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Ethics for the Indiana Physical Therapist and Physical Therapist Assistant

Ethics for the Indiana Physical Therapist and Physical Therapist Assistant
Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, OTR/L
March 28, 2022
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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:

  • Identify at least three principles of ethics and their application to rehabilitation and physical therapy.
  • List at least three codes of ethics that govern physical therapy practice.
  • Correctly apply code of ethics and procedures for analyzing ethical dilemmas in healthcare.
  • Identify at least common ethical issues experienced in healthcare settings.

Principles of Ethics

 
Simply stated, ethics guide the determination of right and wrong in moral life in everything that we do, not just healthcare. One's moral life extends into one's professional life and choices are dependent upon contextual situation and consideration.
 
Let's review the basic principles of ethics as they relate to healthcare and specifically, to physical therapy.

Autonomy

Autonomy refers to one's moral right to make choices and decisions about one's own course of action. In other words, it is the right to self-determination. Respect for autonomy dictates that we refrain from interfering with an individual's own choices. In a health and rehabilitation context, respect for autonomy means allowing and enabling patients and clients to make their own choices. This includes choices that we may not agree with, as clinicians. The desire of health and rehab professionals to help people sometimes results in diminished respect for their autonomy. Choosing not to participate in rehab, for example, is one way that patients may exercise their autonomy.  They may refuse efforts to convince them otherwise.  Sometimes, we as therapists cross that line and cajole a patient to participate without realizing we are taking away the patient's autonomy.

One question that comes up is, Does providing information without any attempt to influence a decision violate the principle of autonomy? This goes back to that question about refusals or what that person chooses to do or not to do. In those scenarios, patient education is important. You can provide education in a way that is not influencing or pressuring that person. Ultimately, if we provide the risks and benefits of participating or not participating in physical therapy, and the person refuses, then you take no for an answer. 

Nonmaleficence

This concept is extrapolated from the Hippocratic Oath, Do No Harm. This ethical principle is one of the oldest. It reminds us that if we can't help our patients, at the very least we have a duty not to harm them or make them worse off than they were before they sought our help. The harm here encompasses a wide range of harms, extending beyond the mere physical or psychological harm. It includes, for example, harm to one's reputation, liberty, or even their property. The questions of whose harm or which harm is open to a lot of different interpretations, especially when we're dealing with patients who might be unable to make their own decisions. Health and rehab professionals' opinions as to what constitutes harm may significantly differ from patients' opinions of what they consider as harm.

Beneficence

Beneficence stands for the duty to prevent harm to others. To remove harm from others and to promote good - isn't that why most of us therapists entered the profession in the first place? One's obligation to this moral duty ends where action can bring harm to oneself.  In the health and rehab context, beneficence means looking out for our patient's wellbeing. However, health and rehab providers can have very differing views on what is good for the patient. You may think that it's good for the patient to walk and to do their strengthening exercises, for example, but the patient may not want to do that. They may not want to walk, transfer, or do their exercises because they have fear of pain or fear of falling (or another reason). While we may consider something to be in their best interest, they may not consider it in their own best interest.  When this happens, we are at a discord.

Justice

Justice looks at ways of fairly distributing burdens and benefits in society and giving individuals their fair share. Fairness is a key element of justice. As more and more people compete for limited healthcare resources, the principle of justice takes a front seat in healthcare decision making. Principles of justice focus on the question of, who should get the resources? This includes an examination of whether some people deserve those resources more than others. It also looks at who is actually making those decisions. Justice and fairness in ethical decision making depend on a lot of contextual factors. These factors include religious beliefs, professional issues, legal issues, institutional policies, procedures or standard operating procedures, and others.  These factors can influence clinical decisions and choices.

Informed Consent and Veracity

This principle obligates all healthcare providers, not just therapists, to provide our patients with the benefits, the risks, and the potential risks of all proposed intervention strategies as well as non-participation.  By providing these details, patients can make a willing and informed choice in their care. On the bottom of your evaluation form, there is likely a statement that says, "patient was educated to risks and benefits" or something indicating that a patient has provided consent.  The vast majority of the time, we probably just check it and move along. This is important and we have to take it very seriously to ensure we truly are educating our patients.  The patients will base their consent on the specific information that we give them about that proposed intervention. Obtaining informed consent relies heavily on veracity or having truth to what we deliver.  Veracity is our obligation to speak and act truthfully and that impacts all communication with our patients. Truthful communication doesn't need to be harsh or condescending. Our communication needs to take into account cultural considerations as well as health literacy considerations of our patients.

Confidentiality

Confidentiality is rooted in the Hippocratic Oath, part of which can be translated as, "Anything I say 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."  All healthcare providers have a duty or an obligation to limit their access to information gathered in the course of treatment and keep that information strictly between the healthcare professional and the patient. There are some other ethical principles we'll discuss later that dictate some exceptions to this duty to keep patient information confidential. Based upon justice and beneficence there are certain laws that mandate breach of confidentiality to protect citizens, such as child abuse laws, mandatory reporting laws, and elder abuse laws. These laws are designed to protect individuals who may be mortally threatened.

Fidelity

Fidelity is closely related to confidentiality but refers to the moral duty to keep your promises and commitments. Patients expect all healthcare providers and therapists to keep their explicit and implicit promises, including the promise to keep shared information confidential and to provide services ordered by a physician. There is a saying in customer service that if you promise it, you better deliver it, and I think that is important for therapists as well.  If we promise confidentiality, let's make sure that we're going to deliver it. If we've promised an intervention or a treatment or a follow-up, we must follow through on those obligations.

Duty

Duty refers to obligations that we have to others within our society. Sometimes those duties exist because of the nature of the relationship between the parties. For example, in therapy, when we start a patient-therapist relationship, we owe certain duties to that patient including the duty to provide a certain quality of care, a duty to provide confidentiality, etc.

Rights

Rights refer to the ability to take advantage of moral entitlement to do something or not to do something. Health care reform has ushered in an updated Patient's Bill of Rights. The Patient's Bill of Rights includes very specific rights such as the right to health insurance without regard to pre-existing conditions. There are other federal statutes that provide patients with very specific rights.  For example, we are all familiar with HIPAA, the Health Insurance Portability and Accountability Act, which states that patients have the right to receive a privacy notice.  States and even hospitals or other settings that have their own Patient Bill of Rights that grant the patient-specific rights or access. The best way to approach patient rights or resident rights is to follow that which is most strict. Follow whichever patient bill of rights is the most strict to ensure that at all times, you are protecting your patients.

Paternalism

Paternalism occurs when we fail to respect autonomy. When we act in a paternalistic manner, we act with disregard to an individual's right and substitute our own beliefs, opinions, and judgments for the patient's judgment. We may act without informed consent. We may act against the patient's wishes or under the guise of a desire to benefit the patient when that's not really what the patient wanted. People will justify paternalistic actions by claiming that they acted in the patient's best interest or they know best because they are the professionals. In healthcare, oftentimes this happens when the patient's wishes and the family's wishes differ from the healthcare provider's wishes. To take it down to a basic level, you can even look at your evaluation and goals. Whose goals are those that you established? Maybe you established a goal for walking, strength, balance, or pain. Is that the patient's goal or is that your goal as a therapist? We always want to respect the patient's autonomy, dignity, and wishes, regardless of our work setting.

Codes of Ethics

Before we get into the APTA Code of Ethics for Physical Therapists, I will first review the background and intent of ethics and codes of ethics.

Professional Ethics

Professional ethics incorporate those values, principles, and morals that go into professional decision-making. If professionals don't have guidance, values, or morals we can fall into trouble not just for us but for our patients, and for society in general. No one in a profession wants to see their colleagues making headlines because of unethical behavior. 
 
I recently taught a class where the participants had to go out and find an article where therapy was considered unethical. Participants found articles related to fraud, abuse, and other unethical behavior involving therapy. I was surprised that all of the articles were very recent, and as mentioned, no one wants to see members of their profession in these situations. We want to avoid ethical and legal problems. To do that, we instill our values to avoid and prevent unwanted behaviors that are unprofessional and unethical. As therapists, we're dedicated to a common purpose and we have common training. We draw from that training and from our professional obligation as a source of our ethical values.

Codes of Ethics

Professional codes of ethics have been designed and promulgated by the professional associations, to help guide behavior in circumscribed professional situations. Professional codes of ethics incorporate sets of rules or principles to express the values of the profession as a whole. If you are a member of the professional association, your membership extends to you an obligation, responsibility, and commitment to that profession to abide by its code of ethics.
 
A profession's code of ethics doesn't just apply if you're a member of the professional association; it applies to everyone covered by that professional association. Licensing boards and other credentialing agencies incorporate professional codes of ethics into licensure regulations or credentialing rules. If you have specialty certification they may embrace or promulgate their own code of ethics for those that they certify. 
 
Codes of ethics will help to promote the basic tenets of the profession. They codify the fundamental beliefs of the profession and the common moral values the profession chooses to protect patients and clients from harm. Codes of ethics give meaning to the uniqueness of what health and rehab professionals do.  They also create a bond between professionals to practice according to common a standard.  The goal is to protect the patients we serve, and society as a whole. Codes of ethics provide the basis, for the meaning of what it means to be a member of that particular health and rehab profession, in this case, physical therapy. It's a set of values that you need to incorporate into your moral and behavioral repertoire, in the same way, that you would incorporate social, cultural. or religious values into your repertoire.
 
Courts will all often refer to the code of ethics as a measure of proper professional behavior as an element of the standard of care that a professional is supposed to render. Remember, a professional code of ethics applies to all members of the profession, even those who choose not to join their professional associations. It's interesting to me that many people don't know what their code of ethics states, what their licensure law states, what their practice acts state. Rarely does a code of ethics provide you with an absolute guide to your behavior or to your decision-making.  What a code of ethics gives you is a starting place or a point of reference.  From that reference point, you can begin interpretation.

