuition or gut instincts. Therefore, relying solely on individual feelings may not always lead to universally ethical decisions.

We often witness the consequences of ethical lapses within our professional circles—colleagues facing sanctions or making headlines in the newspaper or online social networks for the wrong reasons. It makes you cringe.  How did that person allow that to happen? Why did they do that? These instances remind us of the critical need for a strong ethical foundation. Professional ethics act as a safeguard against such missteps, aiming to prevent these issues from occurring in the first place.

In our roles as professionals, we must tap into our training, knowledge, and ethical obligations. These resources serve as pillars guiding our actions and behaviors, helping us make informed and morally sound decisions in our respective fields.

Code of Ethics

Our code of ethics incorporates a set of rules or principles that are intended to express the values of the profession as a whole.

Licensing boards/credentialing agencies incorporate professional codes of ethics into licensure regulations or credentialing rules. This ethical framework isn't confined to association membership; it universally applies to all practitioners within the field. Whether at the state or national level, adherence to the strictest code of ethics should be a priority, ensuring you maintain a strong ethical foundation in your practice.  It may mean, for example, using evidence-based practice, a certain quality measure, or maybe it's incorporating something very specific into our rules. 

The code of ethics plays a pivotal role, promoting the basic tenets of the profession. It  codifies our fundamental beliefs of the professions and the common moral values the profession chooses to protect patients and clients from harm. It gives meaning to the distinctiveness of your role as a physical therapist or physical therapist assistant. It serves as a unifying bond between professionals, fostering a common standard and shaping the very essence of being a practitioner in this field. These values become an integral part of your moral and behavioral repertoire, akin to how you integrate social, cultural, and other personal values.

Furthermore, courts reference the code of ethics to gauge appropriate professional behavior and as a component of the standard of care expected from practitioners. In legal scenarios, the code of ethics can significantly impact the outcome, acting as a measuring stick for proper conduct.

It's important to acknowledge that the code of ethics isn't a comprehensive guide dictating behavior or decision-making with absolute certainty. Rather, it's a foundational starting point, a point of reference, and an aspiration to steer professional practice. While it offers invaluable guidance, there may still be gray areas necessitating careful consideration and ethical discernment.

Unethical Practice

Unethical practice within the realm of healthcare refers to actions that deviate from established professional standards. This deviation spans from practices that are unreasonable, unjustified, or ineffective to those that are outright immoral, harmful, or knowingly wrong. Evaluating ethicality often involves a litmus test, a gut check, where practitioners assess their discomfort or unease with a certain practice.

Ethical analysis is multifaceted, influenced by various perspectives including social, religious, and cultural viewpoints. It's important to acknowledge that not everyone will share the same ethical analysis, and disagreements are part of the ethical discourse.  Oftentimes, as practitioners, we arrive at our ethical analysis from a lot of different views and not everybody will agree with our analysis, and that's okay.

We have to recognize what we will or won't do. Sometimes it's a matter of having a discussion with your supervisor or somebody in your compliance team. Unethical practice has a profound impact, primarily on the patient, but it also extends to the practitioner, the employing organization, insurers, society, and more.  Instances of unethical behavior can lead to loss of professional license and credibility, highlighting the substantial risk unethical practices pose to one's professional investment and the credibility of the healthcare system at large.

Considering the investment of time, effort, and resources put into acquiring professional qualifications, it becomes imperative to safeguard one's ethical standing and uphold the integrity of the profession. Maintaining ethical practice is not only a moral duty but also a strategic decision safeguarding both the individual practitioner and the healthcare system as a whole. Somebody said to me the one day, and it just kind of resonated with me, Gosh, I spent so much money and time to get through school, why would I place that at risk to do anything that I would consider unethical? So I think of it in that regard as well.

APTA Code of Ethics for Physical Therapy Personnel

This delineates the obligations of all physical therapists and physical therapist assistants, as determined by the APTA.

Purpose

There are a few purposes, if you will, for the code of ethics. They include:

1. Define the ethical principles that form that foundation of physical therapy practice in patient management, in consultation, in education, in research, and in administration.
2. Provide the standards of behavior and performance that form that basis of professional accountability to the public, to your patients, again, to insurance providers, et cetera.
3. Provide guidance for you as physical therapy practitioners who may be facing ethical challenges regardless of what your professional role is, regardless of your responsibilities or the setting where you work.
4. Educate physical therapists, students, physical therapist assistants, other healthcare professionals, regulators, and the public regarding the core values, the ethical principles, and the standards that guide your professional conduct.
5. Establish standards for judging unethical conduct 

Code of Ethics

When examining the code of ethics in-depth, it's structured around the five fundamental roles of a physical therapist: patient management, consultation, education, research, and administration. This ethical framework revolves around the core values that underpin the profession, navigating the intricate landscape of ethical action across multiple realms. 

In the realm of physical therapy, practice is fundamentally shaped by seven core values, each playing a significant role in guiding the actions and decisions of practitioners. These core values form the ethical compass of the profession, anchoring the practice within a strong ethical foundation, ensuring the delivery of patient-centric, responsible, and morally sound care.

Those core values are:

1. Accountability
2. Altruism
3. Compassion or caring
4. Excellence
5. Integrity
6. Professional duty
7. Social responsibility

I will say, as somebody who talks about ethics to a number of different audiences, I will share with you that I love the Physical Therapy Code of Ethics because it seamlessly intertwines each principle with its corresponding core values. It's this integration that makes the code particularly effective in conveying ethical guidelines and principles to diverse audiences. Fundamental to this code is that it emphasizes a significant responsibility to empower, educate, and facilitate greater independence, health, and quality of life for individuals facing impairments, limitations, disabilities, and more.

Now, as I said earlier, while a code of ethics serves as a robust guiding framework, it's important to acknowledge its limitations. No code can comprehensively cover every situation or circumstance encountered in practice. In straightforward situations, aligning actions with the code is relatively clear-cut. However, the true challenge lies in navigating the gray areas, where careful consideration of the principles and core values becomes crucial in making ethically sound decisions.

Principle #1

Physical therapists shall respect the inherent dignity and rights of all individuals.

This principle relates back to the core values of compassion and integrity. This means that physical therapy practitioners must act in a respectful manner toward each person, regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, disability. 

Acknowledging and addressing personal biases is a critical principle reiterated in numerous codes of ethics across various professions. The recognition of biases is foundational to providing fair, just, and equitable care to all individuals. In the contemporary landscape, extensive training and emphasis on implicit bias, diversity, equity, and inclusion aim to bring these biases to light and ensure they do not influence treatment, consultation, education, research, or administrative decisions.

Principle #2

Physical therapists shall be trustworthy and compassionate in addressing the needs of our patients.

This principle relates back to the core values of altruism, compassion, and professional duty

You shall adhere to the core values of the profession, act in the best interests of patients and clients over the interests of the physical therapist. It emphasizes the need to provide physical therapy services with a compassionate and culturally sensitive approach, valuing individual differences and backgrounds. Furthermore, ensuring that patients and their surrogates have access to necessary information for informed decision-making is crucial. Collaborative decision-making with patients and clients empowers them in matters concerning their healthcare. Additionally, safeguarding confidentiality and respecting patient privacy are integral components of ethical practice, with disclosures made to appropriate authorities being in line with legal and ethical guidelines.

Principle #3

Physical therapists should be accountable for making sound professional judgements.

This principle relates back to the core values of excellence and integrity.

Physical therapy practitioners should demonstrate independent and objective professional judgment in the patient's best interests and professional judgment informed by professional standards, evidence, experience, and patient values. Physical therapists should make judgments within their scope of practice and their level of expertise. Communicate, collaborate with, or refer to peers or other healthcare professionals when necessary, and not engage in conflict of interest. Provide appropriate direction and communication with physical therapist assistants and other support personnel. 

Principle #4

Physical therapists shall demonstrate integrity in their relationships with patients, families, colleagues, students, research participants, other healthcare providers, employers, payers, and the public. 

This principle relates back to the core value of integrity and this brings us back to veracity.

It emphasizes the importance of providing accurate and truthful information, avoiding any misleading representations, and refraining from exploiting individuals under a supervisory relationship, be it students, patients, or employees. Moreover, it underscores the responsibility to discourage and report misconduct and illegal or unethical acts among healthcare professionals, highlighting the imperative to protect vulnerable individuals from abuse.

The principle's unequivocal stance against engaging in any form of sexual relationship with patients, supervisees, or students reinforces the critical importance of maintaining professional boundaries and ensuring a safe and ethical environment. Additionally, the strong stance against harassment, whether verbal, physical, emotional, or sexual, reinforces the commitment to a respectful and inclusive professional atmosphere. Altogether, this principle underscores a profound dedication to upholding the highest standards of ethical conduct and fostering a culture of accountability and integrity within the healthcare community.

Principle #5

Physical therapists shall fulfill their legal and professional obligations.

This principle relates back to the core values of professional duty and accountability.

This principle includes complying with applicable local, state, and federal laws and regulations. Physical therapists must have primary responsibility for supervising assistance and support personnel. They should encourage colleagues struggling with physical, psychological, or substance-related impairments that could negatively impact professional responsibilities to seek assistance or counseling. Furthermore, if aware that a colleague is unable to perform duties with reasonable skill and safety, physical therapists should report this to the appropriate authority, whether that is a licensing board, organizational leadership, or other governing body. In the event that a physical therapist terminates a provider relationship while the patient still needs services, the physical therapist ought to notify the patient and provide information about alternative care options.

Principle #6

Physical therapists shall enhance their expertise through lifelong acquisition and refinement of knowledge, skills, abilities, professional behaviors.

This principle relates back to the core value of excellence.

This principle encompasses maintaining and improving professional competence through continued professional development based on critical self-assessment and reflection. Physical therapists should evaluate the strength of evidence and applicability of content presented in professional development activities before integrating that knowledge into practice. They ought to cultivate practice environments supportive of professional growth, lifelong learning, and excellence. Lifelong learning is crucial—physical therapists must move beyond checking boxes to satisfy continuing education requirements. Instead, they should actively broaden their skills and knowledge throughout their careers.

Principle #7

Physical therapist shall promote organizational behaviors, business practices that benefit patients, clients and society.

This principle relates back to the core values of integrity and accountability.

This principle involves fostering practice settings that enable autonomous, accountable professional judgment. Physical therapists should seek fair and reasonable remuneration for services, refrain from accepting gifts influencing professional decisions, and disclose any financial stakes in products or services recommended to patients. For instance, they ought to reveal ownership interests in durable medical equipment companies or other healthcare businesses. Physical therapists must ensure documentation and coding accurately conveys the nature and extent of services furnished. They should avoid employment arrangements preventing fulfillment of professional obligations to patients. Billing, coding, HIPAA, and social media merit particular attention, as lapses in these areas frequently lead to disciplinary action.

Principle #8

Physical therapist shall participate in efforts to meet the health needs of people locally, nationally, globally.

This principle connects to physical therapy's core values of social responsibility. Practitioners can actualize this by providing pro bono services to the economically disadvantaged, uninsured, and underinsured, if feasible in their setting. They should advocate reducing health disparities, improving healthcare access, and addressing wellness and preventive services. Though physical therapists often treat existing disabilities and impairments, focusing on health promotion and disease prevention remains crucial.

Physical therapists ought to steward healthcare resources responsibly, avoiding over- and under-utilization. Educating the public about physical therapy's benefits and the profession's unique role is another key facet. Getting involved with advocacy organizations and meeting with legislators to promote the field allows practitioners to fully embody this principle. Having a seat at the policymaking table helps ensure the profession's perspectives are heard.

And part of this speaks to me, I, as mentioned in my bio, I am part of the American Occupational Therapy Association Political Action Committee, one of my other roles with Select Rehabilitation. When I am on Capitol Hill, I'm in front of our senators and our representatives in Congress. That might be an opportunity for you to really enact this principle by getting in front of people and promoting who you are and what you do. Make sure that you have a seat at the table. We have a saying all the time, if you don't have a seat at the table for dinner, you are probably on the plate for a meal.

Licensure

While we've discussed national standards, licensure is state-specific and each jurisdiction has its own code of conduct. States control licensure through individual laws, regulations, and physical therapy practice acts. Requirements vary, though many states have adopted licensure compacts. Regardless, therapists must understand the legal and ethical parameters in their specific state.

Licensure laws aim to protect the public by outlining expected behaviors and minimum competence standards for initial licensure and renewal. Professional association codes of ethics often integrate within state practice acts. Importantly, these laws also detail disciplinary actions and penalties for prohibited behaviors and activities. Though process differs by state, the intent is handling infractions to uphold standards. Therapists must familiarize themselves with their state's particular licensure laws and disciplinary procedures.

The disciplinary process could range anywhere from a fine, a slap on the wrist with a warning to a suspension or revocation of one's license. For example,  a few years ago I remember coming across a story related to HIPAA. A clinician was working in the clinic and witnessed or saw across the room somebody who looked familiar to them. The individual wasn't their patient and was not actively treating this individual. However this clinician went to the nurse's station and found this person's chart. The clinician discovered that this person was in fact a childhood friend's mother, and who had been estranged from her family for upwards of 20 years. 

The clinician tried to approach the person and then called the friend and said, "Hey, I found your mother, she is here in our hospital", several states away. There was a reason this woman was estranged. There was a reason she didn't wanna be found. This particular clinician completely violated HIPAA.  The clinician not only lost their license to practice in that particular state, but because that state had a certain level of reciprocity with other states, could not be licensed in other states. 

Therapists must thoroughly comprehend their state's licensure law and practice act provisions. These documents warrant close study, as they outline documentation frequency, supervisory visit timing for assistants, assistant supervision ratios, continuing education requirements, and more.

Do not rely on employers to convey licensure details - go straight to the licensing board with questions and get interpretations in writing. Recently, a therapist encountered ambiguity around allowable wound care modalities and debridement. The board clarified upon request. However, the practice act itself was unclear. Therapists should proactively join listservs and stay updated on changes to ensure they comply. Though employers may have information, the responsibility ultimately lies with therapists to know the parameters governing their license.