Unethical Practice

Unethical practice refers to the practice that does not conform to established professional standards. It also includes practices that range from those that are unreasonable, unjustified, ineffective, immoral, questionable, knowingly harmful, and knowingly wrong. All healthcare professionals can identify practices that we ourselves consider unethical. However, since we all arrive at our ethical analysis from different perspectives (e.g. social, religious, and cultural perspectives), not everyone is going to agree with our analysis. Unethical practices affect the patient, the health and rehab professions such as physical therapy, employers (because therapists are always a representation of the profession and of their employer), insurance providers, society, and more. Unethical practice can cause serious individual consequences and has potentially far-reaching social ramifications.  In professional journals and online at licensing boards, there are lists of individuals who have lost their license to practice because of immoral or unethical practice or were fined because they billed an insurance company inappropriately.
 

American Physical Therapy Association (APTA) Code of Ethics for Physical Therapy Personnel

 
In this section, I will review the APTA Code of Ethics for Physical Therapists, which you can download from APTA.  You may also find the Standards of Ethical Conduct for the Physical Therapist Assistant here.  

Purpose

The preamble of the code of ethics for the physical therapist (PT) delineates the ethical obligations of all PTs as determined by the House of Delegates of the APTA. The purpose of this code of ethics is to define the ethical principles that form the foundation of physical therapy practice in patient management, consultation, education, research, and administration. It provides standards of behavior and performance that form the basis of professional accountability to the public. It provides guidance for physical therapists who are facing ethical challenges, regardless of their professional roles or responsibilities. It educates individuals including physical therapists, students, other healthcare professionals, regulators, and the public regarding core values, ethical principles, and standards that guide the professional conduct of the PT and physical therapist assistant.  It also establishes the standards by which the APTA can determine if a physical therapist has engaged in unethical conduct.
 
The Code of Ethics is built upon the five roles of the physical therapist (management of patients, consultation, education, research, and administration), the core values of the profession, and multiple realms of ethical action. It looks at individual, organizational and societal types of actions. It is also guided by a set of core values: accountability, altruism, collaboration, compassion, and caring, excellence, integrity, duty, and social responsibility.
 
Fundamental to this Code of Ethics is the special obligation of physical therapists to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness, and enhance the quality of life. No code of ethics is exhaustive, nor can it address every single situation. You are encouraged to seek additional advice or consult in instances if you have a situation and you're not sure what to do after reviewing the Code of Ethics, It's not definitive and may not always give you the guidance that you need. Now we will review its principles.

Principle #1: Physical therapists shall respect the inherent dignity and rights of all individuals

The core values for this principle are compassion, caring, and integrity. This means that physical therapists need to act in a respectful manner toward every single person that we encounter, regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, and disability. The list could go on and on. We also need to recognize our own personal biases and make sure that we're not discriminating against anyone in practice, in consultation, research, administration, or education. I have provided a handout for this course that is a self-assessment tool to look through these various principles and see where you measure up. Sometimes self-assessments may uncover biases or stereotypes and provide an opportunity for you to identify and improve areas related to ethical and professional behavior.

Principle #2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients and clients

The core values here are altruism, collaboration, compassion, caring, and duty. This means that physical therapists need to adhere to the core values of the profession and act in the best interest of the patient over those of the physical therapist. The PT must provide services with compassion and caring behaviors that incorporate the individual and cultural differences of our patients. We must also provide the information necessary to allow our patients or their surrogates to make informed decisions about physical therapy care or participation in clinical research. Additionally, physical therapists need to collaborate with our patients to empower them in healthcare decisions. We must protect confidential patient information.

Principle #3: Physical therapists shall be accountable for making sound professional judgments

The core values here are collaboration, duty, excellence, and integrity. This means that physical therapists should demonstrate independent and objective professional judgment in the patient's best interest and informed by professional standards, evidence, practitioner experience, and patient values. We must take into account all of those elements. This principle looks at that intersection of research, patient expectations, values, ideals, and the therapist. We are the therapists and we don't know everything. We have to take all of those things into consideration when we're developing an appropriate treatment plan for our patients. We need to make sound judgments within our scope of practice. Within our level of expertise, we need to communicate with, collaborate with, and refer to peers or other healthcare professionals when necessary. We must not engage in conflicts of interest. We need to 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

The core value here is integrity. This particular principle means providing truthful, accurate, relevant information, and not making misleading representations. This principle means not exploiting persons that we have supervisory, evaluative, or any other authority over.  Those persons might be patients, students, or employees that we are supervising. We need to discourage misconduct by health care professionals, as well as report illegal or unethical acts to any relevant authority. For example, we must report suspected cases of abuse involving children or any other vulnerable adults to the appropriate authority. We must not engage in a sexual relationship with any of our patients, our supervisees, or our students nor harass anyone verbally, physically, emotionally or sexually.

Principle #5: Physical therapists shall fulfill their legal and professional obligation

The core values here are accountability, duty, and accountability. This principle means you must comply with applicable local, state, and federal laws regulations. In order to comply with those regulations, you have a professional responsibility to know those regulations. You have primary responsibility for the supervision of physical therapist assistants and support personnel. You need to know the rules related to that, in your state, in your organization, by your payer sources, and by your practice venue. We also need to encourage colleagues with physical, psychological or substance-related impairments that might impact their professional responsibilities to seek assistance. Additionally, if we have knowledge that a colleague is unable to perform his or her responsibilities with reasonable skill and safety, we need to report that to the appropriate person. The appropriate person maybe someone within our organization, a licensure board, or local authorities. In the event that the physical therapist terminates the provider relationship while the patient continues to need services, we must provide notice and information about alternatives for obtaining care.  

Principle #6: Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors

The core value here is excellence. This means that you need to achieve and maintain professional competence. This includes taking responsibility for professional development based on self-assessment and reflection, as well as on any changes that have come about in PT practice, education, and/or healthcare delivery technology. Physical therapists need to evaluate the strength of evidence and applicability of content presented during professional development activities before actually implementing content into practice. We also need to cultivate practice environments that support professional development, lifelong learning, and excellence. I am an educator by background and this principle is very important to me personally. Many times we think of completing continuing education (CE) just so that we can check the box off when we renew our licenses. However, this principle is not about CE to renew your license; it is about continuing lifelong acquisition of skills. More importantly, this principle is about making sure that you stay current with what's happening in your practice.  If you don't stay current, you are doing a disservice to your patients and potentially even placing them at harm. I think many people do not take this principle as seriously as they should.

Principle #7: Physical therapists shall promote, organizational behaviors and business practices that benefit patients, clients, and society 

The core values here are integrity and accountability. This means that we shall promote practice environments that support autonomous and accountable professional judgments. We shall seek remuneration or reimbursement as it is deserved and reasonable for services.  We shall not accept gifts that influence professional judgment.  We shall fully disclose any financial interest in products or services that we recommend to patients. Be aware of charges, and make sure that documentation and coding accurately reflect the nature and the extent of the services provided. Refrain from any employment arrangements that prevent you from fulfilling your professional obligations for your patients.  Do not accept kickbacks.

Principle #8: Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally

This principle's core value is social responsibility. Where and when possible, provide pro bono services to those who are economically disadvantaged, uninsured, or maybe underinsured. Advocate for reducing healthcare disparities and healthcare inequities, particularly as it relates to culture. Improve access to health care services, and address the health, wellness, and preventative care needs of people. We need to be responsible stewards of healthcare resources and avoid overutilization and underutilization of services.  We need to educate members of the public about the benefits of physical therapy and the unique role of the physical therapist in the healthcare continuum. You can think of this as offering the right services at the right time, provided by the right person.
 
Later in this course, we will revisit these principles and review examples of unethical behavior.

Licensure

 
Licensure provides another standard of conduct for therapy practitioners. Each state controls licensure through state laws and regulations; requirements vary from state to state. You need to understand the rudiments of licensure in order to practice within legal and ethical parameters. States enact licensure laws to protect the public. To meet that purpose, they usually prescribe some type of behavior that you need to follow within the state. State licensure often incorporates the professional association's code of ethics. Licensure laws or practice acts set the minimum standards for licensure and re-licensure to ensure competent practice.
 
Licensure laws will also enumerate penalties for those who participate in behaviors that they prohibit. The disciplinary actions refer to assigning penalties for unacceptable behaviors. Violating the state's licensure laws subject one to a disciplinary process, which will vary from state to state. The penalties can range anywhere from disciplinary action, to fines, to suspension of your license, to revocation of one's license. I recently read about a therapist who lost their license to practice in a state and they lost their certification ability to practice in any state.  This person spent all those years in school to become a therapist and now they can never practice again.
 
Although the specific, enumerated prohibited behaviors vary from state to state, there are some prohibited behaviors that fall under most state licensure laws or practice act. Those behaviors are sexual relations with a patient, accepting kickbacks, failing to report a change of address to the licensure board, promoting practices of the profession by unlicensed persons, and taking advantage of patients. 
 
Read your licensure law, know your licensure law, and know your practice act. Know what your practice act contains as well as what it prohibits. The practice act can answer a lot of questions and familiarity with it can help you to stay out of trouble. I'm very surprised when individuals don't know what their state practice act states with regard to continuing competence activities, supervision guidelines, or what documentation needs to be in place regarding supervisory relationships. It is your professional responsibility to know what is in your practice act and certainly to follow it. I'm licensed in several states and I keep my practice acts saved on my desktop so that I can refer to them at any time.

Behaviors Subject to Disciplinary Action 

This list is not all-inclusive and could vary from state to state. I will keep repeating this: read your licensure law, read your practice act, and understand what behaviors are acceptable and not acceptable in your particular state.  The second half of the course on jurisprudence will be more in-depth on specific rules and regulations.  
 
Some behaviors that may subject a licensed therapist to disciplinary action include:
  • abuse of drugs or alcohol
  • conviction of a felony
  • conviction of a crime of moral turpitude (example: sex offense, extortion, embezzlement, etc.) 
  • conviction of a crime related to the practice of the profession for which one holds the license
  • practicing without a prescription or referral if one is required by your state practice act or by the payer
  • practicing outside of the scope of your practice act or using interventions for which one is not certified or trained
  • obtaining a license using fraud or deception

We do sometimes see individuals deliver intervention requiring specialty certification who do not have that specialty certification. ​An example of obtaining a license using fraud or deception would be purposely giving an incorrect address or using someone else's credentials to try to get a license. I personally know of an instance where this occurred.

More behaviors that may subject a licensed therapist to disciplinary action are:

  • gross negligence in practicing your profession
  • breaching patient confidentiality
  • failing to report a known violation of a licensure law by some other licensees (example: you saw something and you never reported it)
  • making or filing false claims or reports
  • accepting kickbacks
  • exercising undue influence, over your patients or your clients
  • failing to maintain adequate records

What constitutes adequate records will depend on the state; that can be anything from documentation to supervisory records.

More behaviors that may subject a licensed therapist to disciplinary action are:

  • failing to provide adequate supervision required for an assistant, a student, an aid or a tech
  • providing unnecessary services
  • false deceptive or misleading advertising
  • practicing under a name other than one's own legal name
  • failure to perform a legal obligation
  • practicing medicine when you are not a physician (example: diagnosing and prescribing)
  • performing services that are not authorized by the patient 
  • performing experimental services without informed consent (example: conducting research)
  • practicing beyond the scope that is permitted
  • failure to comply with continuing education (CE) requirements mandated by the state
  • failure to notify the licensing board of an address change (this may result in failure to renew)
  • inability to practice competently

Regarding failure to comply with CE requirements, there is something important to note. You may have completed the required continuing education, but if you are audited you must have records of it.  Always keep appropriate documentation and records for yourself as well as for your patients or supervisory situations.

Fraud and Abuse

I work in an industry where Medicare pays for the vast majority of our services. When we hear about ethical concerns and ethical issues, fraud and abuse is generally front and center. 

Abuse

In addition to licensure, other laws impose legal duties and obligations upon healthcare professionals. For example, an obligation may be to report a suspected abuse of a child, a spouse, or an elder. In an effort to protect citizens, many states go beyond prohibiting abuse. They require us to report suspected abuse. Some states require that only physicians report, while others extend that requirement to other healthcare providers, as well as to teachers, daycare workers, and other professionals. Know your state-specific requirements and whether or not you are a mandatory reporter.  If you are, mandatory reporting of abuse would then serve as an exception to any confidentiality requirement.

Fraud

Fraud occurs when an individual makes a misrepresentation or lies in order to induce an entity or individual to either do something or to refrain from doing something. In the therapy context, fraud most often occurs in the context of billing and documentation. Some common misrepresentations in therapy include: billing for services that were never provided; billing for more services than were provided; billing for non-covered services; backdating of documentation; and fabricating notes for visits that were never made.

Medicare Fraud and Abuse

Medicare fraud and abuse occur when a provider of therapy services knowingly or willingly lies in order to get paid. Medicare covers a lot of different settings and entities and this issue extends to Medicaid as well. Medicare abuse occurs whenever Medicare pays or some other payer pays for an item or a service that it should not be paying for. It also occurs when a provider bills an insurance entity for services that are not medically necessary.  his applies to all insurance, not just Medicare. The Office of Inspector General (OIG) fights Medicare fraud and abuse through tasks forces and audits. Many practice acts and codes of ethics require that therapists report any sort of illegal activities like Medicare or insurance fraud. If you fail to report the illegal activity, in addition to violating your own, professional code of ethics and your practice act, you can face federal criminal charges of conspiracy.

Acts Prohibited by Medicare

You might be thinking that you don't practice in an area that follows Medicare guidelines. The reality is that Medicare is probably the strictest payer that we see in the United States and many insurance companies and other state agencies follow Medicare guidelines.
 
Acts prohibited by Medicare include:
  • making false claims for a payment
  • making false statements for payment
  • billing for visits never made
  • billing for non-face-to-face therapy services
  • billing for one-on-one visits when group therapy or concurrent therapy was provided
  • billing for services that were not provided by a licensed provider
  • billing for therapy codes that reimburse at a higher rate than the code for therapy that was actually provided (this is called upcoding)
  • paying or receiving kickbacks for goods or services
  • soliciting for or paying/receiving payment for patient referrals

The Health Insurance Portability and Accountability Act (HIPAA)

HIPAA relates to the principle of confidentiality. I'm always surprised when I find that people are violating HIPAA and they don't even realize it. I will share a personal experience. Last week, I was in the hospital for a test as a patient. While I was preparing for my own test, another patient on the other side of the room was being interviewed and screened by a healthcare professional.  I could hear the whole interaction including confidential information the health care provider was asking the patient to divulge while I there in the same room.  HIPAA has been around for some time, yet providers still forget to maintain the confidentiality of Protected Health Information (PHI).
 
HIPAA is a federal law that protects the privacy of patient health information and provides for the electronic and physical security of PHI. It prevents healthcare fraud and abuse and simplifies billing and other transactions. It should, in theory, reduce health care administrative costs. The HIPAA Privacy Rule sets forth standards, on maintaining the privacy of PHI. The HIPAA Security Rule requires the security of electronic forms of PHI (known as e-PHI) and defines the standards to implement safeguards to protect e-PHI.

Does HIPAA apply to me?

Yes, it absolutely does. HIPAA requires that we train all workforce members about our HIPAA policies and procedures that may affect the work that you do. These rules apply to you when you look at, use, or share PHI.  The HIPAA law applies to "Covered Entities", which include: individual healthcare providers; health plans like Medicare or Medicaid, insurance plans; and clearinghouses for electronic billing. It also applies to "Business Associates" - the organizations that use and disclose health information to provide services to Covered Entities.

What Information Must be Protected?

Protected Health Information is information related to a patient's past, present, or future physical and/or mental health or condition. PHI can be in any form: written (e.g., a soft chart); spoken (e.g. hallway discussion or a telephone conversation, etc.); electronic (e.g. email, Casamba, Optima Health records, etc.). The PHI is any health information that has a personal identifier. There are 18 different identifiers under HIPAA, examples include name, address, social security number, medical record number, health plan beneficiary number, full face photographic images, or any other image that could be utilized to identify a patient, all elements of dates except year (e.g., birth date, discharge date, etc.).  There are others on the list as well.

Patient Rights Under HIPAA

Patient rights under HIPAA include:

  • right to access their own medical records
  • right to request or amend or correct their records
  • right to an accounting of PHI disclosures 
  • right to request a restriction limiting access by others to their records
  • right to request confidential communications of their health information
  • right to file a complaint if they believe that their privacy rights have been violated
HIPAA issues are often in the news. Recently, I read about a parent who did not want their estranged adult child to have any access to their healthcare information or medical records.  The child visited the parent's healthcare facility in the community and asked questions about the parent and was given information about the parent. The parent filed a complaint and filed a lawsuit citing HIPAA.

Using and Sharing Patient Information

How can we share patient information - what are the best practices?  We can use health information for treatment, payment, and operations (TPO) purposes. Treatment means that medical professionals including physicians, nurses, therapists, and other providers can access a patient's record if it is required for treatment. What we can't do is access someone else's record. For example, if you see a patient across the clinic and they look familiar, but you're not treating that patient, you cannot go look at their medical record. You can look at a patient's record for the treatment that you're delivering to a patient. If you are treating a patient, you can share health information with other health care providers if it is going to be utilized for treatment or to coordinate care. Health information can be used for payment; we share health information regularly with Medicare, Medicaid, insurance plans, and other payers, for the purpose of payments and benefits determination. We can share health information for operations such as for quality assurance, training, and audit purposes.  
 
For purposes other than TPO, unless it is required or permitted by law, you must obtain written authorization from the patient to use, disclose or access patient information. An important term in this regard is "minimum necessary standard". For patient care and treatment, HIPAA does not impose restrictions on use and disclosure of PHI by health care providers. There are exceptions for psychotherapy information, HIV test results, and substance abuse information. In all other cases, HIPAA requires the user to access the "minimum necessary" amount of information to perform their duties and to only disclose PHI to those people who have a need to know. You may not discuss any patient information with anyone unless it is required for your job. 

HIPAA Security Rule Safeguards

This is an area where therapists get into trouble. When PHI is in electronic form, the HIPAA Security Rule requires that administrative, physical, and technical safeguards are established.
Administrative safeguards include the appointment of a company information Security Officer, security training, and developing policies and procedures to protect electronic forms of health information. Physical safeguards include things to protect the physical system and equipment such as data backup, proper storage, and proper disposal. Technical safeguards ensure the protection of health information and its transmittal and include things such as a strong user ID and password and automatic log off from a system.  Along these lines, you should never share your password.  Do not take medical records or health information out of our community.  Do not use external hard drives to store PHI or other technology that is not approved by your IT department.  Keeping health information secure is a part of your job.  Although this may seem very detailed, it is important because it is an area where therapists have had ethical violations due to breached confidentiality of the patient record or inappropriate sharing of patient information.
 
 
Figure 1. lists a few tips and strategies on how to keep health information secure that I will briefly review.
 
For secure faxing, always confirm the fax number, and enter it into the fax machine in a place that is secure. Pre-program frequently used numbers into the fax machine. You can also call and confirm the fax was transmitted and received. At one time or another, you have probably received faxes, emails, or texts that were not intended for you. When this happens, let the sender know you received the information in error and will delete it or shred it.  The onus is on you to ensure you protect confidentiality.
 
For safe emailing, do not open, forward, or reply to suspicious emails. Delete items in your spam folder frequently. Never text PHI.  Regarding Internet safety, do not access websites with questionable content.  If you work for an organization or facility that has an IT team, ask them about any suspicious items you receive. 
 
Use strong passwords and change them on a regular basis. As mentioned, do not share login information, ID, or passwords.  It has happened that due to password sharing, a therapist logged in to a system and did documentation under another therapists' name, or clocked someone else out for the day, or it appears that a therapist was on site for a day when they actually were not in.
Never share passwords as it can lead to these types of ethical violations in addition to HIPAA issues.
 
In terms of conversations, only discuss a resident's health information in private and confidential areas, and only with the resident or those who are authorized to receive that information.
This can be challenging because sometimes we are required to call on the telephone and provide additional information or follow-up.  In these situations, it can be hard to determine who is on the phone with us and to verify their identity.
 
Regarding therapy department security, use locked cabinets and file rooms. If you have soft charts, make sure to limit access to only those persons who should have access. Do not post anything on social media platforms including patient photos and patient information.  I will discuss more about social media later in this presentation.
 