Behaviors Subject to Disciplinary Action

Behaviors subject to disciplinary action will vary by state. Some behaviors that could be subject to disciplinary action include but are not limited to the following:

1. Abuse of drugs or alcohol
2. Conviction of a felony
3.  Conviction of a crime of moral turpitude, meaning a sex offense or DUI, extortion, embezzlement, are just a few examples.
4. Conviction of a crime related to the practice of the profession for which you hold a license
5. Practicing without a prescription or a referral if that is required by your state practice act or by the payer that you're utilizing.
6. Practicing outside of the scope of your practice or using interventions that you've not been certified to use, or trained to use.
7. Obtaining a license using fraud or deception. For example, purposefully giving an incorrect address.
8. Gross negligence in practicing physical therapy
9. Breaching patient confidentiality
10. Failing to report a known violation of the licensure law by another licensee
11. Making or filing false claims or reports
12. Accepting kickbacks
13. Exercising undue influence over patients
14. Failing to maintain adequate records
15. Failing to provide adequate supervision
16. Providing unnecessary services
17. False, deceptive, misleading advertising
18. Practicing under another name
19. Failure to perform a legal obligation
20. Practicing medicine when you are not a physician 
21. Performing services not authorized
22. Performing experimental services without informed consent
23. Practicing beyond scope permitted
24. Failure to comply with CE requirements  
25. Failure to notify the licensing board of an address change
26. Inability to practice competently

Licensure stipulations may seem excessive, but exist due to real infractions. For instance, I was teaching continuing education live and didn't write out the names on the certificates. Someone actually took a blank certificate and then photocopied it, gave it to all of their friends. These therapists were using somebody else's CEs to get their license. That same individual actually utilized somebody else's address and name to get a different type of license. While surprising, such situations demonstrate the need for rigorous standards.

Though seemingly improbable, board documents these policies because such problems have actually happened. Therapists must take licensure provisions seriously, as they aim to uphold patient safety and care quality.

Fraud and Abuse

Abuse

Alongside licensure regulations, other laws impose legal duties on physical therapists, like mandated reporting of suspected child, spouse, or elder abuse. Most states designate health professionals as mandatory reporters to protect vulnerable groups. Physical therapists should familiarize themselves with reporting criteria, timeframes, and agencies in their jurisdiction. These requirements supersede patient confidentiality in cases of suspected abuse or harm. Though details vary by state, understanding mandated reporter status is crucial given physical therapists' ethical and legal obligations to keep patients safe.

Fraud

Fraud generally involves deception to induce someone into action or inaction. In therapy, fraud often occurs in billing contexts. Common examples include:

• Billing for services never performed
• Billing for more units than furnished
• Billing non-covered services
• Backdating documentation
• Fabricating patient visit notes

These constitute true fraud versus colloquial use of the term. Medicare fraud specifically involves knowingly lying or willingly lying in order to get paid.  Other insurers often follow Medicare policies, making their criteria significant.

The key distinction in fraud is purposeful deception to inappropriately bill services, not errors or misunderstandings. Physical therapists must ensure thorough understanding of accurate coding and documentation to avoid fraudulent actions.

Medicare Fraud and Abuse

Abuse occurs when Medicare pays for services that should not be covered or anytime a provider bills Medicare for services that are not medically necessary.

Denials citing "not medically necessary" exemplify abuse. The Affordable Care Act expanded Medicare fraud and abuse oversight, establishing task forces and increasing audits. This receives extensive attention, with Presidents regularly addressing fraud reduction efforts in addresses.

If aware of fraudulent or abusive activities, physical therapists must report them. Failure to do so violates codes of ethics and practice acts while potentially incurring criminal charges for conspiracy in covering up Medicare fraud. Simply witnessing improper conduct triggers responsibility to take action. With increased scrutiny, therapists must ensure documentation proves medical necessity and accurately reflects services delivered.

Acts that are specifically prohibited by Medicare include the following:   

• Making false claims for payment.
• Making false statements again in order to receive payment.
• Billing for visits that were never made.
• Billing for non-face-to-face therapy services. Obviously, we have telehealth right now. Telehealth is a billable service. This does not include telehealth.  I'm referring to situations where the physical therapist bills for services that were never actually provided to a patient. 
• Billing for a one-to-one visit when perhaps group or concurrent or something that was provided. We see this oftentimes, particularly in the Medicare world with students when we look at a student involved in that therapy relationship.  If I'm the therapist and I'm supervising a student and we are both treating a patient at the same time, that would be considered concurrent therapy for Medicare Part A. There is no such thing as concurrent for outpatient or Part B, but we would have to bill that as such. We can't call that one-on-one if truly that person was seen in a concurrent or group situation.
• Billing for therapy services that were not provided by a licensed provider. This comes up when we have a therapy aide/tech in our clinic and they're working with a patient, but they're not technically licensed. 
• Billing for therapy codes that reimburse at a higher rate than the code that was actually provided. This is upcoding. You may have heard others say, you need to bill it under this code because that pays more than this and this is how you justify it. That's not how it works. If you provide a therapeutic exercise, that's what you bill and document and that is the code you use.  You don't bill it under something else just because you think you might get more money for that. 
• Paying or receiving kickbacks for goods or services.
• Soliciting from a physician and offering something to a physician in order for them to send you more referrals. This includes making offer for payment, receiving payment for patient referrals or offering gifts in remuneration for receiving those referrals.  

HIPAA

Protected Health Information (PHI) is any information related to the patient's past, present or future physical and or mental health or condition. PHI can be in any form. It can be written (soft chart), your documentation, electronic email, text, or EMR or spoken (hallway discussion).  It could be a sticky note you leave for a physical therapist assistant or physical therapist who is also working with the patient.  Spoken and electronic text are the ones that I see that gets us into some level of trouble.

For example, this is a true story. I travel quite a bit for my full-time job. I was in the airport sitting at a restaurant eating a meal. There were two people next to me having a full conversation. They were clearly in healthcare because they were talking about a patient. And as I sat there, I kept listening, and after a while, I nudged one of them, and I said, "Look, I don't know who you are, but I sure know who you're talking about. I could find this person if I really wanted to. I know what community you're talking about. I know this person's name and I know their diagnosis. You need to be mindful of what you're saying." 

I don't know about the rest of you, but I'm part of a number of groups on social media, where, people will ask questions about their patients or a tricky case. Well-meaning questions in online forums also risk inadvertent PHI exposure by including identifiable patient information. Physical therapists must remain vigilant about safeguarding confidentiality across all communication channels, including verbal discussions and digital platforms. Unintentional PHI disclosure during attempts to seek help still constitutes HIPAA violations.

PHI Identifiers

There are 18 specific identifiers.  Those identifiers include: 

• Name
• Address
• All elements (except years) of dates related to an individual
• Telephone numbers
• Fax number
• Email address
• Social Security Number
• Medical record number
• Health plan beneficiary number
• Account number
• Certificate or license number
• Any vehicle or device serial number
• Web URL
• IP Address
• Finger or voice print
• Photographic images
• Any other characteristic that could uniquely identify the individual ie. tattoo   

How Can We Use and Share Patient Information? 

So how can we use and share patient information? We can use it with regard to treatment, payment, or operations.

Treatment (T)

Physicians, nurses, therapists and other providers may access a patient’s record for treatment.  Health information  may also be shared with other health care providers outside of the facility  to decide on the best treatment or to coordinate care   

Payment (P)

Health information is shared with Medicare, Medicaid, insurance plans and other payers for claims payment and benefits determination. 

Operations (O)

Health information is used for quality assurance, training, and audit purposes.  This would include working in an organization where they have a quality assurance committee or performance improvement plans that utilize training, and internally auditing chart reviews. 

For purposes Other than TPO

Unless required or permitted by law, must obtain written authorization from the patient to use, disclose, or access patient information. Where I see us get into trouble sometimes with this is related to research first and foremost, and also marketing.

Even positive stories about patient outcomes or new equipment require authorization to share publicly, as they are not considered treatment, payment or healthcare operations. Well-intentioned aggregated data could still indirectly identify individuals, so caution is needed. Sales and marketing teams may propose ideas that breach TPO, requiring therapists to ensure proper protections remain in place. The minimum necessary standard also applies - only essential PHI should be used or disclosed. Openly discussing patients without a job-related purpose violates HIPAA, even if de-identified. When unsure if PHI use aligns with TPO, consult compliance staff rather than risk violations. Their guidance helps ensure therapists avoid missteps while still being able to appropriately leverage data or stories in practice enhancement or referral development. The key is obtaining patient consent and limiting PHI outside of immediate care team needs.

Except for Treatment, the Minimum Necessary Standard Applies

For patient care and treatment, HIPAA does not impose restrictions on use and disclosure of PHI by health care providers. Exceptions: psychotherapy information, HIV test results, and substance abuse information.

For anything else, HIPAA requires users to access the “minimum necessary” amount of information necessary to perform their duties, and only disclose to those that have a need to know. 

You may not discuss any patient information with anyone unless required for your job.

Keep Health Information Secure is Part of Your Job

This includes: 

• Secure Faxing
• Safe Emailing
• No texting of PHI
• Safe Internet use
• Password Protection
• Conversations-Conversations are to be held in a private place
• Department Security
• Social Media
• Discarding Papers
• Computer Security
• Know where you left your paperwork-Check your printers, fax machines, copiers, et cetera. Make sure if you do have soft charts, those are brought back to the appropriate area
• Removal of Records-We don't remove records from our facilities for any reason, unless it is required or requested by a government agency, an intermediary or a carrier.
• Storage of Records-Store records a secure location that is not available for public view or access.
• Building Access-How many times have you used your swipe card to go in a facility and somebody comes behind you? If you don't know that individual, don't allow him or her to enter a secure facility if they're not authorized to do so.
• Verification of Requests-Make sure you know your policy for how to verify those requests. Don't disclose PHI unless you have the written authorization to do so
• Sharing PHI
• Disclosure of PHI

Several excellent points for therapists to ensure HIPAA compliance and safeguard protected health information:

• Avoid transmitting PHI via unsecure methods like plain email/text
• Use strong passwords, never share credentials, and properly secure computers
• Have private conversations away from public areas
• Shred documents and utilize locked cabinets/rooms to limit exposure
• Log off computers when stepping away and confirm printer/fax documents aren't left out
• Do not post any patient details or photos on social media
• Verify identity and authorization before releasing records. Make sure you know your policy for figuring out how to verify those requests. We don't disclose PHI unless we have written authorization to do so.
• Do not allow building access to unknown people
• Check state privacy laws, as penalties for violations are substantial

Even when communicating with a patient's friends or family, the patient must have capacity to consent to disclosing their protected health information. Therapists cannot share details with loved ones without the patient's explicit authorization, even if the intention is to keep them informed. It's an important distinction, as family dynamics can make assumptions of implied permission risky. As you noted, HIPAA violations carry substantial penalties, so obtaining express patient consent prior to any PHI disclosure is essential to avoiding hefty fines or potential legal consequences down the road.

An occupational therapist allowed a student to access the electronic medical record (EMR) using her login credentials, in order to practice documentation. First, students should never have unsupervised EMR access, which should be restricted to treating therapists. However, the larger issue arose when the therapist called in sick the next day. The student then logged into the EMR, treating patients under another's supervision, and charted as though the original therapist had performed the services. This created the false impression of fraudulent documentation by the absent therapist. While technically the student acted without malicious intent, the circumstances suggested falsification and misrepresentation within the medical record. This example clearly demonstrates the risks of sharing login information and permitting improper EMR access. Even for training purposes, such actions compromise data integrity and expose therapists to potential discipline or legal concerns.

Key takeaways include being vigilant about security in all forms of communication, properly disposing of PHI, never sharing login credentials, securing physical records, and carefully controlling information disclosure. HIPAA violations, even accidental, carry steep fines and consequences. Following privacy best practices will help therapists avoid potentially serious ramifications.

Fines and Penalties

HIPAA Criminal Penalties: 

• $50,000 - $1,500,000 fines
• Imprisonment up to 10 years •

HIPAA Civil Penalties: $100 - $25,000 / year fines

More fines if multiple year violations

State Laws: Many states have also enacted medical information privacy laws! For violations, fines and penalties may apply to individuals as well as healthcare providers. Imprisonment and action against your professional license may also apply.

Corrective and disciplinary actions, up to termination of employment

Resident Rights and Elder Abuse

Resident Rights

The 1987 Nursing Home Reform Law established critical protections for long-term care residents, though these rights broadly apply across settings. Providers participating in Medicare/Medicaid must uphold resident dignity, self-determination and wellbeing. The overarching right is to receive services enabling the highest possible physical, mental, and psychosocial health per an individualized care plan developed with patient and family involvement whenever practical. This landmark legislation obligates facilities to actively promote and safeguard rights through person-centered care planning and an environment fostering choice, inclusion and purposeful living. While originating in long-term care, these principles today help shape contemporary practice expectations for empowering patients and optimizing quality of life across the healthcare continuum.

The Right to Be Fully Informed 

Individuals have the right to full disclosure regarding services, associated charges, governing rules and regulations, and a written copy of their rights. They must receive contact information for resources like the state ombudsman and applicable survey agency. Facilities should provide access to survey reports and any plans of correction following deficiencies. Patients/residents deserve advance notice of room or roommate changes, along with appropriate assistance for sensory impairments. Importantly, they have the universal right to obtain all information in an understandable language or format, whether Spanish, Braille, or other accommodations tailored to needs. Care settings must take steps to ensure transparent communication and cognizance of rights, including through translation or accessible means for diverse populations.

Right to Complain

Individuals have a right to present grievances without any sort of fear of reprisal and a prompt effort by the community to resolve those grievances. They have a right to complain to the Ombudsman and they have a right to file a complaint with a state survey or any other certification agency.

Right to Participate in One's Own Care

They have a right to participate in one's own care. That includes receiving adequate and appropriate care, informed of any change in medical condition, participating in their care planning, treatment, and discharge. They have a right to refuse medication, treatment, therapy, restraints (chemical or physical). They have a right to review their medical record and they have a right to be free from charges of services that might otherwise be covered by an insurance provider. 

Right to Privacy and Confidentiality

This right included private and unrestricted communication with any person of their choice during treatment and care. The communication could be regarding medical, personal, or financial affairs.

Rights During Transfers and Discharges

This right is very specific to long-term care. Individuals need to know that whatever that transfer is, it's necessary to meet their welfare.  Maybe they've improved and no they no longer need care. It might be needed to protect other individuals including safety of other residents or staff or, they haven't paid their bill, quite honestly. Individuals are to receive a thirty day notice which includes the reason, effective date and location.

Right to be Treated with Dignity, Respect, Freedom, and to Self-Determination

Individuals have a right to be treated with consideration, respect, dignity and be free from abuse. 

Right to Visits (or refuse visits) 

Individuals have a right to visits and that could be from anybody including their physician, a representative from the state survey, ombudsman, relatives, friends, other individuals, or organizations who might be providing social legal services.

Right to Make Independent Choices

This going back to autonomy, right? This right can include what they wear, or how they spend their free time.  It includes the right to choose their own physician, their accommodations, to participate in community activities and manage their own financial affairs.

Again, this is very specific to long-term care. However, I think you can see the applicability to any setting that our patients might be in.