When doing paperwork, discard papers with PHI in a secure way such as by shredding them. Do not leave paperwork sitting in the copier or fax machine.
If you have to walk away from a computer that has PHI, even for a second, log off.  You never know who may walk by that computer screen. I heard of a situation where a medical community had a shared computer that was used by both pharmacy and medical personnel.  There was an issue when the pharmacy did not log out, and someone else came by and altered documentation in the system.  You may think, "Why would anyone do that?".  Not everyone is as moral and ethical as you are. 
 
Do not ever remove records from your community. Store records in a confidential manner.  make sure you store them in a way that is very confidential. Building access is important.  Yesterday I was working at a facility where they had recently changed their security, and people were walking in behind the therapists at the front door.  The building required you to scan your ID to get in, and as the door was opened by one person, other people would walk in behind them. 
 
Whenever anyone asks you for information about a patient, verify those requests related to PHI. Make sure to get authorization whenever needed, to ensure you only disclose information to those who have a need to know. If you are not sure, it is professional to say, "Let me make sure I am able to share this with you." 

Fines and Penalties

HIPAA criminal penalties range from $50,000 up to $1.5 million in fines, and imprisonment up to 10 years.  HIPAA civil penalties may apply, with more fines if there are multi-year violations. Many states have also enacted medical information privacy laws. Violations, fines, and penalties may apply to individuals as well as healthcare providers. Imprisonment and action against your professional license may also apply.  Most employers may also institute corrective and disciplinary action, up to and including termination.
 

Resident Rights 

The terms resident, patient, and client are used interchangeably, so the terms resident rights and patient rights are also interchangeable. Resident rights began with the Nursing Home Reform Law of 1987.  This law specifically requires nursing homes to promote and protect the rights of each resident, with a strong emphasis on individual dignity and self-determination. Nursing homes must follow this law in order to participate in any sort of federal program.

These rights extend to many other venues. There are patient bills of rights in hospitals, outpatient clinics, and pediatric practice.  I will review typical patient rights in the following section.

Right to be Fully Informed

The patient needs to be fully informed of the services, charges for the services, and facility rules or regulations. This includes having access to written copies, which they can request at any time. Examples include state surveys and JCAHO surveys. The patient has a right to Ombudsman information or the address and telephone number of someone in their community that can help them if there's an issue. Patients have rights to know in advance of any changes such as room changes or changes in plans of care. They have a right to assistance if a sensory impairment exists. If you have someone who has difficulty hearing, they can get an amplification device; if they are deaf, they have a right to an interpreter.  If they speak another language, they have a right to an interpreter in their own language. They have a right to receive information - both oral and written - in a language that they understand. 

Right to Complain

Patients have a right to complain and present grievances without fear of reprisal. There needs to be a prompt effort to resolve the issue. They can file a written complaint or make a verbal complaint to anyone, and they need to know that no one is going to retaliate against them. I should note that patients also have a right to appeal their billing and to ask for what is known as a "demand bill". 

Right to Participate in One's Own Care

Patients have a right to participate in their own care and again, this extends to all venues.  They have a right to appropriate and adequate care, and to be informed of changes in their medical condition.  They have a right to participate in their own assessment, in their plan of care, in their treatment, and in their discharge. They have the right to refuse medication and treatment. They have a right to review their own medical record.  In exercising these rights, they must not be retaliated against. I was recently in the hospital and I did refuse a number of medications that they wanted to give me. I explained my rationale, and the providers indicated that yes, I had the right to refuse the medications.

Right to Privacy and Confidentiality

Patients have the right to privacy and confidentiality as we reviewed earlier in this course. Keep in mind that they have the right to privacy and confidentiality during treatment and when caring for their own personal needs, such as when using the restroom. At my treatment venue, we oftentimes stand outside the doorway of the restroom and ask, "Are you okay?" If you're peeking in on them it's not necessarily respecting their privacy.

Rights During Transfers/Discharges

This is specific to long-term care. Patients have a right to receive a 30-day notice of any transfer or discharge. The notice should include all details such as the reason, the date, the location, etc. They also have a right to appeal.

Right to Dignity, Respect, and Freedom

Patients have a right to be treated with consideration, respect with dignity.  They have a right to be free from mental and physical abuse, corporal punishment and voluntary seclusion, and physical and chemical restraints.  They have a right to self-determination and to have the security of their possessions. We hear frequently about people who went into a hospital or some sort of community and had possessions taken from them. 

Right to Visits (or to Refuse Visits)

Patients have a right to visits and to refuse visits. We are not in a place to say who is or is not allowed to visit our patients, whether those visits are from a personal physician, state surveyor, relatives, friends, or other organizations.

Right to Make Independent Choices

Patients have a right to make independent choices and personal decisions. These decisions include what to wear, how to spend their time, what to engage in as it relates to the therapy plan of care, choosing a physician, managing their financial affairs, and others.

What is Our Role in Resident Rights?

In all settings, we need to know the rights of our patients. We need to always protect their dignity and privacy - 24 hours a day, seven days a week. Communication is important: we need to speak to everyone respectfully and in a positive manner. While positive and respectful communication is not necessarily an ethical consideration, disrespectful or unprofessional communication could certainly call into question your ethics. We need to allow our patients to make choices about their care and respect their right to refuse. This is true when working with pediatrics and allowing the families, parents or legal guardians to make choices about their children's care. We need to listen to our patients and their family members who have concerns and make appropriate referrals when necessary to address their questions and concerns.  

 

Elder Abuse and Prevention

Elder abuse is an increasingly important concern given the demographic changes in our society with the growing aging population. We need to have an informed and enlightened social policy and awareness with regard to the extent and the magnitude of the issue. We need to look beyond protective services records and examine financial, medical, social, and long-term care areas for possible difficulties and solutions. When we look at elder abuse, we find there is an obvious breakdown in the health system and social system.

An elder is anyone who is 65 years of age or older.  Elder abuse is defined as acts of omission or commission by a person who stands in a trust relationship that results in harm or threatened harm to the health and/or welfare of an older adult. A caregiver in this situation is any person who has the care, custody, or control of or stands in a position of trust, with an elder or a dependent adult.  A dependent adult is an adult over the age of 18 or 21 who potentially has a developmental disorder or developmental delay.

In terms of prevalence, it is estimated anywhere between 2% - 10% of elders are abused.  Statistics show that 90% of the abusers are known to the victim.  We may think of abuse as it pertains to children but we need to be attuned to the signs of abuse for all of our patients, regardless of their age. In most states, we are mandatory reporters whenever abuse is suspected. 

Elder Abuse Indicators

Here is a listing specific to elder abuse, and I will provide some further details:

  • physical abuse
  • sexual abuse
  • emotional abuse
  • neglect
  • abandonment
  • financial exploitation
  • self-neglect

Physical abuse indicators are injuries that are unexplained, or explanations for injuries are implausible. This also applies to abuse with children. With sexual abuse, the patient may express fear of being touched or display inappropriate modesty on evaluation.  With emotional abuse, they may be evasive, anxious, or hostile. With neglect or self-neglect, they may present as dirty, wearing inappropriate clothing, have an odor, or show poor hygiene. With self-neglect, there is self-imposed isolation, or they may have a marked indifference. Financial abuse is one we are seeing more often, and this is where adult children are taking advantage of their parents. The parent may not always speak up; they may have fear, anxiety, or provide vague answers when questioned about their personal finances. There may be a disparity between assets and appearance and general condition.  With financial abuse, indicators also include failure to purchase medicines or medical assistive devices, failure to seek medical care, or failure to follow medical regimens.

The Elder Justice Act

There is a very significant reporting structure with regard to elder abuse. As a healthcare practitioner, if you witness anything that could potentially be construed as elder abuse, you have a duty to report. You have a duty to report any suspected acts involving resident mistreatment, neglect, abuse, crimes, misappropriation of resident property, or injuries of an unknown source. The vast majority of the time, the elder lives in some sort of facility or community establishment like a nursing home or Assisted Independent Living facility.  Each facility has a reporting structure. They have to report any reasonable suspicion of a crime against a patient, to the Secretary of the US Department of Health and Human Services (HHS) and to law enforcement authorities in the political subdivision where that facility is located. 

There are specific timeframes for reporting, as well. If the events that cause the suspicion of a crime result in "serious bodily injury", the report by the facility must be made to HHS and law enforcement immediately, but no later than two hours after forming the suspicion. If the events that cause the suspicion of a crime do not result in "serious bodily injury", the report must be made by the facility to HHS and law enforcement authorities not later than 24 hours after forming the suspicion. Serious bodily injury is defined as one involving extreme physical pain or substantial risk for death; protracted loss or impairment of a bodily member organ or mental faculty; or an injury requiring medical interventions such as surgery, physical rehabilitation, or hospitalization.

Legal Issues

Malpractice

We'll start this section with a discussion of malpractice. Most claims of malpractice rest with the contention on the theory of negligence.
 

Negligence. Negligence occurs when the therapist's conduct falls below an acceptable standard of care for the profession. With negligence, you need not have intended to do something poorly. Negligence concerns itself with your conduct, not your state of mind. In other words, what matters is what actually what you did, not necessarily your intention.

Under the theory of negligence, in order for an accuser to prove that a therapy professional was negligent, there were need to be proof of these four elements:

  1. A relationship between the parties must exist that creates a duty to act in a particular way.
  2. Conduct fell below the professionally reasonable standard of care, thereby breaching that duty to act in a particular way.
  3. Breach of the standard of care caused the damages suffered.
  4. The person must prove that he or she, actually suffered actual harm or damages.

Sometimes, it is very difficult to justify negligence because all four of these elements need to be in place.

Discrimination Laws

Discrimination laws raise legal and ethical issues for health and rehabilitation professionals, particularly in relation to patient issues and student issues, including patient treatment and education. Laws exist that state that we cannot discriminate the services or the supervision based on age, race, disability, religion, nationality, sexual orientation, marital status, and others. While these are the typical things mentioned in discrimination laws, refer to your state practice act for specifics in terms of exactly what is included.  This relates back to the initial ethical principles we discussed, specifically, that we need to treat everyone fairly and equally.