Your Role

So what's your role? Your role is to

• Know the rights of your patients wherever it is that you're working.
• Respect their dignity and their privacy, 24 hours a day, seven days a week. That means knocking on the door before you enter and asking permission.
• Speak to individuals respectfully in a positive manner
• Allow them to make choices about their care, giving them that informed consent that we spoke about.
• Respect their right to refuse therapy, to refuse care, medications, a specific diet, activity, or whatever that happens to be.
• Listen to them, their family members as well who might have concerns about their rights, treatment,  and/or their plan of care. Refer individuals who maybe have questions or concerns to the appropriate person. 

Elder Abuse

Elder abuse is a growing geriatric concern. There are a lot of ethical issues related to this. It is a concern that we need to look beyond just protective services records. We need to look at financial, medical, social, long-term care areas  all of these areas for any sort of breakdown, possible difficulties and solutions.

Key definitions:

• Elder: 65 years or older
• Elder abuse: An act or omission by someone in a trusted relationship that harms or threatens an older adult's health/welfare
• Caregiver: Anyone with custody or control over an elder

Estimates suggest 10-15% of elders experience abuse. While there is no single victim profile, 90% of perpetrators are known to the victim, mirroring child abuse dynamics. As therapists work closely with seniors and caretakers, we are well-positioned to detect and address signs of abuse through appropriate reporting and interdisciplinary collaboration. Education and advocacy regarding this often hidden issue are crucial.

Forms of Abuse

• Physical abuse
• Sexual abuse
• Emotional abuse
• Neglect
• Abandonment
• Financial expoloitation
• Self-neglect

Elder Abuse Indicators

• Physical Abuse. Sprains, dislocations, fractures, or broken bones. Burns, internal injuries, abrasions, bruising. Injuries are unexplained or explanations are implausible. 
• Sexual Abuse. Fear of being touched/inappropriate modesty on evaluation. Inner thigh/breast bruising, tenderness. 
• Emotional Abuse. Depression, sleep and appetite disturbances, decreased social contact, loss of interest in self, apathy and suicidal ideation. Evasiveness, anxiety, hostility. 
• Neglect and Self - Neglect. Inadequate, dirty or inappropriate clothing, malnutrition, dehydration, odor and poor hygiene, pressure sores. Misuse/disregard/absence of medicines, medical assistive devices, medical regimens. 
• Self-Neglect. Eccentric or idiosyncratic behavior, self - imposed isolation, marked indifference. 
• Financial Abuse. Fear, vague answer, anxiety when asked about personal finances. Disparity between assets and appearance and general condition. Failure to purchase medicines, medical assistive devices, seek medical care or follow medical regimens. 

Some potential signs of elder abuse include depression, fear of being touched, and eccentric behavior. Importantly, many elder abuse indicators are very similar to bullying warning signs across age groups. As therapists, we must pay attention to these red flags wherever they occur and report them. Our skills in building trust, observation, and intervention enable us to identify concerning behaviors among vulnerable individuals at any age. 

Elder Justice Act

You have a duty to report any suspected acts involving resident mistreatment, neglect, abuse, crimes, misappropriation of resident property, or injuries of unknown source. The facility must report any reasonable suspicion of a crime against a resident or patient to: the Secretary of the U.S. Department of Health and Human Services (HHS), and the law enforcement authorities in the political subdivision where the facility is located. 

There are very specific timeframes to report any sort of elder abuse.  if the events that cause the suspicion of a crime, suspicion is the key, we don't have to prove that truly elder abuse occurred. If we have a suspicion that it may have occurred, we have to report it.

• Result in “serious bodily injury”, the report by the facility must be made to HHS and to law enforcement authorities immediately, but not later than two hours after forming the suspicion.  
• •Do not result in “serious bodily injury”, the report must be made by the facility to HHS and to law enforcement authorities not later than 24 hours after forming the suspicion.

Serious bodily injury is an injury  

• • involving extreme physical pain or substantial risk of death;  
• • involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or
•  • requiring medical intervention such as surgery, hospitalization, or physical rehabilitation

QUESTION: There is a question in queue, "Have you ever encountered situations where false accusations of elder abuse have occurred and how have those played out?"

ANSWER:  That's a great question. I will say yes, absolutely. But going back to the Elder Justice Act, it is the suspicion that something occurred. We don't have to prove that it occurred. An investigation occured and the situations that I've seen when that investigation has played out, something had happened. It may have been against facility protocol, policy or procedure, what have you, but it wasn't true abuse of that individual. There were repercussions for the individual involved, indicating that action was taken. They faced a reprimand due to a breach of facility policy and procedure. However, it's important to note that the allegations were unfounded. Investigations should be thorough, treating this case like any other. Unfortunately, there have been instances where individuals raise suspicions, not related to elder abuse but about fraud or other matters. Regrettably, I have witnessed situations where people make such claims to settle personal scores, implicating someone in wrongdoing that didn't actually happen. This is an unethical practice.

Legal Issues

Malpractice

Most claims of malpractice surround negligence  

Negligence occurs when you as the therapist, your conduct falls below the acceptable standard of care for the profession. The important piece with negligence is that you didn't need to intend to do something poorly. Negligence concerns itself with the conduct, not your state of mind. So it's not necessarily your intent, it's what your actual conduct was.

Negligence

Proving malpractice within the framework of negligence presents challenges in a court of law. To substantiate such a claim, several critical elements must be met.

Firstly, there must be a clearly defined relationship between the involved parties, establishing a duty to act in a specific manner. Building on the foundational principle of ethical practice, this duty sets predetermined expectations, and failure to meet them signifies a breach of the established standards.

Secondly, the plaintiff, the individual alleging negligence, must show that your conduct fell below the accepted professional standards of care, thereby breaching your expected duty.

Thirdly, the plaintiff must establish a direct link between your breach of conduct and the resulting harm or damage. It is crucial to demonstrate that the breach directly contributed to the harm suffered by the patient.

Lastly, the plaintiff must present evidence of tangible harm or damages incurred. This requires illustrating the adverse consequences of the breach, emphasizing the actual and quantifiable impacts of the alleged negligence. While it is a demanding process, meeting these criteria is attainable with the right evidence and legal support.

Discrimination Laws

Discrimination laws raise a lot of legal and ethical issues for us in relation to patient and student issues. We are aware that there are laws in place, and our code of conduct expressly prohibits discrimination based on a number of things. Those include age, race, disability, religion, nationality, sexual orientation, gender, and marital status.

Whistleblowing

The term whistleblower is used to describe a person who exposes an activity that is illegal, unethical, or incorrect.

As a physical therapy practitioner, when you encounter such situations, you have an ethical obligation to act as a whistleblower. Determining who to report the issue to can be complex as it often involves multiple parties.

It's crucial to acknowledge that many individuals hesitate to report due to fears of retaliation or prejudice from colleagues or supervisors. However, numerous protections are in place to encourage reporting without fear of repercussions. Nearly all states, if not all 50, have laws safeguarding whistleblowers. Additionally, companies have their own policies that emphasize protection against retaliation. At a federal level, the United States Congress passed the Whistleblower Protection Act in the late 1980s, providing protection for federal employees. The Sarbanes-Oxley Act in 2002 further fortifies protections for individuals who expose wrongdoing. The guiding principle remains: if you witness something wrong, speak up and take appropriate action.

Mandatory Reporting

As state licensed healthcare workers, most are considered mandatory reporters. It's a fundamental obligation, and this holds true across all 50 states within the United States. However, the specifics regarding the types of abuse that necessitate reporting can vary from one state to another. Each state has its own set of explicit guidelines delineating the obligations and procedures for reporting. Additionally, the definition and parameters of abuse, as well as the required reporting language and formats, will exhibit unique variations in accordance with the particular state's regulations. Healthcare practitioners must familiarize themselves with the distinct reporting requirements of the state in which they practice, ensuring compliance with the specific language and procedures dictated by that jurisdiction.

Common Ethical Issues

Ethical Challenges vs. Ethical Dilemma 

In my readings within the nursing literature, I encountered a distinction that resonated with me: ethical challenges versus ethical dilemmas. Ethical challenges encompass a broad spectrum of ethical issues, ranging from the ordinary to the significant. These challenges permeate our everyday professional experiences.

On the other hand, ethical dilemmas represent a unique subset wherein we grapple with choosing between distinct options, both of which may have ethical merit. The complexity lies in the realization that in an ethical dilemma, no choice is unequivocally ideal. When faced with such a dilemma, we find ourselves navigating the delicate balance of competing values. Regardless of the path we choose, we must come to terms with the fact that each option will bear its own set of consequences. 

Everyday Ethical Issues vs. Big Ethical Issues

In the realm of ethics, when delving into the literature, it becomes evident that ethical issues can be broadly categorized into two major groups: everyday ethical issues and significant ethical dilemmas.

1. Everyday Ethical Issues:

   • These encompass a wide array of common ethical challenges encountered in daily practice. Examples include issues related to informed consent, respect for autonomy, refusal of services by patients, addressing offensive behavior, and maintaining confidentiality. These issues are part of routine practice and require consistent attention and ethical decision-making.

2. Significant Ethical Dilemmas:

   • On the other hand, significant ethical dilemmas represent a more profound and intricate set of challenges. These encompass issues such as end-of-life care decisions, the delicate choices regarding withholding or withdrawing life-sustaining treatments, and the ethical considerations surrounding hospitalization. These dilemmas often involve critical and profound decisions, forcing healthcare professionals to weigh conflicting values and principles.

Reasons for Ethical Dilemmas

• Patients or their loved ones must make life or death decisions
• The patient refuses treatment
• Staffing assignments may contradict cultural or religious beliefs
• Peers demonstrate incompetence
• Inadequate staffing or resources

Patients are making possibly life or death decisions. Patients are making choices in general. The patient refuses some level of treatment, whether, again, that's physical therapy, medication, or food for examples. 

Moreover, healthcare professionals often encounter ethical challenges tied to cultural or religious beliefs, especially when these beliefs conflict with the assigned staffing arrangements. Such conflicts can raise dilemmas regarding balancing one's professional responsibilities with personal convictions.

Equally concerning are instances where healthcare professionals witness peers engaging in incompetent practices, potentially compromising patient safety and care quality. These situations force ethical deliberation on whether and how to address these concerns.

Inadequate staffing and resources, a pervasive issue and is a reality for most of us right now in today's healthcare landscape, present a critical ethical dilemma. Healthcare professionals often grapple with delivering optimal care under strained conditions, where there's an ethical tension between providing the best care possible and dealing with resource limitations.

Common Ethical Issues in Healthcare Setting

In the healthcare profession, we commonly encounter several ethical issues that deserve our careful attention. These encompass both the need for thorough and accurate documentation as well as navigating complex workplace demands:

• Documentation Lapses
  • Ensuring timely and accurate documentation of patient encounters is critical. We should be documenting every single encounter as soon as it occurs or shortly thereafter, at least at a bare minimum every day. Lapses in documentation, such as shortcuts, using X's or dots, or cloning/copy-pasting records, can compromise patient care and credibility in legal situations.  Documentation needs to accurately reflects what we did.
• Employer Demands and Productivity Quotas
  • Balancing productivity demands with ethical practice is essential. While efficiency and productivity are not inherently unethical, falsifying billing or misrepresenting services to meet quotas is unethical.
• Use and Supervision of Support Personnel
  • Utilizing support personnel within the boundaries of state practice acts is crucial. Clearly defining roles and responsibilities of support staff to ensure they adhere to legal and ethical guidelines is vital.
• Impaired Practitioners
  • Recognizing and addressing impaired practitioners due to mental health issues or substance abuse is essential for patient safety and maintaining professional ethics. Prompt intervention and support are imperative in such cases
• Student Supervision
  • Adequate supervision and mentorship for students during clinical placements are ethical responsibilities. Neglecting to provide proper guidance and supervision can compromise the learning experience and ethical conduct of students. I have heard of students complain that their mentors didn't supervise them.  

Addressing these ethical challenges involves upholding professional standards, prioritizing patient care and safety, and ensuring compliance with legal regulations. It's incumbent upon healthcare professionals to maintain ethical conduct while navigating the demands and responsibilities inherent in their roles. I remember going on my field work a long time ago and I was just left to my own. I saw my supervisor the day that I walked on the job and at the end of my field work. That is reasonably unethical.

Common Ethical Issues in Student Supervision

• Patient welfare must come first
• Cannot delegate clinical decision making
• Must inform client of qualifications/credentials
• Increase supervision based on knowledge, experience, competence
• Document amount of supervision
• Protect client confidentiality
• Unethical for therapists to sign for clinical hours they did not supervise

Patient welfare should always remain the top priority in healthcare settings. When supervising a student, the responsibility for clinical decision-making lies with the experienced practitioner, not the student. The role of the supervisor is to facilitate, guide, and collaborate with the student, but the ultimate responsibility for patient care and decisions rests with the supervisor.

Medicare and the setting can determine the level of supervision in the facilities I work in. It is also crucial to determine the appropriate level of supervision based on the student's competence. This supervision level may vary from direct onsite supervision to less direct supervision based on the student's abilities, experience and current regulations. Clear documentation of the level of supervision provided is essential, ensuring transparency and compliance with guidelines.

Additionally, it's vital to inform the client about the presence of a student, sharing the credentials and qualifications of the supervisor. This transparency fosters trust and allows for informed consent, maintaining the integrity of the patient-provider relationship. The supervising practitioner remains accountable for the entirety of the patient encounter, overseeing and ensuring the quality and safety of care provided.

Common Ethical Issues in Confidentiality

• Records management, storage, ownership, retention
• Information exchanged
• Disclosure/release of information
• Access to records
• Exchange of records between professionals

Common Ethical Issues in Client Abandonment

Examples of misconduct

• Failing to give sufficient notice
• Failing to provide an interim plan
• Failing to complete paperwork
• Withholding paperwork
• Removing materials or records
• Maligning the facility or organization
• Recruiting clients

There is nothing unethical about leaving a place of employment.  You maybe leaving for a family reason, found a better job or a position advancement, however, you still need to focus on ethics and welfare of your client.

Key ethical conderations during change of employement include:

Handling transitions in healthcare employment with ethics and patient welfare in mind is critical. Here are key ethical considerations during such transitions:

• Giving Adequate Notice
  •    Provide sufficient notice to your employer before leaving to prevent treatment disruptions for your clients. Be mindful of the impact on patient care and work with the employer on a transition plan.
• Completing Paperwork and Orders
  • Ensure that all necessary paperwork, including treatment orders, is completed before leaving. Do not withhold essential documentation, as it may adversely affect patient care during the transition.
• Maintaining Professionalism and Integrity
  • Refrain from maligning your previous employer or facility when leaving. Maintain professionalism and ethical conduct during your departure, and consider assisting in recruiting efforts if requested.
• Avoiding Client Recruitment
  • Avoid soliciting clients to follow you to a new practice, as this can be seen as unprofessional and may compromise patient trust and continuity of care.
• Addressing Patient Abandonment
  • Take responsibility for patient care to prevent abandonment during transitions, especially in critical settings like nursing homes. Collaborate with appropriate authorities and healthcare professionals to ensure patient safety and continuity of care.
• Reporting Ethical Violations
  • if faced with severe ethical violations, such as client abandonment, consider reporting to the relevant boards or authorities to ensure accountability and protect patient well-being.

These ethical guidelines underscore the importance of maintaining patient welfare, professionalism, and integrity throughout career transitions within the healthcare field. Balancing personal or professional changes with ethical obligations is essential to uphold the standards of care and trust patients place in healthcare professionals.

Examples

Reflecting on past experiences, I vividly recall an incident when transitioning into a new contract. The preceding provider chose to discharge every therapy order before departing, potentially as a means to inconvenience the incoming provider. However, the true consequence of this action was a disservice to the patients, who were left without the necessary therapy services. It reinforced the importance of considering patient welfare above all else.

As you leave prior employment, it's essential not to remove essential services or contribute to a negative environment. Maintaining professionalism and a sense of responsibility toward both the facility and the patients is paramount. Additionally, refraining from recruiting clients away from the previous facility showcases good professional practice and helps in building positive relationships within the healthcare community.

One incident that stands out in my career involved a nursing home experiencing a change in ownership. In an unexpected turn of events, almost all the nursing staff, except two CNAs, decided not to report for duty. This left therapists and the remaining staff in a difficult position, risking patient safety and care. There was nobody there to pass meds. It was a very unsafe situation. It was a stark case of client abandonment, necessitating immediate action and involving authorities to address the situation.

In challenging circumstances like these, reporting such cases to the relevant boards is an ethical obligation to uphold the integrity of the profession and ensure accountability. This incident underscored the critical need to prioritize patient well-being and act in the best interest of those we serve, even in the face of unexpected and unprecedented challenges. In this case, the individuals were reported and a number of those individuals did in fact lose their license to practice. 

Common Ethical Issues in Reimbursement for Services

• Misrepresenting information to obtain reimbursement
  • Accurate documentation is required
  • Must remain current with payer policies
• Providing service when there is no reasonable expectation of significant benefit
  • Cannot provide services when the prognosis is too poor to justify therapy
  • Cannot exaggerate extent of improvement to obtain reimbursement

Accurate and honest documentation is fundamental in healthcare. When delivering therapeutic activities, it's crucial to document correctly what was performed and billed accordingly. Misrepresenting services for the sake of obtaining higher reimbursement is not ethical and undermines the integrity of the healthcare system.If you did therapeutic activities, that's what you document, that's what you bill. It's really just as easy as that.

Ethical practice necessitates ensuring that the services provided hold a reasonable expectation of benefiting the individual receiving care. It's essential to continuously evaluate the efficacy of the interventions and modify the plan of care if necessary. If a person reaches a plateau or the chosen interventions no longer yield benefit, adjustments must be made to the plan of care in an ethical and professional manner. 

Exaggerating improvement or progress merely to increase payment is both unethical and compromises the trust and accuracy required in healthcare practice. Upholding transparency and providing care based on genuine need and benefit to the patient should always be the guiding principle in healthcare documentation and billing.

• Scheduling services not reasonably necessary
  • Must be based on clinical need
• Providing more hours of care than can be justified
  • Must be based on clinical need
• Providing complimentary care or discounted care
  • Fee alterations are not provided based on referral sources or personal relationships

Scheduling and providing services that are not clinically necessary or justified is an ethical concern in healthcare. It's essential to base the scheduling and provision of services on a genuine clinical need and avoid unnecessary or excessive care that doesn't benefit the patient. Similarly, offering more hours of care than what is genuinely required can lead to overutilization of resources and may not align with the best interests of the patient. It's important to ensure that the care provided is appropriate and in line with the patient's needs and treatment plan. 

Providing complimentary care or discounted care that are typically billable can be ethically complex. It's essential to consider the overall impact on the healthcare system, patient expectations, and professional standards when determining the appropriateness of offering care without reimbursement. Now this is a little different from pro bono services that might be applicable for your setting. This is more like, "Hey, if you follow me to this practice, I'll discount your bill by 25%.

I'll make it worth your while." That's what we don't do. Or, "I wanna continue services. Do you mind doing those for free even though they can't be reimbursed?" Those are the things that we shy away from.

Common Ethical Issues in Therapy with Children

When it comes to working with children, it's essential to prioritize the child's best interests. However, common ethical considerations often revolve around follow-up care for the child. These issues may include families failing to adhere to appointments or follow your instructions, or confidential information being shared with non-family members. Sometimes, there can be ambiguity in the relationships and responsibilities involved in managing the therapeutic alliance with parents and caregivers.

Distrust or frustration regarding the limitations of reimbursement, concerns about parenting techniques, or potential neglectful behavior can also arise. In some cases, parents may misuse resources, not follow the care plan, or even threaten to withdraw the child from services. Privacy and confidentiality issues persist, particularly when conducting telephone follow-ups, where the identity of the caller may not be clear, or non-legal guardians seek information they're not entitled to. Parents themselves might request confidential information they shouldn't have access to, further complicating these situations.

Common Ethical Issues

• Documentation lapses
• Employer demands/lack of resources
• Impaired practitioners
• Coercion

These are some of the common issues. To reiterate, ethical concerns among staff members are prevalent, with approximately 90% of clinicians acknowledging that they encounter ethical challenges in their daily work. These issues typically revolve around everyday matters, not necessarily major ethical dilemmas. A significant concern, reported by 79% of clinicians, is the lack of resources. This shortage can encompass various aspects, from the unavailability of durable medical equipment (DME) to the absence of leg rests for wheelchairs, among other things.

Coercion is another significant ethical concern. It's not limited to therapy but can extend to various situations. For example, you might have observed people secretly mixing medications into applesauce for someone without their knowledge. This is an act that could easily be avoided by simply informing the person about the medication. Additionally, lapses in documentation, as previously discussed, are common ethical issues in healthcare.

Ethical Dillema Examples

Now, I'm going to share a few ethical dilemma examples, some of which may involve therapy, while others are situations that have arisen recently.

Inadequate Staffing Example -Nurse Cathy is working the evening shift. The SNF has established protocols that include nurse - patient ratios.  There was a call out leaving 3 staff to provide care for the whole unit.

So I'm focusing on nursing here, but I think we could extrapolate this to therapy. 

Resource limitations and staffing shortages are common challenges in healthcare. Dealing with these issues may require creative solutions and proactive communication. Consider strategies such as:

1. Calling in PRN Staff: If available, part-time or PRN (as needed) staff can help cover shortages.

2. Overtime: In some cases, asking existing staff to work overtime may temporarily alleviate staffing issues.

3. Supervisor Involvement: Reporting your concerns to your supervisor is essential. They may have insights, and their involvement can help address resource challenges.

4. Prioritizing Care: While not ideal, prioritizing patients based on their needs may be necessary during staffing shortages.

5. Flexible Scheduling: Adjusting treatment schedules, including evening sessions if possible, can help manage patient loads more effectively.

6. Team Collaboration: Work closely with your team to share responsibilities and help each other during resource shortages.

It's crucial to address these challenges promptly to ensure patient care remains a top priority and ethical standards are upheld.

Inadequate Resources Example-Nurse Judy is the wound care nurse for a home health agency. She stopped by the office to pick up additional wound care supplies for her weekend visits. However, the charge nurse told her the wound care supplies delivery did not arrive. As a result, there are not enough supplies on hand for the visits Nurse Judy has scheduled.

Nurse Judy is facing a challenging situation with a shortage of wound care supplies for her scheduled weekend visits. To handle this issue ethically, she can consider several approaches:

1. Purchase Supplies: As suggested, Nurse Judy could explore local pharmacies or medical supply stores to purchase essential wound care supplies. While this may be an added cost, it ensures that patient care remains uninterrupted.

2. Physician Consultation: Nurse Judy can contact the physicians for patients with wound care needs. She can discuss the supply shortage issue with them and request adjustments in orders based on the current supplies available.

3. Supply Allocation: Prioritize the most critical cases based on the remaining supplies. Ensure that patients with more severe conditions receive the limited available resources.

4. Notify Patients: If it's unavoidable that some visits will need to be postponed due to supply shortages, Nurse Judy should contact the affected patients as soon as possible. She should explain the situation honestly and reschedule their visits.

5. Resource Management: Collaborate with her team and the agency's management to develop strategies for better resource management and supply monitoring in the future.

In all these actions, open and honest communication is crucial. Nurse Judy's primary ethical responsibility is to maintain patient safety and ensure that their care is not compromised.

Keep in Mind

Ethical issues in healthcare, including those related to resource shortages, patient care, and professional conduct, remain consistent regardless of the payer or healthcare setting. The fundamental ethical principles and values that guide healthcare professionals apply universally. Whether one works in a private practice, a public hospital, a home health agency, or any other healthcare context, the obligation to prioritize patient well-being, maintain confidentiality, and adhere to professional standards remains constant. Understanding and addressing these ethical challenges is a critical part of delivering quality healthcare services.

In the realm of ethics, it is essential to emphasize the role of evidence-based practices. Specifically, when considering treatment protocols for various diagnoses or clinical considerations, we must rely on empirical evidence. Questions that demand our attention include the frequency of treatment for a given patient, the duration of treatment (in weeks), the number of visits, time allocation, and the selection of appropriate modalities.

Within my practice, which primarily focuses on long-term care and involves Medicare, it's worth noting that Medicare administrative contractors often incorporate evidence into their guidance. This evidence-based approach determines which treatments are eligible for reimbursement and which are not. In cases where the evidence does not support a specific treatment, they make it clear that reimbursement is not feasible.

Ideally, they define the recommended number of treatments, the appropriate timeframe for treatment delivery, and the associated guidelines. However, exceptions are acknowledged and justified through thorough documentation. It is imperative to highlight that quantifiable, measurable changes resulting from treatment interventions play a pivotal role in justifying the continuation of care. It's important to remember that our compensation typically hinges on the treatments we provide in each session. Exceptions arise only when a treatment session faces a challenge, such as a denial. In such cases, the accurate presentation of information is of utmost importance.

Cultural Biases

We need to be able to examine our own biases and change them in our daily practice.

• Stereotyping is common
  • Examine your own beliefs and values about aging
  • How do you react to bias or stereotyping?
• Values and beliefs impact care
  • •What care is provided, when, where, why, and how it is provided
  • E.g., frail elderly stereotype may mean we do not provide necessary therapy
• Practitioners must treat with respect, dignity, worth, individual uniqueness, unrestricted by social/economic status, personal attributes, or nature of health problems. 

If you haven't explored this before, there are various cultural bias inventories available online that can help you assess and understand your own potential biases. This is a crucial step because acknowledging and addressing our biases is essential. It's a recognized fact that biases exist within us; the challenge is not allowing those biases to influence how we deliver treatment. Even as healthcare professionals, we are not immune to making assumptions and stereotypes. We must take a closer look at our own beliefs and reactions.

For instance, consider how you respond when you hear statements like, "They're old; they've earned it, they can manage on their own," or, "I'm highly focused on this issue, so I'm less concerned about that one." Our personal biases, values, and beliefs undoubtedly impact the way we provide care. This includes decisions related to when and where care is delivered and the methods used.

So let's give an example of a bias related to, again, the elderly. If we stereotype the elderly as frail and in need of protection, we might inadvertently overlook the full spectrum of therapy or treatment necessary to address their unique issues. Thus, it is imperative to approach care provision with unwavering respect, dignity, recognition of their self-worth, and a celebration of their individuality, all while consciously considering and mitigating our biases. 

Ethical Dillema Example

Nurse Gloria is instructed by the attending physician to have Mr.Isaac sign a consent form before a scheduled colonoscopy. As she goes over the form with the patient, she notices that he seems confused, is unsure where or how to sign the paperwork.

There can be various factors contributing to this situation, and it's worth considering that it's not exclusive to the nursing profession. We may encounter similar scenarios when explaining the potential benefits of a treatment, such as aquatic therapy. The patient's confusion may stem from a genuine lack of understanding. In such cases, the fault may not lie with the patient, but rather with the way information has been conveyed. Perhaps medical jargon or overly complex language was used. Cultural factors could also come into play; English might not be the patient's first language, further complicating comprehension. In such instances, the involvement of an interpreter or a cultural broker may be necessary.

The paramount concern here is to avoid any form of coercion. It's imperative that the patient is fully informed about their options and the procedures involved. When in doubt, the principle of caution should guide our actions. Re-engaging the physician, presenting the information in a different manner, or bringing in a translator, among other possible solutions, may be required to ensure the patient's understanding and informed decision-making.

These are everyday types of ethical issues. Somebody understanding us is important. Sometimes we don't see those really big ethical issues, but it is our ethical obligation, as outlined in our professional code of ethics, to educate and ensure informed decision-making.

Education

• Ethical duty to educate the public and ourselves
  • Are you as educated as you should be about longterm care?
  • Do you listen for and correct misperceptions?
• Staying current in one’s profession is an ethical duty to the constituency the profession serves
  • Formal education, clinical competence, personal growth

It is essential to continuously educate the public while also maintaining our own knowledge base. A fundamental question we should ask ourselves is whether we are as well-informed as we need to be in our specific clinical setting. This involves being aware of the rules and regulations governing our practice, staying updated on legislative developments in Congress relevant to our field, and understanding the dynamics with our payers.

How often have we heard someone say, "I simply don't grasp the complexities of insurance," or witnessed a divide between those in acute care and long-term care, each harboring misconceptions about the other's domain? As professionals, we have a duty to address such misperceptions. Whether it's debunking the idea that a particular care setting is only for end-of-life care or correcting misunderstandings between colleagues, it falls upon us to ensure clinical competence and foster personal growth.

In the realm of physical therapy, competence is not merely a goal; it is an expectation. We trust that our colleagues are competent, and it is our responsibility to uphold and contribute to this competence as well.

Ethical Dillema Examples

• Incompetence among peers
• Asked to perform a treatment for which you are not trained or competent
• Questioning MD orders (e.g., order written for medication to which patient is allergic)

Nobody wants to entertain the thought of someone being incompetent to provide care. However, the reality is that issues of incompetence do exist and can present significant ethical dilemmas in therapy. What should we do when confronted with a situation where we are asked to perform a treatment for which we lack training or competence? Ideally, we should respond by acknowledging our limitations and readily admit that we are not qualified for the task, while suggesting a more suitable colleague who can address it effectively. For example, if it involves a specialized treatment like lymphedema therapy, we should refrain from attempting it ourselves, assuming we can manage it or misrepresenting our capabilities.

Another vital aspect of our professional duty is to question physician orders when we have concerns. If we encounter a treatment plan or modality that raises doubts or poses a risk to the patient's well-being, it's our ethical responsibility to express these reservations. For instance, if a physician orders a specific modality, but we suspect that the patient's skin integrity in that area is compromised and unlikely to tolerate it, we should seek clarification from the physician or suggest an alternative approach.