Whistleblower

The term "whistleblower" is used to describe a person who exposes an activity that's deemed illegal, unethical or incorrect. When an unethical or an illegal situation occurs, you as the physical therapist have an ethical obligation to act as the whistleblower.  You need to decide to whom to report the incident. Every situation is complex and involves more than one person, more than one circumstance, and more than one context. Often, people do not report incidents because they fear retaliation or prejudice from co-workers or superiors. The good news is that there are laws to protect whistleblowers such as the Whistleblower Protection Act, that the US Congress passed in 1989, which provided protection for federal employees. Sarbanes Oxley protects non-federal employees when reporting such incidences. Currently, 48 states have whistleblower protection laws. Many companies have their own reporting policies, and you need to familiarize yourself with the laws in your state and organization. In some instances, such as the Medicare whistleblower laws, the whistleblower receives a percentage of recoupment if what they reported is found to have truly occurred.

Mandatory Reporting

Mandatory reporting primarily refers to abuse, specifically child abuse. As state-licensed healthcare workers, you are a mandatory reporter of abuse. All 50 states have specific guidelines on who are mandatory reporters and the procedures for reporting, so again, refer to your practice act. The exact type of abuse that you as a PT are required to report will vary from state to state. Each state has its own unique language and requirements for reporting. 

Common Ethical Issues

Now I will discuss common ethical issues that occur in many venues. Some of the issues I will discuss are specific to long term care, as many ethical concerns that are reported to state and national associations are from the long term care sector.

Documentation Lapses

Documentation issues are common. Documentation issues include when a supervisor requests that you sign off on documentation for patients that you didn't evaluate or you didn't treat. In many settings, mandatory documentation is required. If a supervisor asks you to document something for a patient you never actually treated, what are you supposed to be?  An ethical issue may arise regarding supervision if you are requested to sign off on a student or an assisted-provided treatment that you didn't actually supervise. Disagreements about the time needed to complete documentation properly are common. Providers may have a certain productivity standard and there may be discord between what employers require and what a therapist is reasonably able to do.

Employer Demand

The most common employer demands are high caseloads, tighter time limits, higher productivity quotas, and a rejection of a therapist's independent judgment. These demands can sometimes tempt you to act unethically. Individuals who find themselves in these positions often feel that they do not have a choice of they will be terminated.  Part-time or PRN therapists feel that they will not be asked back if they do not succumb to these demands. That outcome does not necessarily have to be the case.

Use of Supervision and Support Personnel

Ethical issues arise with the use of supervision and support personnel. Support personnel are used in many different settings and go by many different terms: therapy assistant, aid, tech, rehab tech, etc. Preparation of support personnel may vary considerably and tasks that are performed by support personnel vary widely.  They may or may not be regulated by state laws or regulations; their activity may or may not be recognized by various funding sources or funding programs. They may or may not hold credentials. For all of these reasons, it is critical that you know your state practice act as well as the guidelines from your professional association. Most importantly, know your pair coverage guidelines as well as the guidelines for your particular work setting. In some settings, you can use a rehab tech and in other settings, possibly you cannot. It is your professional responsibility to utilize support personnel appropriately. Furthermore, it is your responsibility to ensure that anyone under your supervision, behave in an ethical manner.  Engaging in an ethical manner includes not engaging in activities outside of their level of training, their experience or their competence. We cannot delegate something to support personnel that is outside of their scope of practice and/or competency.  We must ensure that what we delegate is carried over in a manner that will benefit the patient, which relates back to beneficence. 

Impaired Practitioners

Every practice setting may have impaired practitioners. Impairments range from untreated or undiagnosed mental health issues to all types of substance abuse. I will share an example from my personal experience. Many years ago, I worked in a clinic where one of our clinicians was abusing drugs. It was a scary situation that I would have never expected to encounter in my career.  Issues surrounding impaired practitioners can have legal implications as well as ethical implications. In this case, it was both a legal and ethical issue. Later, I learned that the particular clinician who was abusing drugs was incarcerated. 
 
If a colleague is impaired, it is a liability to the patients and also to you; the liability increases with time and opportunity. It is a complex ethical dilemma that you will likely not take on by yourself. It is a difficult situation and there is rarely a zero risk option. Even doing nothing poses an ethical risk. Your best path is to take seek ethics guidance - from Human Resources, your professional association, or other resources.

Student Supervision

The most common complaints reported to state and national organizations are from students. Students may indicate a failure of their mentors to appropriately supervise them or to demonstrate appropriate ethical behavior. Supervisors may complain that students demonstrate careless attitudes towards delivering treatment and professional services. This is not only an ethical issue but also a professional issue.
 
If you are supervising students, you are bound to honor the responsibility to hold paramount the welfare of the persons you serve. It is your responsibility to ensure that services are provided competently by students under your supervision. You cannot delegate the responsibility for clinical decision-making and management to students; those are still your responsibility as the certified individual. As part of the education process, the student may make client management recommendations and decisions pending review and approval by the supervisor. 
 
Furthermore, the supervisor needs to inform the client or the client's family of the qualifications and the credentials of the students involved in the provision of clinical services. We cannot pass off a student as if he or she were a fully licensed and credentialed therapist; we have to let them know that the person is a student. You need to provide no less than the level of supervision that is outlined in your current professional standards. You must increase supervision as needed based on the student's knowledge, experience, and competence. For example, a guideline may say that the student does not have to have a line of sight supervision, but you would provide line of sight or more supervision if the student is not competent to be without it.  You are also required to document the amount of direct and indirect supervision provided to students. You must design and implement procedures that protect client confidentiality. And, it is unethical for you as a supervisor or a therapist to approve or sign off for clinical hours where you did not provide the supervision.

Confidentiality

We have already discussed confidentiality but I would like to mention some issues with regard to record management. Common ethical issues arise with records storage, ownership, and retention. Consider who has access to patient records, statutes of limitation, and transferring information. Many entities today are looking at meaningful use measures and coordinating electronic medical records (EMRs) between the levels of service. Transferring information in a HIPAA-compliant, encrypted manner is important to these efforts.  Other ethical issues that arise in this area are requests for information by someone other than the client, and the use of client records for research, maybe without the consent of the patient.

Client Abandonment

Examples of misconduct related to client abandonment are:

  • 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
These issues may occur for a variety of different reasons, such as when a therapist leaves a practice to pursue another career opportunity or to relocate.  There is nothing unethical about terminating a relationship with an employer, but you need to maintain your focus on the welfare of the clients.  You need to give adequate notice to prevent those treatment disruptions. Even when therapists give adequate notice, employers may pressure or threaten the departing clinician to either stay or give unreasonable amounts of notice. It is unethical to try to exert that moral pressure on the clinician to continue once they've indicated their plans to depart.
 
Be mindful of the fact that your departure could result in clients being left without the appropriate care. When you leave a caseload without coverage, it is called client abandonment. Prior to your departure, you need to make your best available efforts to provide for continuing care. The more seamless it can be, the better.  In addition to providing sufficient notice and providing an interim plan, are documentation considerations. Failing to complete any reports, billing slips, required paperwork, or withholding paperwork are ethical issues. If the clinician successor does not have access to the entire record, you set them up for failure. Removing materials, records, protocols or any other materials without the consent of the facility or the organization are further examples of misconduct.  Do not malign the facility or organization in the presence of the clients, and do not recruit clients to your new employment setting.
 
If requested, assist the organization with recruiting your replacement and offer to participate in the orientation with that replacement if possible. Professionalism goes a long way.  Sever professional ties amicably.  Employers should also cooperate in every way to safeguard the well-being of the clients. When a clinician's departure has been precipitated by difficulties in the workplace, there is an increased potential for behavior that violates those principles of ethics and the code of professionalism. Do not engage in behaviors that are retaliatory or slanderous. Angry, spiteful words, obstructive actions, and uncooperative behavior may harm your clients and will reflect poorly on you and your profession. If an employee is dismissed for cause, it is the employee's responsibility to terminate with the dismissal, and the facility assumes all the responsibility for seeing that the clients suffer no harm.

Reimbursement for Services

Common ethical issues regarding reimbursement for services revolve around intent, fraud, and misrepresentation. Misrepresenting information to obtain reimbursement or funding, regardless of the motivation of the provider, is an ethical issue. Accurate documentation is critical and is the responsibility of the person who is providing services. Regardless of the manner in which the bills are submitted for reimbursement, you must ensure your documentation supports everything that you do.
If you are providing treatment, avoid misrepresenting information about the nature of the treatment even if you believe that you have the patient's best interests in mind. Along these lines, using the therapy code for an individual treatment when group treatment was actually provided is an ethical violation. You cannot select a code solely for the purpose of attaining reimbursement.
 
Similarly, to obtain insurance coverage when it is not otherwise available, you might report the patient's physician or referral source when the patient was not referred by that physician - this is an ethical violation. Do not document or submit bills for services that never occurred. It is also your responsibility to remain current with payment policies and updates from all payers. That can be challenging because healthcare is changing rapidly.
 
Another ethical issue related to reimbursement is providing services when there is no reasonable expectation of significant benefit for the person who is being served. You cannot provide services when the prognosis is too poor to justify professional treatment.  If you continue to give treatment anyway, you are exploiting those who are being served regardless of whether the services are undertaken for the purpose of reimbursement or another reason. In addition, you cannot exaggerate the extent of improvement to obtain reimbursement.  The point here is that you should deliver the right services at the right time to the right person for the right reason. Do not continue treating someone if there is no reasonable benefit, just because the patient or family asked you to continue treatment. 
 
Scheduling services more frequently or for longer than is clinically necessary or reasonably necessary is another ethical issue related to reimbursement. Again, everything we do has to be based on the clinical need of the individual rather than any availability of funding from payers. Requiring staff to provide more hours of care than can be justified by a particular payer is also an ethical issue. We are oftentimes pressured to increase the frequency or the intensity of services to compensate for low patient census or high staffing (or other reasons), and this could be a violation of the code of ethics. Finally, providing complementary care for referrals or otherwise discounting care not based on documented need is an ethical issue. This is very different from pro bono services.  Fee alterations must not be provided based on referral sources or personal relationships. In a highly competitive marketplace, we might be induced to discount our rates to persons who are referred by a specific physician who makes a large number of referrals but we must avoid doing so. Likewise, we cannot alter our fees based on a favored referral source or accept kickbacks.

Therapy with Children

For all healthcare providers, not just therapists, issues can arise when promoting children's best interests in complex and resource-poor homes and social settings. It is problematic when you treat a child and the family is not following through with appointments or instructions, and you know it is maybe not the best environment for that child.  You may feel like sharing information with nonfamily members because the family member is not complying. There may be issues with unclear relationships, so you don't know who is in charge. In these situations, you must use your resources to your best advantage, whether that involves calling in social services, a social worker, or your supervisor.  Get support to help you to figure out how to best navigate the situation.
 
Another issue with children is managing the therapeutic alliance with parents and caregivers. Parents may be distrustful about care; they may be angry about the rules or the limitations on care or reimbursement. You may look at the parenting techniques that they're utilizing, and view them as inadequate. You may suspect that some parents are abusing the resources that are available to them. You may encounter a disruptive parent who threatens to remove that child from services that you know the child really needs. Again, you will likely need support to manage these types of complex issues. 
 
There are some unique privacy and confidentiality issues in working with adolescents.  For example, you may receive a telephone follow up where you are not sure of the role of the person who is calling you and therefore it is an ambiguous relationship. A nonlegal guardian may request information about an adolescent. There may be a custody battle going on, or a situation where there is protection from abuse from a parent and you are not sure with whom you can share information.  Parents may be requesting confidential information that should not be shared.  Keep in mind that it is your responsibility to protect privacy and confidentiality and to avoid breaches of confidentiality, particularly in situations where we have mandatory reporting.

Common Ethical Issues - Additional Considerations

You will be confronted with the common ethical issues that I reviewed in every scenario, in every type of setting, regardless of payer, regardless of setting, and regardless of your type of patient.
 
Keep in mind that whether your interventions are restorative, preventative, or maintenance, you need to consider evidence-based practices. You need to make sure that you always document quantifiable and measurable changes and that your documentation is objective. Avoid making subjective remarks or opinions that may be disparaging, including toward another discipline. The paramount rule is for ensuring proper representation and connection with diagnosis and treatment is that professionals follow their best clinical judgment. Follow your best clinical judgment in formulating diagnoses, prognoses, and treatment plans. Present the information for reimbursement accurately, and consistently with your diagnosis and treatment plan. Do not alter a diagnosis or a treatment plan for the sole purpose of getting more payment, a bonus, etc.  

Resolving Disputes

Disputes and complaints can arise even in the best professional relationships, whether the parties involved are employer and employee, colleagues, health care providers, patients, or clients. Determining how to address disputes and/or ethical issues requires consideration of many different factors. There are many different options to resolve disputes, and not every single option will be appropriate for every situation. Note, too, that third party involvement is not always the most effective way to resolve disputes and it is not always required. Depending on your situation, after examining all of the options, it may be beneficial to discuss the dispute with legal counsel. In other cases, it may be best to go back to seek counsel from a colleague or trusted employer, family member, or friend. 

Examine the Situation

First, you need to examine the situation. If you believe that the matter may give rise to legal or ethical considerations and you are thinking of involving a third party, consider whether you know or can obtain all of the facts. For example, you may need to obtain documents protected by privacy laws or that may only be uncovered by contacting individuals with first-hand knowledge of the situation. Knowing all of the facts may impact how you proceed in your scenario.

Review Laws, Rules, and Regulations

Next, you need to review all of the applicable laws, rules, and regulations. As discussed, licensure is required in every state where physical therapists practice, and you need to practice within the scope of your state physical therapy practice acts. You need to review those acts, along with any accompanying rules and regulations, to assist you when it comes to legal and ethical issues. In addition, you have to consider federal laws, and federal rules and regulations. An example of federal law is privacy.  If privacy may have been violated, it may impact your decision on whether or not to file a complaint with Health and Human Services.
 
For any matter that raises ethical issues, examine your applicable state practice acts that include language addressing adherence to ethical standards to the physical therapy profession. Depending on the language in those acts, failure to adhere to the ethical standards of the physical therapy profession may be grounds for discipline under state law. In addition, review the APTA Core Ethics Documents, which include the Code of Ethics for the Physical Therapist, Standards of Conduct for the Physical Therapist Assistant, and the accompanying guides for conduct. Review those documents for your ethical obligations.

Contacting a Third Party

Should you contact a third party when you have ethical issues or dilemmas? It is challenging to determine what, if anything, you should do about these matters. Ethical matters can be very complex, particularly when involving a third party. You may reach your own conclusions about whether something is legal or ethical but a court, agency or other authority may engage in their own analysis of those same facts. It can be a challenge, if not impossible, to know the conclusion that will result from the third party's final analysis. Therefore, you may want to consider the time and the cost of obtaining a decision from a third party and whether that decision will actually assist you in achieving a resolution. Alternately, you may talk with a colleague, a physical therapist or physical therapist assistant, or someone you trust.
 
One way to resolve that dispute is to talk about the issue of concern with someone else. Often two parties can resolve the dispute and reach a resolution without the need of involving someone else. In addition, by engaging in a dialogue, you may learn information and better form an understanding of the situation.
 
You might ultimately seek the advice of counsel to assist in determining how to proceed with an ethical matter. Counsel can help you to examine the facts, and provide guidance on applicable laws, rules, and regulations. They can confidentially provide legal assistance or guidance tailored to your unique set of facts.
 
You may choose to address the circumstances or the issue with the entity that employs the physical therapist or the assistant. Hospitals and other groups have a grievance procedure you may choose to follow.  You could file a complaint with a state licensing board; each licensing board will have a different procedure to follow. They have extensive investigative abilities, including the abilities to subpoena records. They also have the authority to take action against a physical therapist or an assistant's license. More information can be found on the Federation of State Licensing Boards website, www.fsbpt.org.
 
There may be other third-party agencies that you can contact. For example, if the situation warrants it, you may contact the Better Business Bureau or the Medicare fraud hotline. If the issues involve HIPAA, you may consider contacting the Department of Health and Human Services.
 
In addition, APTA has a very specific process to file an ethics complaint against an APTA member, physical therapist or assistant. The first step is sending a signed, written complaint to the APTA chapter in your state; they do not accept email. Very detailed information is required for them to make a discretionary decision about whether or not to issue charges. They can only take action if the PT or the PTA is actually a member of APTA and therefore any action, reprimand, probation, suspension, etc. is limited to that person's membership in the association.

Issues Affecting Elderly

 
Some of the issues affecting elderly adults are: lack of resources, scarcity of providers, financial barriers, and cultural barriers and biases. These issues are seen in many different venues with other populations as well.

Cultural Biases

It is very important to address cultural barriers and biases.  As therapists, we need to consistently examine our own personal biases and strive to change those in our daily practice. You may not think you have biases but I can almost assure you that you do.  Biases and assumptions are not necessarily a bad thing unless you provide differential care based upon them.
 
We need to examine our beliefs and our values. How do you react when you hear biases expressed by other healthcare workers or by your patients or their families?  How much does that influence your decision to give care, withhold treatment, or to obtain or not obtain informed consent? It certainly has an impact. Examining your own values and beliefs is important in ethical issues because they impact the care that we provide as well as when, where, and how we provide it.
 
Regarding the elderly population, one common stereotype is that all elderly people are frail, and therefore we believe that we need to protect them. We may not provide all of the necessary therapy treatment to address their issues. In the professional relationship, the therapist should practice with compassion and respect for the inherent dignity and uniqueness of every individual. We need to always put the patient's best interests at heart and not let any biases regarding age impact our decision making. The principle of respect for individuals seems intuitive. However, that principle implies that we, as therapists, value the individual's beliefs and wishes and we must consider them in the therapist-patient relationship. It is sometimes not easy to do in practice. One example is when a conflict arises between what the patient needs to know and what you, other healthcare workers, or family members believe the person should be told. It is an ethical issue around truth-telling and informed consent and we need to examine our biases in these areas.

End of Life Wishes

Young (2013) discusses end of life care, and decisions to treat against the wishes of a dying person. These issues may also arise when people are facing terminal illnesses. Have you ever known family members or other healthcare workers persuade someone to prolong (or even start) treatment when it was expressly against the wishes of the dying person? Have you ever been in a situation where we fail to ask in a timely manner what kind of care that person actually wants? There are a number of issues about public policy related specifically to end of life care. Most of us examine these issues on a personal level. At the bedside, it's not uncommon for us to hear statements like, "We can't just let mom die", or, "Mom wouldn't have wanted to live like this".  It is fine when the families of the dying person voice those types of statements and the statements are reflective of the wishes of the dying person. If there is no conflict, it is within our scope of practice. But members of the same family often express conflicting statements or never asked the dying person's wishes related to end of life care. These are complicated scenarios because therapists can be caught in the middle. You may have the adult daughter saying one thing and the adult son saying another thing, and no one consulted the patient. In those types of conflicts, consider how the autonomy and self-determination of a competent dying person can be upheld and preserved. Our primary commitment is to the patient. When you have conflicting statements, remember, your first duty is to your patient. Secondly, your duty is to the family to help the family to respect and support the dying person's wishes. We can be patient advocates, advising and facilitating discussions about end of life issues to help individuals make informed decisions. Having discussions about end of life wishes early on in the treatment process helps to avoid being stuck in the middle wondering what the person's choices would be when the time comes.  

Lifestyle Choices

Lifestyle choices can raise ethical questions about individual client responsibility and preferences. Ethical questions around lifestyle choices may not always be obvious. How often do you discuss exercise, religious beliefs, or cognitive activities? Do you routinely screen for depression, for functional change, or cognitive changes? Or, do you wait until those symptoms become problematic? At a practice level, it's not uncommon for therapists to voice biases in these areas. 
 