In all cases, the guiding principle must be the unwavering commitment to putting the patient's best interests first. Our paramount duty is to ensure the highest level of care and safety for our patients, even if it means challenging or seeking clarification on medical decisions.

Involving Patients in Medical Decisions

Frequently, healthcare providers encounter situations where there is a conflict between the preferences of the patient and the desires of their family, significant other, adult child, or parents. These conflicts can manifest in various ways, such as a patient refusing medication when their family insists they should take it, or family members wanting to withhold information from the patient, thereby excluding them from their care plan. Other examples include patient's refusing nutrution, treatment and blood sugar control.  

Ethical Dillema Example

Mr. Morris is in end - stage renal failure. Despite efforts to help manage the disease, including dialysis three times weekly, his condition has worsened. Mr. Morris's physician has noted the decline in his status and has informed the family that Mr. Morris may have only a few weeks to live. Mrs. Morris and their children are skeptical about telling Mr. Morris how bad his condition is, and the physician has made no effort to talk to the patient about it. After his family left for the evening, Mr. Morris called for the nurse and asked her to tell him what the doctor said, stating he felt like he was not getting the whole story.

This is a real ethical dilemma. It is not uncommon for family members or significant others to withhold information, often with the intention of protecting their loved ones. Nevertheless, from an ethical perspective, this raises concerns related to paternalism, where someone else presumes to know better than the patient. Ethical principles such as veracity, informed consent, and autonomy are paramount here.

In situations like this, it is vital for healthcare practitioners to uphold their duty to provide information. The patient has the inherent right to be informed about their condition and prognosis. While it may not always fall on the physical therapy practitioner to deliver such information, it is crucial to know where to direct the patient to ensure they receive the information they are entitled to. Resolving such situations requires a collaborative approach, ensuring that the patient's rights and autonomy are respected while addressing the concerns of their family. This case highlights how various ethical principles intersect and must be carefully navigated to provide the best possible care.

End of Life Wishes

This issue frequently arises, particularly in settings like acute care, hospitals, long-term care, and even home care. A survey of ethical challenges in end-of-life care often reveals two prevalent issues: a lack of resources and a breach of the patient's autonomy. In these circumstances, family members, healthcare staff, or others may exert pressure on the healthcare team to undertake actions that run counter to the wishes of the dying individual.

What becomes paramount in such cases is the necessity to be aware of the dying person's wishes. Is there an advanced directive or some form of documented guidance in place? Waiting until the last moment to address these critical matters is far from ideal. Ideally, well in advance, someone should have worked with the patient to articulate their true desires and what they wish to avoid in their end-of-life care.

The complex aspect emerges when family members express differing opinions from the patient. Some may assert, "We can't just let mom die," while others may believe, "Mom wouldn't have wanted to live like this." When family members concur with the patient's wishes, there is no conflict of interest. However, it's common for conflicting statements to arise, complicating the situation. Healthcare providers, including therapists, can sometimes feel caught in the middle, as they hear both the patient's and the family's perspectives.

In such situations, it can be beneficial to involve an ethics committee. The central principle to uphold is that of autonomy and self-determination. The patient's voice and choices should be respected and preserved whenever possible.

This underscores the fact that our primary duty and commitment always lie with the patient we are treating. Patient advocacy remains paramount, but there may be scenarios where family interests come into play, as our second duty is to the family. 

Ethical Dillema Example

Mrs. Douglas has metastatic lung cancer. Her physician has advised about treatment options that may prolong her life by six months to a year. However, to the dismay of her family, Mrs. Douglas has chosen comfort measures only. Mrs. Douglas has prepared an Advanced Directive, including signing a DNR. 

In cases like these, where the patient's wishes diverge from those of the family, it is crucial to prioritize the patient's autonomy and their documented preferences. The patient's wishes, as outlined in their Advanced Directive, should be respected and followed. This is a fundamental principle of medical ethics and legal practice.

Conversely, if a patient lacks an Advanced Directive and the healthcare facility is unsure of their preferences, it is imperative to initiate the appropriate discussions. While it may not fall upon us directly, someone within the care team should engage with the patient and their family, if possible, to understand their preferences and document them. These critical conversations should explore the patient's values, goals, and treatment preferences, ensuring that their decisions are at the forefront.

Lifestyle Choices

• Ethical questions can be raised about individual client responsibility and preference about lifestyle choices
  • Do we discuss choices about exercise, religious beliefs, or cognitive activities?  
  • Screen for depression, functional change, or cognition changes, or do we wait to do these screens until symptoms become problematic?
• Commonly voiced beliefs, biases, and stereotypes, make health promotion harder to implement
• Health promotion is seen as easier to set aside than other health care
• Elderly have chronic conditions linked to lifestyle choices that do not include positive health promotion activities

The role of lifestyle and health promotion in our practice is a critical but often overlooked aspect. We must ask ourselves how frequently we engage in discussions about exercise and cognitive activities with our patients. Do we regularly screen for issues like depression, functional changes, and cognitive decline, or do we wait until these problems become severe? It's a common scenario where we only address these concerns when they reach a critical point.

To illustrate, a recent case came to my attention where an occupational therapist questioned the responsibility of addressing lifestyle choices with a patient, specifically regarding type 2 diabetes. The therapist observed the patient's diet and lifestyle choices and wondered about their obligation to initiate a conversation about healthier lifestyle choices, including nutrition. While we are not dietitians or nutritionists, this raises the question of our ethical obligation in promoting healthier choices.

Unfortunately, we often encounter biases and stereotypes in our practice, such as the belief that people's choices are unchangeable or that older individuals can do as they please because they've reached a certain age. These preconceived notions can hinder our efforts in health promotion, prevention, and addressing lifestyle-related chronic conditions. We must revisit our professional code of ethics and remember that health promotion is a crucial part of our role, not to be set aside in favor of solely focusing on impairments. This applies across all age groups and emphasizes the importance of encouraging positive health promotion activities.

Issues Surrounding Dementia

In the realm of end-of-life care and the advanced stages of dementia, we often encounter complex scenarios where patients may refuse nutrition, fluids, or treatment. These behaviors can sometimes serve as a form of communication or be linked to the need for human contact. Additionally, in cases where two individuals with dementia are attracted to each other, it can be challenging when one of them is married. Family members may voice concerns, and the facility may prioritize the family's wishes over the desires and happiness of the individuals involved.

This situation underscores the complexity of balancing patient autonomy with the concerns of family members. It can be a difficult task to navigate, but it is essential to genuinely inquire about what each individual involved wants and what brings them contentment.

Engagement in meaningful activity is another critical aspect, and we often encounter situations where individuals are not actively participating in activities and are, as you described, "busy doing nothing." Encouraging proper hydration, a healthy diet, and physical activity is well within our professional scope. While we may not provide detailed dietary recommendations, we can certainly promote general principles of a healthy lifestyle.

The topic of sexuality can be equally complex and sensitive, and the approach may vary depending on the specific care setting and policies in place. Having clear policies and procedures to address such issues is essential. When these situations arise, it's crucial to know who to consult and how to appropriately handle them, ensuring the rights and dignity of all involved are respected.

Accountability

Our primary accountability in healthcare is to the patient. The patient's well-being and best interests should always be at the forefront of our decisions and actions. Our families are second. However, there are situations where it might be necessary to consider the family's needs and welfare as well.

For example, I observed the following:

A well-intentioned daughter took her father into her home after discharge. The daughter had a family including a husband and children. During the home care sessions I was witness to frequent and excessive demands on the family by the father. While the daughter aimed to provide care, the unreasonable requests placed major strain on the household.

An example illustrating when family interests may take precedence is when a patient's unreasonable demands, which they are capable of handling themselves, begin to put undue stress and burden on their family members. In such cases, the distress and disruptions caused by the patient's behavior can lead to the potential breakdown of the entire family unit. When this occurs, healthcare professionals may advise the family to seek alternative care arrangements, prioritizing the family's well-being.

Nonetheless, these instances are exceptions and should be approached with careful consideration of the clinical situation, social dynamics, and the best interests of all parties involved. In most cases, our primary obligation remains with the patient. The concept of a "rejection of responsibility" is complex and should be assessed on a case-by-case basis, considering the patient's specific circumstances, their family dynamics, and the broader context.

This issue frequently arises when working with adults who have faced neglect or abuse early in life or when dealing with complex family histories, such as a caregiver with a history of alcoholism. In each case, it's essential to gather all relevant information to make a sound value judgment regarding whether a true rejection of responsibility is occurring and how to best address it while upholding the patient's rights and well-being. 

Ethical Dillema Example

Mr. Simms was diagnosed with lung cancer three years ago. After chemotherapy, he experienced a brief remission but recently learned the cancer has recurred. Mr. Simms's doctor advised him and his family that treatment will likely be unsuccessful and, although it may offer a few more months of life, Mr. Simms's quality of life will rapidly deteriorate. The doctor recommends hospice with comfort measures only, including oxygen and opioid pain relievers. Despite symptoms of pain, such as grimacing and crying, Mr. Simms refuses pain medication, stating he does not want to experience the effects of feeling sleepy and missing precious time with his family. His wife is distraught and asks the nurse if there is a way to administer pain medication without her husband knowing.

The ethical dilemma presented in the case of Mr. Simms revolves around the tension between beneficence and autonomy. Beneficence dictates the healthcare provider's duty to act in the best interests of the patient, ensuring their well-being and comfort. In this scenario, it translates to providing pain relief to alleviate Mr. Simms's suffering.

On the other hand, autonomy grants patients the right to make decisions about their own care, including the choice to refuse certain treatments or interventions. Mr. Simms, despite experiencing pain, exercises his autonomy by refusing pain medication, fearing that the side effects may deprive him of precious time with his family.

The wife's distress and her inquiry about administering pain medication without Mr. Simms's knowledge introduce a complex layer to the situation. It implies a level of paternalism, where she believes that she knows what is best for her husband's well-being.

This scenario serves as a poignant example of the ethical challenges healthcare professionals face when trying to balance the principles of beneficence and autonomy. It highlights the need for careful analysis, communication, and ethical decision-making to ensure that Mr. Simms's wishes are respected while also addressing his pain and suffering in a way that aligns with his values and preferences.

Entering a SNF

• Disparity between views (taking a medication or getting a specific type of treatment)
• Paternalism contradicts autonomy
• Must discuss decisions with the client in detail and make the decision best for the client and the family

Entering a SNF, highlights the common disparity between the views of healthcare professionals and patients or clients regarding certain treatment options or medications. This discrepancy often underscores the ethical conflict between paternalism and autonomy.

Paternalism suggests that healthcare providers may act in what they believe to be the best interests of the patient, even if it means overriding the patient's autonomous decision. However, this approach contradicts the principle of autonomy, which grants patients the right to make informed decisions about their care.

It is imperative to engage in detailed discussions with the client or patient, providing comprehensive information to ensure informed consent. Open and honest communication, or veracity, is critical to ensure that the patient truly comprehends the options and is actively involved in the decision-making process. Ultimately, the decision should be one that best serves the well-being and preferences of the client and their family.

The scenario becomes even more complex when a person's legal competence is in question, particularly in the context of seniors. 

Legal Incompetence

There has to be legal incompetence. We look to the family when the person is cognitively unable to make a decision. Actual decision rests with the legal guardian who must weigh the implications of the family’s standpoint in relation to the patient’s interests. Consideration is to be given to the patient's needs, physical condition and personality and whether continued home care is possible.

If the individual has not been deemed incompetent, they need to be part of that decision. If we are looking at some level of placement, again, this is where ethics comes in quite a bit. Consideration needs to be given as to whether or not that person truly could be cared for at home.

Internet is an Electronic Billboard

You may expect electronic messages to remain private, but once you send it or post it you’ve lost all control over it 

Deleting an electronic message does not make it invisible or undiscoverable

NO Social media! Do not post patient - related or sensitive information on a website or social networking site

Online communications like texts, emails and social media posts are discoverable even after "deletion." While encrypted networks provide some protection, best practice is to avoid any patient-related information online whatsoever. Therapists should operate under the assumption that anything posted could potentially become public, regardless of privacy settings or quick retractions. Violating patient privacy through digital channels can generate HIPAA violations and legal consequences. 

Texting

When is texting appropriate at work?

If your message is urgent or short & sweet:

• “Call Me”
• Say “I just sent you an email and I need a response”
• Logistical communications: travel information, dates, times, locations of meetings are ok (if no names).  Make sure not to place protected health information in a text.

Voice Mail 

Don't leave a detailed voicemail unless absolutely necessary.  Never leave substantive patient related messages on unfamiliar phone numbers.  Instead just say, "Hey, this is Kathleen from therapy. I need to speak with you. Call me at your earliest convenience. 

Do not use a speaker phone unless privacy is assured.  When using your phone through the car's Bluetooth system, the audio can be heard by people outside of the car. It's important to be mindful of this, especially when parked. To maintain privacy, it's a good practice to use earphones or AirPods if you need to have a private conversation or maintain discretion.

Don't forget that voice mails are easily forwarded, passed along and otherwise shared. 

Best Practices for Voice Communication

Do not give PHI over the phone unless you confirm the identity of the listener & their authority to receive PHI  

Be aware of your surroundings and who is around to hear any discussions concerning PHI     

Refrain from discussing PHI in public areas such as coffee shops, airports, elevators, rest rooms, and reception areas 

Recommendations for E-mail

E - mail PHI only to a known party (e g , patient, health care provider)

Do not e - mail PHI to a group distribution list unless individuals have consented to such method of communication

In the subject heading, do not use patient names, identifiers or other specifics; consider the use of a “confidential” subject line

Again, I don't put any sort of PHI into my emails. I would just say, "Please contact me. I need to speak with you." Oftentimes I do this within my own organization. If I need to speak with somebody about something that could be compliance related or something like that, I'll just send an email, "Hey, I have that information, I'm following up. Can you give me a shout?" And that's kind of my code to say, I need to talk to you, but I'm not putting that in writing. Always consider what you put in writing.

Healthcare Ethics & Common Related Offenses

Confidentiality

• Records management, storage, ownership, retention
• Information exchanged
• Disclosure/release of information
• Access to records
• Exchange of records between professionals

Example HIPAA Violations

Unencrypted Thumb Drives and Laptops

Recently, a Department of Health and Human Services Administrative Law Judge ruled in favor of the Office of Civil Rights (OCR) and required a Texas cancer center (MD Anderson) to pay $4.3 million in penalties for HIPAA violations for failure to mitigate known security risk vulnerabilities and the use of unencrypted thumb drives and laptops. 

OCR is serious about protecting health information privacy and they will pursue litigation.