Consider the perspective around elderly individuals. You hear people say, "If you live to be 80, you deserve to be able to do whatever you want". These commonly voiced beliefs can be based on stereotypes, and make health promotion harder to implement. Health promotion is often set aside, for a number of reasons. Technology focuses on health care rather than health promotion.  With staff shortages, resources for implementing health promotion may not be in place. The results from health promotion are not easy to document. However, as therapists, we need to collaborate with other healthcare professionals and the public in promoting community, national, and international efforts to meet health needs. We oftentimes forget adults in that health promotion. Young (2013) points out that despite the growing stress placed on health promotion, a large number of adults with chronic conditions linked to lifestyle choices are not included in positive health promotion activities. This is challenging for us as therapists; we need to be responsible for health promotion but we still need to honor people's choices and their dignity. Somehow we have to find a balance between the two.

Accountability

To whom is our accountability? Is it to the patient? If the patient is an elderly person, are we accountable to the family because the patient has serious problems? Generally speaking, the patient is our priority but we need to deal with the complex environment of the patient. In addition to a diagnosis of disease, we have situational diagnoses, the burden of the patient, and the burden of the family, that we have to consider in light of these ethical decisions. For example, think about a situation where there is a well-meaning daughter who took care of her father while also raising her own large family. Perhaps there were unreasonable demands on the part of the father, and he was quite capable of meeting those demands himself rather than at the expense of the needs of the young family. There is stress with that family situation. When we look at accountability, priority may be given to the family's needs in some cases while keeping in mind that our accountability is to the patient. The question arises of how far a family is obligated to respond to a demand of a parent for care and attention, particularly in old age. A dilemma and refusal could occur where despite devoted care to that parent, the care of the family becomes the first priority. Unfortunately, we also see situations where adult children reject the responsibility of taking care of a parent because they feel that they were not taken care of during childhood by that parent. Perhaps the parent was an alcoholic and the child felt mistreated. We see those dilemmas in families. There is no answer to these types of dilemmas; you do need to appraise the clinical facts, the social facts, and involve social services, or other disciplines.

Entering a Skilled Nursing Facility (SNF)

At times there is a significant disparity between the views of the elderly person, and that of the child or caregiver, or the authorities that are charged with the care of that person. You hear the saying, "It's for your own good" regarding moving to a SNF, but that is paternalism. Paternalism contradicts the person's autonomy, particularly if they have been minimally involved or not involved in the decision. A common example of paternalism is when the parent is told, "You can't manage on your own anymore, you can't be safe on your own, and I can't be with you all the time, so you need to go to a SNF."  The dilemma here is that there is often right and wrong on both sides.  The professional evaluation by a geriatric team then comes into play. If we want the transition to be a happy one, it needs to be handled delicately with careful judgment as to the wishes of that elderly individual. We must discuss decisions with the client in detail and make the decision best for the client and the family.  

Legal Incompetence

An elderly person may be demented such that they are unable to grasp the implications of decisions and declared legally incompetent. If the patient is declared legally incompetent, then the actual decision rests with the legal guardian who must weigh the implications of the family's standpoint in relation to the patient's interest. A problem arises when a person has not been declared legally incompetent and they are still able to make decisions, yet we take the decision-making ability out of their hands. In those situations, we need to look at the patient's needs, his or her physical condition and personality, and whether continued home care is possible. We need to look at how the patient's needs might be addressed by institutional care versus other options. What are the risks and benefits? Sometimes we actually do better to accommodate that person's wishes or their needs.

Analyzing Ethical Dilemmas: CELIBATE

The first method I will discuss for analyzing ethical dilemmas is CELIBATE, which is an acronym for Clinical Ethics and Legal Issues Bate All Therapists Equally.  
 
You may identify an ethical dilemma or have a gut feeling that something is wrong in a situation but are not sure what to do. When faced with these situations, you need to be able to respond rather than just react. We serve many different entities: ourselves, our patients, employers, the law, and our profession, just to name a few. How do you balance these often conflicting demands? Making ethical decisions and being able to effectively resolve ethical dilemmas requires a lot of effort, and can improve with training, self-reflection, and practice. The analysis of any dilemma involves this multi-step process and a lot of different sets of values that will guide your decision.
 
The CELIBATE method considers both ethical and legal issues.  There are 10 steps:
1. What is the problem?
2. What are the facts of the situation?
3. Who are the interested parties? They may be: facility, patient, other therapists, observers, payers, or others.
4. What is the nature of their interest?  Why is this a problem?  It may be: professional, personal, business, economic, intellectual, or societal.
5. Is there an ethical issue?  
  • Does it violate a professional code of ethics? If so, which section(s)?
  • Does it violate moral, social, or religious values?

6. Is there a legal issue?

  • Practice act/licensure law and regulations?  If so, which section(s)?
  • Review the checklist for possible legal issues: Legal Issues Checklist 

7. Do I need more information? 

  • What information do I need?
  • Is there a treatment, policy, procedure, law, regulation or document that I do not know about?
  • Can I obtain a copy of the treatment, policy, procedure, law, regulation or document in writing?
  • Do I need to research the issue further? What does the literature say?
  • Do I need to consult with a mentor, my manager, an expert in this area, or someone else?

8. Brainstorm possible action steps.

9. Analyze action steps:

  • Eliminate the obviously wrong or impossible choices
  • How will each alternative affect my patients, other interested parties, and me?
  • Do my choices abide by the applicable practice act and regulations?
  • Do my choices abide by the applicable code of ethics?
  • Are my choices consistent with my moral, religious, and social beliefs?

10. Choose a course of action (considering ethical principles and philosophies):

  • The Rotary Four-Way Test: Is it the truth? Is it fair to all concerned? Will it build goodwill and better friendships? Will it be beneficial to all concerned?
  • Is it a win-win?
  • How do I feel about my course of action?
I'll discuss a few details in regard to using this method.
 
The first step is what is the problem? Some people may see an obvious ethical dilemma that makes them uncomfortable, while someone else may look at the same situation and not see any ethical issue. Before you can even begin to analyze ethical dilemmas, you need to identify the problem. That sets the stage for the remaining analysis.
 
The second step is to examine the facts. The facts help you determine the interests of all the parties involved and to narrow down the action steps. The facts are not just your side of the story; there could be multiple sides of the story. Gather the facts from all sides.
 
The third step is to ask yourself, who are the interested parties? They may include; the facility, the patient, other therapists, observers, payers, the patient's family or caregiver, your supervisor, the rehab director, the administrator of your site or the CEO, the facility as a whole, the community or the setting that you work within, potential patients, potential employers, the federal government, the college that you graduated from, your professional association, the state licensing board, etc. The list can go on and on.  At times it may just be you and the patient. Look well beyond your circle of influence, as there may be ramifications further out.
 
The fourth step is to ask the question, what's the nature of their interest? Why is this a problem? Is it professional? Is it personal, business, economic, intellectual or societal?
 
The fifth step is to examine if there is an ethical issue. Did this violate a professional code of ethics and if it did, which section or sections? Does it violate a moral, social or religious value that perhaps someone holds? This inquiry requires you to carefully review your own professional code of ethics, your own moral compass and then compare this also to your professional code of ethics and professional responsibilities.
 
The sixth step is to determine if there is a legal issue. Did they violate the practice act? Did they violate the licensure law or regulations and if so, which section? At this particular point, you need to review all applicable state practice acts, licensure laws, and federal regulations. Use a checklist because it may not just be a licensure issue, it could be a criminal or civil issue as well. 
 

Legal items checklist. Download the Legal Issues Checklist here. Many of the items on the checklist have civil or criminal categories associated with them - for example, age discrimination, antitrust, assault or battery, child abuse, copyright violation, disability discrimination, elder abuse, and embezzlement. Insurance fraud is both a criminal and civil issue. There may be issues in the checklist that you do not understand, for example, gag clauses. During your ethical analysis, you will need to do your research to find out what they are and if they apply to your situation. Using modalities without training is an issue that occurs in our profession. Negligence may be an OBRA violation (Omnibus Budget Reconciliation Act), which applies in long term care communities. Patient confidentiality, plagiarism, sex discrimination, and having sex with a patient obviously have criminal and civil implications, as does sexual harassment, spousal abuse, theft, disclosing trade secrets, and treating without a prescription or referral. Again, refer to this checklist during your analysis.

The seventh step asks, Do I need more information? Is there a treatment, policy, procedure, law, regulation, or some document that potentially would help guide the decision-making? Can I get it in writing? It is important whenever possible to have documentation. You may need to do further research or refer to the literature. Consult your professional journals, professional guidelines, or the medical literature and see what it states about this particular issue. You may need to consult with a mentor, manager, other experts, or a third party. 

In step eight, you brainstorm all the possible action steps. In step nine, analyze those possible action steps and eliminate the ones that are obviously wrong or impossible. Look at how each and every alternative affects your patient, other interested parties, and yourself. Consider how your choices will abide by the applicable practice act, the regulations, and the applicable code of ethics. Are your choices consistent with your own moral, religious, and social beliefs?

Finally, in step ten you choose a course of action considering all of the ethical principles and the philosophies that are at hand. At this point, use the Rotary Four-Way Test (Is it the truth? Is it fair to all concerned? Will it build goodwill and better friendships? Will it be beneficial to all concerned?). Ask if it is a win-win and how you feel about the course of action.

This 10-step process is not an easy process. There are a lot of components, and oftentimes still a lot of gray areas in ethical dilemmas.

Case Study - CELIBATE Method: Terri

Let's look at an example using this CELIBATE method. Terri is a student at the Sunnyside Nursing Home and she has struggled throughout her entire student internship. Calling her performance marginal would be a compliment. As her supervisor, you've given her very specific feedback repeatedly, instructing her in ways that she can change her behavior. Unfortunately, Terri fails to heed your advice. At her midterm, her performance merited a failing grade. She is making errors on simple things like forgetting to lock the brakes on the wheelchair. She shows a disregard for patient safety precautions. You now approach her final evaluation and you are struggling with a failing final evaluation. Your boss, who is the rehabilitation director, looks over your shoulder and tells you, "Don't fail Terri - she has done her best despite her learning disability. Even though she really failed this internship, it's just too much trouble to give her a failing grade." Your boss also reminds you that the facility does not want to be sued for an Americans with Disabilities Act (ADA) violation. 
 