Dermatology Practice Penalized for HIPAA Violations

Private practices are the kind of covered entity most scrutinized by the Office of Civil Rights (OCR).

In one HIPAA violation case, a dermatology practice lost an unencrypted flash drive that contained protected health information.

The group was fined $150,000 and was required to install a corrective action plan.

Submitting Bills to Collections with Protected Information

This one was related to billing and sending past due bills to a collections agency.  Dr. Helfmann’s employees regularly forwarded past due patient bills to a collections firm. The bills contained protected info like CPT codes, which can reveal patient diagnoses and they didn't remove that information prior to sending to collection agency.  Collections agencies have no need to know other informaiton other than the amount that was owed. As a result, the State of New Jersey sought to suspend and revoke Helfmann’s license.

Hospital Worker Charged with HIPAA Violation

In 2014, Texas hospital employee Joshua Hippler got an 18 - month jail term for wrongful disclosure of private patient medical information.  He was arrested in Georgia and found to be in possession of medical records.  Though the filing didn’t say how many records he had, he was charged with wrongful disclosure of private health information for personal gain.  

Case Against Walgreens Pharmacist Leads to $1.4 Million HIPAA Award

Also in 2014 a Walgreen Co. pharmacist shared confidential medical information about a customer who once dated her husband. $1.4 million lawsuit and the customer’s lawyer, Neal F. Eggeson Jr., said the case sets an example, since it proves businesses can now be held liable for the actions of their employees.   

HIPAA Violation-OBGYN office

A similar situation I read recently was a woman went to her OBGYN, and when she got there, the person who worked the desk knew her mother and she just said, hi, hello, how are you? The women went in to see her OBGYN and found out that she was pregnant. She did not want to be pregnant and that was the key here. The patient left and the person behind the desk who was friends with mom, looked at that person's record. She had no right to look at that record and she phoned the patietn's mom who was her friend, and said, oh, congratulations your daughter is pregnant, this is wonderful. The patient didn't want her mom to know that she was pregnant. Again, there was a lawsuit there.

Criminal HIPAA Conviction for Respiratory Therapist

Jamie Knapp, a respiratory therapist and an employee of ProMedica Bay Park Hospital in Ohio, accessed 596 medical records in a 10 month period. 

Knapp was authorized to view records as part of her job, but only for the patients she was treating.  Allegedly, she viewed files for almost 600 unrelated patients.

Knapp was convicted on criminal HIPAA violations by a federal jury in Ohio, facing up to one year in prison.

$2.5 Million Settlement in Stolen Laptop HIPAA Case

A cardiac monitoring vendor got into HIPAA "hot water" when a laptop containing hundreds of patient medical records was stolen from a parked car. The OCR reached a $2.5 million settlement with the vendor, demonstrating that the federal government is extremely aggressive in prosecuting HIPAA cases involving third parties and portable digital media.

Facebook HIPAA Violation

In 2017, a HIPAA violation resulted in the firing of a medical employee after she posted about a patient on Facebook.  

The 24-year-old med tech commented on a post about a patient killed in a car crash, using the words, “Should have worn her seatbelt…”  While that seemed pretty innocent, believe it or not, it disclosed patient health or protected health information about that patient.

The person was fired and there was a obviously HIPAA violation. Past that I don't remember what happened, but at a bare minimum they were fired.

Analyze Ethical Dilemmas-CELIBATE

CELIBATE stands for clinical ethics and legal issues bait all therapists equally. 

The process for analyzing ethical dilemmas, as presented, is a comprehensive and multi-step approach that takes into account both legal and ethical considerations. This systematic multi step process can guide healthcare professionals through complex ethical situations. Here are the key steps in this analytical method:

1. Identify the Problem: The first step is to clearly define and identify the problem or ethical dilemma at hand. This step sets the stage for the subsequent analysis.

2. Gather All the Facts: It's essential to gather all the relevant facts and details pertaining to the situation. This includes not just the surface-level information but a deep dive into the specifics of the case.

3. Identify Interested Parties: Determine all the individuals or groups who have an interest in the situation. This can range from the patient and healthcare professionals to colleagues, supervisors, rehab directors, administrator, family members, caregivers, payers, and more.

4. Understand the Nature of Their Interest: For each interested party, it's crucial to understand why the issue is important to them. This may be related to professional, personal, business, economic, intellectual, societal, or other factors. This helps in assessing the motivations behind their perspectives.

5. Assess for Ethical Issues: Analyze whether there is a genuine ethical issue at play. Evaluate whether the situation violates your professional code of ethics, state practice act, or any other moral, social, religious, or cultural values. It's vital to compare the actions or decisions to the relevant ethical standards.

6. Consider Legal Aspects: Determine if there are any legal issues involved. This entails a review of practice acts, licensure laws, and regulations to identify which sections, if any, are being violated.

Legal Issues 

Legal issues can be any of the following:

• Age Discrimination?
• Antitrust?
• Assault and/or battery?*
• Breach of contract?
• Child abuse?
• Copyright violation?
• Confidentiality of student records?
• Covenants not to compete?
• Disability Discrimination?
• Elder abuse?
• Embezzlement?
• Family Medical Leave Act?
• Fraud? (Insurance)*
• Gag clauses?
• Guardianship/ conservator ship?
• Kickbacks?
• Malpractice?
• Medical fraud?
• Modalities without training?
• Negligence?
• Omnibus Budget Reconciliation Act (OBRA) violation-long-term care facilities would ascribe to?
• Patient confidentiality?
• Plagiarism?
• Sex discrimination?
• Sex with a patient?
• Sexual harassment?
• Spousal abuse?
• Theft?
• Trade secrets?
• Treatment without a prescription or referral?
• Violation of privacy laws?

Addressing ethical issues within your workplace is a complex matter that can lead to various outcomes and ramifications. It's essential to consider both your professional and personal perspective when deciding how to handle these situations. Here are some key points to keep in mind:

Many ethical issues can be addressed internally within your workplace. Depending on the nature and severity of the issue, actions taken within the organization may include verbal warnings, written warnings, suspensions, or even termination. Your workplace policies and procedures will guide the internal resolution process.

The decision to involve licensing boards should be made on a case-by-case basis. There may be instances where a breach of ethics is severe enough to warrant reporting to the relevant licensing board. This is typically appropriate when the issue involves a violation of professional standards outlined in your state's practice act.

Deciding whether to report to the board is a personal choice. It depends on the specific circumstances, your level of involvement or responsibility, and your own ethical and professional standards. There is no one-size-fits-all answer, and it's essential to consider the potential consequences and the potential impact on your career.

Familiarize yourself with your state's practice act and any specific requirements related to reporting ethical violations. Your practice act provides guidance on when and how to report violations and the potential consequences.

Some ethical issues may have legal implications, leading to criminal or civil lawsuits. In such cases, you may need to contact the relevant legal authorities or law enforcement agencies, depending on the nature of the issue.

Ultimately, how you address ethical issues in your workplace should align with your professional and personal values, as well as the specific circumstances of the situation. It's important to act in a way that upholds the integrity of your profession while also considering the best interests of all parties involved.

The remaining steps in this process:

7. Assess the Need for More Information: Determine if you require additional information to fully understand the ethical dilemma. Consider whether there are policies, procedures, laws, or regulations that you may not be aware of and need to research. Explore the existing evidence and literature related to the issue. Consult with experts, mentors, supervisors, or individuals who can provide guidance and expertise in the specific area of concern.

8. Brainstorm Possible Action Steps: Generate a list of potential actions or solutions that could address the ethical dilemma. Brainstorming encourages creativity and exploring various options.

9. Analyze Action Steps: Evaluate the proposed action steps and eliminate those that are obviously inappropriate or unfeasible. For the remaining options, consider how they will impact the patient, involved parties, society, and yourself. Assess whether the choices align with your practice act, regulations, code of ethics, as well as your personal moral, religious, and social beliefs and values.

10. Choose a Course of Action: Select the most appropriate course of action based on the analysis, considering all relevant factors. Evaluate your decision using criteria such as the Rotary Four-Way Test: Is it truthful, fair, goodwill-building, and beneficial to everyone concerned? You should strive for a win-win outcome, but that may not always be possible.  You may not feel great if you had to report somebody to the board, or they lost their job, but you have to feel good about the fact that you made the best choice that you possibly could considering the available information and ethical considerations.

This structured approach helps healthcare professionals navigate complex ethical dilemmas, ensuring that their decisions are well-informed, ethically sound, and aligned with their professional and personal values.

Let's Practice: Example  (Terri)

Terri is a student at the Sunnyside Nursing Home.  She has struggled throughout her student internship. Calling her performance marginal would be a compliment. As her supervisor, as her CI, you have given her very specific feedback repeatedly. Instructing her in various ways that she can change her behavior. Unfortunately, Terri fails to heed your advice. At midterm, her performance merited a failing grade. She forgets to lock the brakes on wheelchairs. She shows a complete disregard for other patient safety precautions. Well, here you are now at her final evaluation and after spending a half an hour at a minimum struggling with this failing final evaluation, your boss, the rehab director looking over your shoulder says, "Well whoa, you can't fail, Terri. She's done her best, despite the fact that she has a learning disability." And she says, "Even though she really failed this field work or this internship, it's just too much trouble to give her a failing grade." Your supervisor reminds you that your clinic or whatever doesn't wanna be sued for an Americans with Disabilities Act violation. And should Terri fail her field work, that's what you would see. You had no previous knowledge of Terri's learning disability, only her failing performance.

Let's go through the steps.

What is the problem?   

• The boss wants the supervisor to pass a failing student intern whose performance doesn't warrant a passing grade. I would hope that that would make most of us feel some level of conflict and discomfort.

What are the facts of the situation?  

• Terri is a student intern at Sunnyside Nursing Home
• Midterm performance was failing  
• Terri’s supervisor provided her with adequate supervision, ample specific feedback in ways that she could perform better, improve her performance in various areas.
• Terri failed to modify her behavior in response to your feedback
• Terri forgets to abide by patient safety precautions
• Terri’s is still failing at the end of the fieldwork
• The supervisor intends to fail her
• The rehab director tells the supervisor not to fail Terri
• The supervisor learns for the first time of the learning disability
• The learning disability was not considered  
• The facility does not want a lawsuit

We know that she is not abiding by safety precautions, specifically locking the brakes on wheelchairs during transfers and some other things. We also know that at the end of this clinical affiliation/field work, she is still warranting a failing grade. The supervisor feels that Terri earned a failing grade and intends to fail her. The rehab director tells the supervisor, you are not to fail Terri. At the end of the internship, the rehab director informs the supervisor for the very first time that she has a learning disability. In assigning a failing grade, the supervisor did not consider any sort of learning disability. And the rehab director tells the supervisor that he/she cannot fail her because of the fear of an unwanted ADA lawsuit. 

Who are the interested parties?

• Terri
• Supervisor  
• Rehabilitation Director and facility
• Terri’s future patients and employers  
• Academic program from which Terri came
• Other therapists/students at the facility
• Terri’s professional association/licensing board

What are their nature of their interests?

Many different stakeholders have interests in Terri's situation as an intern struggling to pass her clinical/fieldwork. Analyzing the nature of these interests is complex but necessary to make an ethical decision.

Terri - Personal (she wants a job and needs to pass). Professional (she wants her license and desires to practice therapy) and Economic interests in passing the clinical, obtaining licensure, securing employment as she spent a lot of time and money going to school.  

Supervisor - Professional interest in competent therapists and reputation; Personal desire to avoid failing students; Business interest as a supervisor need to balance management expectations and patient safety 

Facility - Economic/business interests 

Terri’s parents - Economic interest in her career success 

Terri’s future patients - Safety and quality care

Federal government - Societal interest- individuals with disabilities are not denied opportunities

Academic program - Reputation and student outcomes

Other therapists - Professional standards  

Licensing board - Public protection

Considering these diverse perspectives helps illuminate the full scope of consequences in either reporting Terri or assisting her. An ethical resolution will account for all stakeholder needs.

Is there an ethical violation?

Yes. At the very least, passing a student who achieved a failing grade violates a code of ethics addressing justice, veracity, and maybe non-maleficence too, because this student could possibly harm someone in the future.

Is there a legal issue?

Again, we would need to look at the practice act there. We don't have a lot of information there.

Are there other possible legal issues?

Although our information is limited, it's possible that an ADA violation occured, filing a false report, contract breach, or confidentiality issue. Additionally, issues of negligent supervision could come into play.

ADA, filing a false report, practice act, contract breach, confidentiality, negligent supervision, some other types of legal issues. Do you need more information? Possibly, possibly. Other good information. Was this this person's first internship or would maybe it was the last? If it was the first, maybe there's another opportunity. Maybe you do fail her because she would have another opportunity. Maybe you need to familiarize yourself with ADA, the practice act, maybe somebody else on the management team for advice. So let's brainstorm. Remember there's no right or wrong answers here. What can you do?

Do you need more information? 

It's conceivable that this may not have been Terri's first internship, and there might be more at stake than initially apparent. If it indeed was her first internship, other opportunities may be available. It would be prudent to familiarize yourself with the ADA and the practice act, or seek advice from a colleague within the management team. Let's brainstorm. Remember, there's no definitive right or wrong answer in this situation. What options can you consider?

• Brainstorm possible courses of action
  • Fail Terri
  • Pass Terri 
  • Call the coordinator at the university 
  • Research the ADA issue  
  • Complain to the rehabilitation director’s boss 
  • Call the police?  Terri’s parents? 
  • Contact the Justice Department 
  • Consult with an ADA lawyer 
  • Discuss the situation  
  • Quit your job rather than fail Terri

You might choose to fail Terri, or you could pass her. Another approach would be to contact the university's academic coordinator and request guidance. Researching the ADA to determine if a failing grade is permissible is another avenue. Discussing the matter with the rehab director's immediate supervisor is a possibility. Alternatively, you could reach out to the police or Terri's parents. If you're unsure, you could contact the Justice Department, responsible for enforcing the ADA, to inquire if failing Terri violates the law. Consulting with an ADA lawyer is also an option. You could discuss the situation with your spouse, significant other, or a religious or spiritual advisor. Quitting your job rather than failing Terri, however, is an extreme step.

Let's evaluate these options by first eliminating those that are clearly inappropriate. Calling the police is unnecessary as there is no criminal activity involved. Contacting Terri's parents, your spouse, or your clergy would breach confidentiality. Quitting your job is not a rational choice. Now, let's apply a moral and ethical litmus test to the remaining choices. Do they align with your personal code of ethics and professional standards? Finally, you can select the best course of action based on the contextual factors at hand.

In this case, it might be advisable to call the academic program to seek guidance and involve another supervisor at the facility to gather additional insights before making a final decision. Keep in mind that the goal is to achieve a win-win outcome, ensuring that your choice aligns with the situation's ethical considerations. There may not be a definitive answer, but this is how we could approach the analysis.

RIPS Model

The RIPS Model is another way of analyzing ethical dilemmas.

Step 1: Recognize and Define the Ethical Issue 

• Realm
• Individual process
• Implications for action
• Type of ethical situation
• Barriers

Step one involves recognizing and defining the ethical issues at hand. This process is quite similar to our previous discussion. In this step, you need to determine the realm, the process, the implications for action, the nature of the ethical situation, and any barriers you might encounter. Let's delve into these aspects in greater detail:

Realm. Begin by identifying the ethical realm to which the issue belongs. There are three primary realms to consider:

• Individual Realm: This pertains to matters related to the well-being of the patient or client. It focuses on rights, duties, interpersonal relationships, and individual behaviors.

• Institutional or Organizational Realm: Here, the emphasis is on the well-being of the organization. You should consider the structures and systems in place that contribute to the achievement of its goals.

• Societal Realm: This realm is concerned with the common good of society as a whole. It involves ethical considerations that transcend individual or organizational interests and aim to benefit the broader community.

Individual Process. The second aspect of recognizing ethical issues involves assessing individual processes. These processes help you understand how the problem manifests in terms of moral decision-making. Consider whether the issue aligns with any of the following aspects:

• Moral Sensitivity: This is about recognizing, interpreting, and framing ethical situations. It involves being aware of the ethical dimensions of a situation and understanding the potential implications for all involved parties.
• Moral Judgment: In this step, you are tasked with making decisions that involve determining what is morally right or wrong. You evaluate the ethical principles and values at play and decide on the most appropriate course of action.
• Moral Motivation: Moral motivation concerns your ability to prioritize ethical values, principles, and considerations over personal financial gain or self-interest. It involves a willingness to act in accordance with one's ethical beliefs even when there may be external pressures to do otherwise.
• Moral Courage: This aspect is about implementing the chosen ethical action, even when doing so may lead to adversity or challenges. It requires the determination to follow through with the right course of action, despite potential consequences or resistance.

Situation. How do you classify the ethical situation? To effectively analyze the ethical situation, you should classify it into one of the following categories:

• Problem or Issue: Determine whether the situation qualifies as a problem or issue, meaning whether important moral values are being challenged.
• Temptation: If the situation involves a choice between a right action and a wrong action, where the wrong action may offer personal benefits, it falls under the category of temptation. This often tests your moral integrity.
• Silence: When key parties recognize the existence of ethical issues but remain passive, not discussing or taking any action to address them, the situation can be classified as one of silence. This is a scenario where there is an unspoken agreement not to confront ethical challenges.
• Distress: If a structural barrier hinders you from doing what you believe to be the right thing, it falls under the category of distress. There are two subcategories:
  • Type A Distress: In this case, the barrier is apparent, but it prevents you from doing what you know is right.
  • Type B Distress: Here, there is a barrier, but you are uncertain about the specific nature of the problem. Something feels ethically wrong, but you may not be able to pinpoint it.

Dilemma. There are two or more correct courses of action that cannot both be followed. You're doing something right and also doing something wrong and most often this involves ethical conduct. Ethical dilemmas typically involve the need to balance and make decisions between conflicting principles. Some common examples include:

• Honoring Autonomy vs. Preventing Harm: On one hand, you may be required to respect an individual's autonomy and their right to make decisions about their own life, even if it might lead to harm. On the other hand, there's an obligation to prevent harm, which may require intervention that infringes upon their autonomy.
• Conflicting Traits of Character: Ethical dilemmas can also involve conflicting traits of character, such as honesty vs. compassion. For instance, you might need to decide between being completely honest and potentially hurting someone's feelings or showing compassion by withholding some information to protect them.

Step 2 Reflect

• Background
• Major stakeholders
• Consequencses of action or inaction
• Laws broken?
• Professional guidance
• Right-versus wrong tests

The process is very similar to the ethical decision-making (CELIBATE) model we discussed earlier. When faced with an ethical dilemma, it's crucial to carefully consider the following factors:

• Relevant Facts and Contextual Information: Begin by gathering all the pertinent facts and contextual information about the situation. This provides the foundation for making an informed ethical decision.

• Major Stakeholders: Identify and understand the key parties involved in the situation, as their interests and perspectives can significantly influence the ethical implications.

• Consequences: Analyze both intended and unintended consequences of potential courses of action. This includes considering the impact on individuals, organizations, and the broader community.

• Relevant Laws, Duties, and Ethical Principles: Examine any applicable laws, regulations, professional duties, and ethical principles that are relevant to the situation. These provide a framework for ethical decision-making.

• Professional Guidance: Seek guidance from your profession's ethical guidelines or code of conduct. This guidance can help you align your decision with industry standards and values. Examine whether the situation aligns with the code of ethics, the guide to professional conduct, or any core values of your profession.

• Right vs. Wrong Tests: Evaluate the situation by asking if a course of action is morally right or wrong, considering your own values and principles. You may include: 

  • Legal Test: Determine if any actions taken by the involved parties are illegal, as this can impact the ethical assessment.

  • Stench Test: Assess whether the situation simply feels wrong or unethical, even if it may not be clearly defined as such by laws or regulations.

  • Publicity or Front Page Test: Consider how the situation would be perceived by the public or if it were to become widely known. This can shed light on potential reputational and ethical concerns.

  • Universality or Mom Test: Reflect on whether the decision is the right thing to do, regardless of who is involved. Consider what your moral compass or what your "mom" would advise. 

Step 3 Decide the Right Thing to Do

You can do this in three different ways. It's rule-based. You follow only the principle that you want everyone else to follow us. So that's deontological. It's end base. So you do whatever produces the greatest good for the greatest number of people. That's teleological. Or it's care-based. Do unto others as you would have them do unto you. That is the golden rule.

Step 4 Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

So what we're really looking at here is you know, we're gonna implement. And then did it turn out as we wanted to? What were the challenging aspects? You know, how did it compare to other situations? Did it make you a better professional? Do we need to put a policy or procedure into effect to prevent this from happening in the future?

Example Using RIPS Model (Kate)

Kate graduated last year from State University and is working at County Hospital. Her best friend from PT school, Sandy, is working across the state in a small rehab hospital. They often compare experiences and ideas for interventions. The young colleagues, typical of their generation, primarily communicate via text messaging and Facebook. They rarely talk on the phone.  

One Monday morning, Kate begins her workday by pulling charts of her scheduled patients. Among the new admissions she sees in the chart rack is a familiar last name. She checks the face sheet. And after confirming the patient's place of employment, confirms that the patient is Ms. Edwards, one of her former professors at state. She thumbs through the chart, surprised to see the reason Ms. Edwards was admitted was to rule out a brain tumor. 

Kate takes a walk down the hall to see her former professor, but she's not in the room. She assumes she's undergoing tests and makes a mental note to stop by again later. Kate never does meet up with her professor that day. That evening, Kate is on Facebook and writes a message on her friend Sandy's “wall” about their former professor's admission. The message is posted on the Facebook “news feed,” and within minutes Kate is “chatting” about Ms. Edwards' admission and condition with several of her former classmates, and others as well. 

Later that evening, Ms. Edwards daughter is surprised to read about her mother's hospitalization on the social networking site. She calls her mother who finds the news upsetting, immediately contacts Joanne, who is County Hospital's Director of Physical Therapy. Joanne calls Kate in her office the next day and in an irritated tone, asks Kate to explain herself. Kate is really unsure why there's even an issue. She attributes the flap to a generation gap between Ms. Edwards and Joanne, both of whom are baby boomers and herself. She quotes, "This is how people my age share and communicate things." Joanne counters that the issue isn't one of technology or even etiquette; its one of confidentiality. Kate is truly puzzled by Joanne's exasperation.

This example is very similar to that situation that I mentioned earlier where the person wasn't even treating the patient and called the family and everybody else to say that the estranged mother was located.

Let's go through the RIPS model now. 

Step 1: Recognize and Define the Ethical Issue  

• Realm: While Kate is sure it is individual, Joanne considers it institutional.  
• Individual process: Kate doesn't have the moral sensitivity to even recognize that her messagages were a breach of confidentiality, as too was her decision to read the chart of a patient to whom she had no professional connection or obligation.
• Implications for action: Joanne is obliged to address Kate's obvious lack of understanding of confidentiality issues.
• Type of ethical situation: A problem; It's a problem in that the inappropriateness of Kate's actions are really not even clear to her
• Barriers: Yes, there are barriers. Joanne has the authority to take action, but it's not clear if she fully understands the generational challenge with which she is confronted.

Step 2: Reflect

• Background: We don't really know any more than this. What we know is that Kate is not treating Ms. Edwards, she's just curious about her.
• Major stakeholders: Kate, Joanne, Ms. Edwards, and Kate's friend, Sandy, who is dragged into this because Kate was chatting with her.
• Consequences of action or inaction: Yes. Joanne is obligated to take action. Kate is obliged as a new professional to understand that her personal life and values are affected by her professional responsibilities.
• Laws broken: Yes, at a bare minimum there is a HIPAA violation.
• Professional guidance: Kate would do very well to reflect on the principles of the code of ethics regarding respectively the rights and dignity of all individuals and the exercise of sound professional judgment. She needs to look at integrity and social responsibility.
• Right versus wrong tests. Is it illegal? The situation feels wrong for sure, if not to Kate. Is there discomfort if this information becomes public? Probably. Would your parents take action in a similar situation? The answer is probably yes. Finally, as there violation of the professional code of ethics? Again, the answer is yes.

Step 3: Decide the Right Thing to Do

So what do you do? Well, for Kate, the barrier to behavior change is getting her to understand that her actions, while perhaps socially acceptable and expected among her peers, are inconsistent with the expectations from her profession and her patients.

Step 4: Implement, Evaluate and Assess Needed Changes to Prevent Recurrence

So what do you do? This situation very well may result in a change in institutional behavior, as Joanne looks at her orientation program and recognizes she has young staff with social norms the differ from her own. 

This whole situation looks at confidentiality and how we as therapists manage protected health information that we have at our disposal. Confidentiality again is our, one of our biggest obligations. Changes in technology and communication are challenging how we view confidentiality. It is something that we need to look at in light of the technology. There should be some level of policy and procedures in place that are reviewed regulary and part of orientation as well.

Second Example (RIPS model-Mike and James)

James is working in home care. He enjoys the independence and variety of work. One of his current patients, Mike, an active 72 year old retiree and widower who recently had a left total knee replacement, spent a week at a rehab center before he came home.

Mike has a great attitude, eager to get back in the swing of things. Payment for his physical therapy is unaffected by outpatient guidelines as long as he remains at home. This makes James very happy because Mike is a hard worker and he is an ideal patient. He can't afford to pay for physical therapy beyond what Medicare and supplemental insurance will allow. James aim is to ensure Mike's safety in the home environment and his ability to manage on his own. His discharge goal is to be self-sufficient while possibly experiencing some residual pain, and capable of transporting himself to physical therapy on an outpatient basis. Plan of care estimated at three times a week for three weeks.

When the PT arrives for his third appointment in the first week, he notices that his patient's car is in the driveway rather than in the garage. Mike answers the door and goes into the kitchen, where he's putting away groceries. James knows that there's no family in the area and he asks Mike who did the driving and the shopping? Mike says, "Well, I did." James is surprised because Mike should be technically homebound to recieve physical therapy in the home. There are physical issues and clinical issues, but Mike's like, "Yeah, I get it, but there's gotta be a little bit of wiggle room. What harm is there in me trying to do a little bit for myself?"

When James arrives for the next follow-up appointment, Mike's car is gone. About five minutes later, Mike returns in his car. Mike stated that went to the hardware store for plumbing supplies to fix the leaky sink.  Jamies notices Mike is getting up the stairs and he's getting back into the home safely, but obviously with some level of effort. 

James feels conflicted. Mike needs more physical therapy, but based on the fact that he's shown obvious progression, he's technically no longer home bound, what does he do? Does he continue home care or does he discharge and send him to outpatient?

Step 1: Recognize and define the ethical issue

• Realm: Individual and societal
• Individual process: Moral sensitivity on James's part
• Implications for action: Mike will stop receiving PT that can benefit him
• Type of ethical situation: A dilemma
• Barriers: Concern for Mike's safety 

The realm is individual between James and Mike, but I think there's a societal element as well here because of reimbursement obviously. In the individual process there's that moral sensitivity, particularly on James' part.

Implications for action. So if James exercises moral courage, Mike is gonna stop receiving home care that could possibly benefit him and we don't really know if he could or could not go to outpatient at this point. Is this a, what type of situation? This is a dilemma. Mike is exercising his autonomy, but James is concerned for his safety. James is exhibiting non-maleficence in wanting to keep Mike on program. James is also concerned about veracity. He believes in being truthful. He doesn't wanna lie about the homebound status. Are there barriers? Yes, one barrier is for Mike's safety if home health is discontinued.

Step 2: Reflect

• Major stakeholders: James and Mike
• Consequences of action or inaction: If James takes action, Mike will lose additional PT he needs.  Inaction means that he receives PT while not technically homebound
• Laws broken? Medicare laws are very specific regarding homecare
• Professional guidance: Principle 7 of the Code of Ethics
• Right vs. Wrong: Illegal? Yes. Situation feels wrong? Yes. Discomfort if information becomes public? Yes. Your parents likely to take action in similar circumstances? Yes. Violations of APTA's professional codes and documents? Yes. 

But inaction means that he has a patient who is not by definition home bound. Are there laws broken? Yeah, Medicare has very specific laws regarding home care, obviously. What is the professional guidance? Obviously regarding the state, the code of ethics, a physical therapist shall seek only such remuneration as is deserved and reasonable. There's a core integrity here as well. Right versus wrong tests. I think all of these, we could say it feels wrong. Your parents, your mom would take action in a similar situation. It doesn't pass the stench test.

Step 3: Decide the Right Thing to Do

• So what does James do? While James must consider discharge, he also must do all he can to see that Mike will maintain access to the outpatient services he needs in order to ensure his safety.  

Step 4: Implement, Evaluate and Assess Needed Changes to Prevent Recurrence

• It's unclear that any change in institutional policy or culture is warranted, but that possibility should be fully explored. I think what we're looking at here is to some degree there's pressure to provide patients with optimal care within the guidelines. There's pressure to always do the right thing in light of reimbursement. You can't let reimbursement drive practice. We have to make sure that proper sequence is followed and that we do the right thing for our patient and for our practice as well.

Example-Jenna

Jenna has been working at Pond View for about six years. She is known for her wound care expertise. She's been the CI for the past four years and recently completed the CI credentialing course. She supervises at least three students a year as they rotate through their clinical experience. She enjoys the interactions particularly related to wound care. This is the next to last clinical rotation for Brendon, a third year DPT student at the local university who made a career change from the corporate world and thus is a little older than the students who generally rotate through. He is working with another PT, Mary, for the first part of his rotation and then he is gonna move on to Jenna's supervision about midway through.

One day, three weeks into the affiliation Brendon stays late to finish up some paperwork. He ends up leaving the building at the same time as Jenna, who also worked late. They get into a long conversation while standing in the parking lot. Brendon's very interested in wound care, asks Jenna a lot of questions about what he'll be seeing when working with her in the next few weeks. They also exchange a little small talk during which Jenna mentions that her birthday is the next week. With the conversation winding down after 20 minutes, Brendon asks Jenna if she would let him buy her a birthday drink at a bar that is nearby (within walking distance). She responds that she appreciates the offer but it strikes her as inappropriate given that she'll be his supervisor in just a few weeks.

He responds that having worked in the corporate environment, he's sensitive to these types of issues. "It's just one birthday drink and anyway, you can think of it as a penny for your thoughts because I want to pick your brain about some cases that I've seen." She sees this as reasonable. Would having a single drink with Brendon while engaged in a professional dialogue be so wrong?

I would like you to take this one back with you and go through the steps I have laid out.  

Step 1: Recognize and define the ethical issue

• Realm: Into which realm or realms does this situation fall: individual, organizational/institutional, or societal? 
• Individual process: What does the situation require of Jenna? Of Brendon? Which individual process is most appropriate: moral  sensitivity, moral judgment, moral motivation, or moral courage?
• Implications for action: Are there implications for action on the parts of anyone besides Jenna and Brendon?
• What type of ethical situation is this: a problem, dilemma, distress, or temptation?
• Are there barriers to Jenna taking action?

Step 2: Reflect

• What do you know about the legal obligations Jenna may face?  
• Who are the major stakeholders?
• What are the potential consequences of action or inaction on Jenna's part?
• What ethical principle or principles may be involved?
• How does this scenario stack up against the “tests?”

Step 3: Decide the Right Thing to Do

• If it fails all of the “tests,” this step is superfluous
• If it passes the tests, then determine the right thing to do
  • Rule - based: Follow only the principle you want everyone else to follow
  • Ends - based: Do whatever produces the greatest good for the greatest number of people
  • Care - based: Do unto others as you would have them do unto you

Step 4: Implement, Evaluate and Assess Needed Changes to Prevent Recurrence

• Having determined in your own mind the right thing to do and the best way to implement the decision, reflect on the course of action chosen and think about whether a change in the clinic's organizational policy or culture might prevent this scenario from recurring

Rest’s 4-Component Model

Okay, I'm gonna go through this next model quickly because this is a nursing model, but I do believe it is appropriate and it looks at four different areas.

• Moral Sensitivity  
• Moral Judgment  
• Moral Motivation  
• Moral Action

Moral Sensitivity

• Recognition that an ethical dilemma exists  
• Ability to empathize with others  
• Be aware of how one’s actions affect other people  
• Recognize values, beliefs, understandings and obligations of others  
• Appropriate emotional response  
• Impact of actions on others  
• Discern relevant aspects of the situation  
• Consider other aspects such as care

Moral Judgment

• Judging which action is most ethically justifiable for a moral dilemma  
• Identify the morally relevant aspects of the situation  
• Weighs significance of aspects  
• Identify potential actions and consequences  
• Clarifying factual, conceptual and ethical issues

Moral Motivation

• Whether the practitioner is motivated to enact the moral decision made  
• Internal or external barriers can undermine motivation  
• Requires clarity, courage, support, skillful advocacy and a willingness to subordinate other important commitments  
• Wisdom and virtue as essential elements

Moral Action 

• Executing and implementing a plan with perseverance and resoluteness  
• Consider the best way to implement the decision  
• Requires diplomacy, skilled communication, collaboration and strategic planning  
• Create a trustworthy process with clear expectations, fair processes and precise communication  
• Attention to objections/resistance

Consequences Of Ethical Dilemmas

Ethical dilemmas can take a toll on individuals, potentially leading to burnout and stress.  It's essential to address these dilemmas promptly and effectively for several reasons. Ethical dilemmas left unaddressed can fester and grow, making them more challenging to resolve later. Addressing them early can prevent escalation. Swift resolution of ethical dilemmas can help reduce the stress and emotional burden that staff may experience. This, in turn, supports their well-being and mental health.

Some ethical dilemmas may have legal consequences, potentially resulting in actions such as loss of licensure, termination of employment, reprimand, or the implementation of an action plan as a response to the issue.

Ethics Committee

Hopefully, you have an ethics committee that you can go to with some of these issues. If you don't, it might be something that you consider in your place of employment, suggesting or at a bare minimum, having a team there.

As previously mentioned, I practice in nursing homes, and I recently came across a study. In this study, out of 40 ethics committees, a striking 29 of them did not include a single patient. This underscores the importance of having all relevant stakeholders, including the patients, actively participating in an ethics committee. Ethical discussions should encompass not only major ethical dilemmas but also the everyday ethical considerations that arise in our practice.

Avoiding Ethical Dilemmas

How do you avoid ethical dilemmas? You do it by Protecting Thy Patients and Thyself. It's a mnemonic.

• P: Put a copy of your licensure law on your desk and read it!
• R: Report ethical and legal violations
• O: Open your eyes
• T: Tell them you want it in writing or in email.  If it doesn't seem right, it probably isn't right. Tell them you want it in writing or an email. If somebody asks you something and it just doesn't make sense or you're questioning it, (it doesn't pass your stench test), ask for it in writing. If it's illegal or it's unethical, they won't put it in writing typically.
• E: Encourage ethical behavior
• C: Complete, thorough documentation
• T: Think!! Don't fall into the trap of panicking first and thinking later.

• T: Take the patient’s interest above all
• H: Handle situations as they arise
• Y: Yearn to learn

• P: Plug into your professional associations
• A: Ask a lot of questions
• T: Train and supervise all subordinates properly
• I : Internet sources (but be cautious too-clarify and make sure you have the correct information)  
• E: Establish a relationship with a mentor or peer
• N: Never fall behind
• T: Take a good look at the professional literature
• S: Surf the internet for regulatory changes   

• &

• T: Take the time to read your code of ethics
• H: Hand over patients to those with expertise
• Y: Yield to the dictates of payers  
• S: Save a copy of correspondence
• E: Explore all alternatives
• L: Look at professional association/licensure homepages
• F: Fill out all forms accurately and truthfully

Resources to Help

• Core documents from APTA -- APTA code of ethics, Guide to Physical Therapist Practice, and Guide for Conduct and Professionalism
• Other resources from APTA
  • Coding and Billing
  • Compliance
  • Managed care contracting tool kit  
  • PT in motion

Situational Examples

I'm gonna go through these exapmles a little bit on the quick side. I would like you to bring back to your clinics and maybe talk about it as a group as they relate to ethics.

You discover when compiling documents for an additional development request that the restorative nursing assistant documented that services were rendered when the resident was clearly out of the facility at the hospital. 

I've seen this in physical therapy and occupational therapy where we just continue to document and the patient was discharged. It's clear the person was never seen or actually treated because we probably would not have that documentation. That is truly an ethical violation and you can kind of brainstorm what you would do.

You, the therapist, have delegated treatment of a client to the physical therapy assistant under your supervision.  The client complains of pain during the treatment session.  The PTA applies ultrasound to the patient during the session without consulting you and without a physician script/order to do so.

We see this sometimes where the PTA has applied a modality that was not part of the plan of care and they have changed the plan of care without consulting the physical therapist - of course, that is a huge "no."

You discover when reading the daily notes of the assistant that you are supervising that he is adding and changing goals for the client without consulting you. 

This is very similar to the prior example.  This is also a no-no, as this is not in the PTA's scope of practice, and the therapist has to be consulted on any change to the plan of care (treatments and goals).

You are working in an outpatient clinic that deals primarily with Medicare Part B as a payer.  You have an aide in your clinic.  You ask the aide to complete the therapeutic exercise program with the client.  You bill for these services.

This example goes back to fraud and abuse. We cannot bill for services provided by individuals that are not legally allowed to provide that service in that setting.

You have been told as a PT to continue treating your patient – just 3 more sessions – so the facility can continue to obtain skilled reimbursement and because the family is not quite ready at home for discharge.

Could there be something you could work on? I suspect maybe yes, but if it's just for that facility to get reimbursement, that might not be the right thing. So I think you'd have to look at that one cautiously - if there truly is something clinically skilled that you could be doing, then by all means, but if there isn't, then we would probably want to continue with discharge.

A patient went to a follow up appointment which did not go as expected – there was bad news.  The patient wants to know the extent of the report, but the family wants to withhold the information to protect their emotions. 

We talked about this earlier - again, maybe it's not up to us to give that information, but it is definitely up to somebody to share that information with the patient.

A 56 year - old man is referred to physical therapy for sciatica, degenerative disc disease, and degenerative joint disease. He is the sole caretaker for his disabled wife. Over the last month he has lost his capacity to bend, lift and carry during activities of daily living and work. Medicaid will only provide for a PT evaluation.  No follow up services are covered.  The PT recommends follow - up twice a week for 4 weeks.

I mean this is a tough one. How do you proceed? Should the patient be asked to pay out of pocket? Should the patient be offered free or discounted services? No, because we don't do that. We need to maybe look at additional alternatives to traditional duration and frequency, models of care. Maybe there are some other options there. Maybe we need to be an advocate to the insurance provider to seek additional services. 

As a therapist, you suspect that a patient is concealing information that may impact his health, but you want to respect his privacy.

This situation is a tough one. If your patient doesn't share, they don't share. We develop that trust relationship and we hope that they do share with us. We have to obviously always keep their confidentiality.

As the supervisor of your department, you see that Marie, one of the PTs, has been receiving expensive gifts on a regular basis from the family of the elderly woman.  The woman was scheduled to be discharged from program weeks ago, but Marie continues to delay the discharge citing myriad reasons.

This is a problem. I think most of us work in a situation where we are not allowed to accept gifts and it looks like we're getting some sort of gift or kickback from this patient. That is a no-no. 

You are friends with Paula, on Facebook and you happen to notice that she is friends with several of your patients and their family members, too. 

Is that terribly wrong? Not necessarily, but I think at a bare minimum, we would want a policy that addresses the ability to be friends with these individuals or not. Maybe we could be friends after treatment ceases and maybe not while treatment is occurring. Again, that would be up to a policy and procedure there.

Lauren, a PT, is the only witness to a patient fall in the clinic gym. The patient has balance problems and the PTA, Hal, working with her was not guarding her. Lauren observes Hal place a gait belt on the patient after the fall and before calling for assistance. Lauren is unsure what to do about this situation. 

That's an another ethical situation. This person was not maintaining patient appropriate patient safety and that would need to be addressed.

Jim, a PT, works at a private practice that has a number of clinics throughout the region. It has a centralized management structure. One of the top managers calls Jim and asks him to call a previously scheduled new patient to re - schedule an initial evaluation since a VIP/shareholder has been referred to the clinic wants to be seen as soon as possible. Jim is uncomfortable with this request.

This goes against justice and fairness, really. What do you do here? It's an ethical consideration. I don't know that we have an exact answer, but I think it's something we need to talk through. Maybe there's room that both people can be treated. If there's not, then we have to obviously put our patient first.

Sara works in a private practice in which there is a profit sharing plan. Her year - end bonus is directly related to maximizing return visits as they are the most cost effective. Her boss has been heard to say to other staff members that they should treat patients to the maximum of their benefits; after all, you can always change the goals so there is more therapy to do – it just requires being a little creative. She has also been heard to encourage therapists to discontinue treatment early for those patients with poor reimbursement. Sara is uncomfortable with this situation but is counting on her year-end bonus.

Obviously, this needs to be addressed. This is a serious "no" that would be frowned upon by any state practice act, where we are delivering treatment based on not the needs of that patient, but something else.

Rob, a morbidly obese disabled veteran, arrived at an outpatient clinic, requesting PT services. His doctor referred him to this clinic because of their great reputation. Mary, a PT, working in the gym saw Rob walking into the clinic. She called the front desk requesting they not assign her the patient. The patient was scheduled two days later for another PT. Ellen, a PTA who works with Mary, overheard the conversation requesting that the patient not be assigned to her. Ellen knows that Mary is a fitness fanatic and has heard her make derogatory comments about people who are overweight. Ellen feels very uncomfortable about this situation and wonders if she should do anything.

If there was a real reason for that person not to be on her caseload, that's one thing, but if it's because of bias, that's a whole other issue, or discrimination that would need to be addressed. 

Q&A

Q: "Working in home health, sometimes I'm assigned more patients than I can see. How can I ethically navigate which patients to see? I can't see them all, there's not enough staff. Some patients will have a missed visit."

A: So, you know, that's an interesting one. I think that's one where you have to go back to, there's no easy answer here. You have to go back to your supervisor, talk about staffing, what else can we do? Can we, you know, could some visits be shortened, some visits be longer? Could you look at frequency and duration, et cetera? Unfortunately, in some cases, I think do need to prioritize, and I know that's not the right answer, but, you know, this person we can put off today and maybe see tomorrow because they're doing very well. Maybe that person, it's time for them to go to outpatient. Again, it's an ethical challenge, but I think at a bare minimum, you have to go back to your supervisor and discuss that.

Q: "If an aid or a rehab tech is guiding your patient to complete the rest of their exercises during a session, how do you bill for this?"

A: Well, you know, again, I'm gonna caution what I say. You have to know the payer source and whether or not you are permitted, to, quote unquote, bill for those services. I come from an area of Medicare Part B, where again, we can't bill for those services. So in that case, if the tech is overseeing that and you are not there, that is likely not a billable service. You have to go back to the payer, of course. The question then becomes, you know, should this just be turned over to an independent home exercise program? If the patient can do it without you physically present, is there a skill that you are bringing to the table? And I think the answer to that would be no. So I cautiously answer that question. I would go back to your payer first and see what you are allowed to do with that tech.

Q: "If you're leaving a practice and you have patients who want to know where you'd be practicing next, would this be seen as recruitment to share that information with them?"

A: That is a wonderful question. Thank you for asking that. If the patient says, "Hey, where are you going next?" And you say, "Oh, I'm going to Happy Day Clinic down the street." That is one thing. Then if that patient chooses to follow you to that new practice, that's a different story. I think what we discussed taking patients with you by saying, "Hey, I provide really, really good care. This place really doesn't. I'm moving down here, you need to follow me." So enticing or asking them is one thing. Them asking us, I think is a totally different story. 

I know I went through those last couple scenarios kind of quickly, but the whole point, I don't always intend to review those. It's really more so for you to take back and things for you to consider. And again, maybe deep dive with the folks in your clinic. 

References

Please review the handout for a full list of references for this course.  

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