Should Terri fail her internship? You had absolutely no knowledge of Terri's learning disability until now. Let's go through all 10 of the steps.
 

Step 1 - What is the problem? The problem is the boss wants the supervisor to pass this student intern who demonstrates failing performance that does not warrant a passing grade. Most supervisors would feel some inner conflict and some discomfort in this situation.

Step 2 - What are the facts of the situation? Terri is a student at the Sunnyside Nursing Home. Her performance at midterm warrants a failing grade. Terri's supervisor provided her with adequate supervision, and ample specific feedback about ways to improve her performance in various areas. Terri failed to modify her behavior in response to the feedback that was given to her. Terri forgets to abide by many patient safety precautions, such as locking the brakes on wheelchairs during transfers. Terri's performance at the end of this internship still warrants a failing grade. The supervisor feels that Terri earned a failing grade and intends to fail her. The rehab director tells the supervisor not to fail Terri. At the end of the internship, the supervisor learns for the first time of Terri's learning disability. In assigning Terri a failing grade, the supervisor did not consider the learning disability. The rehab director indicates that the facility does not want a lawsuit.

Step 3 and Step 4 - Who are the interested parties? What is the nature of their interest and why is this a problem? The interested parties include Terri, who has a personal interest. She needs a job, she needs to pass, she does not want the embarrassment of failure. She wants a license and desires to practice therapy.  The supervisor is an interested party.  She has a professional interest and wants a competent student who will be a competent therapist. She wants her professional and personal reputations intact. She does not want one of her students to fail. There is a business interest here, as the supervisor needs to balance the facility management's needs with her duty to her patients and their safety. The rehab director has a business and an economic interest also. The facility is an interested party, and it wants to avoid possible litigation.  Additional parties include Terri's parents who paid for her education, Terri's future patients who want her to be a competent therapist, and Terri's future employers. The federal government maybe has a societal interest as they want to ensure that persons with disabilities are not denied opportunities. Terri's academic program may be an interested party, as well as other therapists at the facility who have witnessed the situation and will know if Terri obtains a passing or failing grade. Other fieldwork students at the facility may also be interested parties. Terri's professional association and the state licensing board may also be interested parties. There are a lot of factors at play.

Step 5 - Is there an ethical violation? Yes. Passing a student who has achieved a failing grade violates the code of ethics provisions addressing justice, veracity and likely nonmaleficence because this student could harm someone in the future.

Step 6 - Is there a legal issue? This would require a review of the state practice act, but there is likely an issue. Are there other possible legal issues? Yes, there are several possible legal issues, such as the ADA, filing a false report, violation of the practice act, negligent supervision, breach of contract between the school and the facility, and confidentiality of student records.

Step 7 - Do you need more information? Other helpful information might include knowing whether this is Terri's first internship or last internship? If it is the first, then maybe there is another opportunity for Terri to succeed in her next internship, and the supervisor might consider failing her.  In addition, the supervisor might need to familiarize herself with the ADA and the practice act. She might want to consult with someone else, the facility management team for guidance. 

Step 8 - What are all of the different possible courses of action? As you brainstorm, there are no right or wrong answers, even if they seem crazy, far-fetched, or impractical to the situation. In this case, the supervisor can fail Terri or pass Terri. She can call the academic program coordinator at the university and ask for guidance. She can research the ADA issue to determine whether or not a failing grade can be given. She can complain to the rehab director's immediate supervisor. She can call the police; she can call Terri's parents. She can contact the Justice Department that enforces the ADA and ask if failing Terri violates the ADA. She can consult with an ADA lawyer. She can discuss the situation with her spouse, or her religious advisor. She could quit her job rather than fail Terri.

Step 9 - Analyze the possible action steps. Eliminate the obviously wrong or the impossible choices, such as calling the police (since there is no crime). She would not contact Terri's parents or speak with a spouse or the clergy as that would violate confidentiality. Why would she quit her job? Perform this litmus test with all of the other choices. The supervisor needs to ask herself if the options abide by her moral and applicable code of ethics. 

Step 10 - Choose a course of action as determined by the contextual factors. In this case, the best options might be to call the academic program for guidance and/or another supervisor at the facility to get additional feedback before deciding on the ultimate course. Remember, the course of action should be a win-win for everyone, if possible. In addition, you need to feel good about the choice that you make given the situation you are faced with in ethical dilemmas.

Analyzing Ethical Dilemmas: RIPS Model 

 
The RIPS model is another model to analyze ethical situations. RIPS is an acronym that stands for Realm-Individual Process-Situation. It is a four-step model.

Step 1: Recognize and Define the Ethical Issue

In step 1, consider the realm, the individual process, the implications for action, the type of ethical situation, and any barriers.

Realm. Ask yourself, under which realm does this ethical issue fall? It may be an individual realm that is concerned with the good of the patient and is focused on the rights, duties, relationships and the behaviors between individuals.  It may be an institutional or organizational realm that is concerned with the good of the organization and focuses on structures and systems that will facilitate their particular goals. It may be a societal realm that is concerned with the common good of society in general.

Individual process. Does the problem appear to be a moral sensitivity, moral judgment, moral motivation, or moral courage issue?  Moral sensitivity relates to recognizing interpreting and framing ethical situations. Moral judgment is deciding between right and wrong actions. The moral motivation process is prioritizing ethical values, over financial gain or self-interest.  Moral Courage is implementing the chosen ethical action even though doing so causes adversity.

Situation. Then we go in and look at the situation. How do you classify this particular ethical situation? Is it a problem or an issue where important moral values, are being challenged? Is it a temptation which is a situation where a choice must be made between the right action and a wrong action where the wrong action may benefit the decision-maker in some way? Is it a silent situation where the key parties realize ethical values are being challenged but ultimately they do nothing about it? Is it a distress situation where there is a structural barrier to doing the right thing? With type A distress there is a barrier keeping you from doing what you know is right and with type B there's a barrier because something is wrong but you're just not sure what that something is. So you can't put your finger on what's wrong but you know something is wrong.

Dilemma. There are two or more correct courses of action that both cannot be followed. So you have to choose one or the other, you can't follow both of them. You're doing something right but you're also doing something wrong, in the course of doing something right. Most often, these involve ethical conduct, for example, honoring autonomy versus preventing harm and this may involve conflicting traits of the character. For example, honesty versus compassion, and the character of that individual who is making that decision or who is in that dilemma.

Step 2: Reflect

Step two of the RIPS model is reflecting and includes the following questions: 
  • What are the relevant facts and contextual information? 
  • Who are the major stakeholders?
  • What are the potential consequences intended or unintended?
  • What are the relevant laws, duties, and ethical principles?
  • What professional guidance do we have?
  • What do the "right versus wrong" tests suggest you should do?
  • The legal test: Did anyone do something illegal? 
  • The "stench test": Does the situation "smell" wrong or just not sitting right with you?
  • Publicity test, also known as the "front page test":  Would any of the parties involved be embarrassed by the truth coming out and being splashed across the headlines of the newspaper?
  • Universality test (the "mom test"): What would your mom do? Is this the right thing to do regardless of who's involved?
  • The ethics test: Do the Code of Ethics, or the Guide to Professional Conduct, say anything about this particular situation?

Step 3: Decide the Right Thing to Do

Step three of the RIPS model is deciding, the right thing to do or maybe it's not the right thing to do.  It's just deciding what to do. There are three different ways you can do this. It could be rule-based where you follow only the principle that you want everyone else to follow (deontological). It could be an ends-based decision where you do whatever produces the greatest good for the greatest number of people (teleological). Finally, it may be care based where you do unto others as you would have them do unto you ("golden rule"). So it's the golden rule and you apply the golden rule.
 

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

In this step we might also need to examine the policies of the facility or employer to determine whether those policies are sufficient to protect both patients and staff, should a similar situation arise and if not, work with management staff to implement appropriate policies.
 

Implement: Moral courage (role play, prepare, imagine)

Evaluate and reassess

  • Did things turn out the way you wanted them to do?
  • What went well?
  • What didn't go so well?
  • What were the challenging aspects of that situation?
  • How did that particular situation, compare with others you've encountered or you've read about? 
  • How will this experience make you a better professional? 

RIPS Model Example 1 - Kate 

 
Kate graduated last year from the doctor of physical therapy program at State University and has been working since that time at County Hospital. She loves her position there. Her best friend from PT school, Sandy, is working across the state in a small rehab facility. They often compare experiences and ideas for interventions. Typical of their generation, they primarily communicate via text messaging, Facebook, and Instagram. They rarely talk on the phone. On Monday morning, Kate begins her workday on the fourth floor, a general medical floor, at County Hospital. She pulls the charts for the patients on her schedule and among the new admissions, she sees a familiar last name. She checks and after confirming the patient's place of employment, confirms that the patient is Ms. Edwards, one of her former professors at State University. She thumbs through the chart and is surprised to see that the reason Ms. Edwards was admitted was to rule out a brain tumor. Kate takes a walk down the hall to see her former teacher but she is not in a room. Kate assumes she is undergoing tests and makes a mental note to stop by 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 to County Hospital.  She writes this on Kate's wall - the space on every Facebook User Profile Page where friends can post messages. The message is posted on the Facebook newsfeed and within minutes Kate is having conversations on Facebook about Ms. Edwards' admission and condition with several of her former classmates. Later that evening, Ms. Edward's daughter is surprised to read about her mother's hospitalization on Facebook. She called her mother who finds the news upsetting and immediately contacts Joanne, County Hospital's Director of Physical Therapy. Joanne calls in Kate and in an irritated tone, asks Kate to explain herself. Kate is unsure why there's even an issue. Kate attributes the flap to a generation gap. Ms. Edwards and Joanne are baby boomers. This is how people my age share and communicate things, Kate explains. Joanne counters that the issue is not one of technology or even etiquette, it is one of confidentiality. Kate is puzzled by Joanne's exasperation.
 
So let's go through the steps.
 

Step 1. Recognize and Define the Ethical Issue

Realm.  While Kate is sure it's individual, Joanne considers it institutional. In today's world, time-honored conventions of confidentiality are encountering the open communication that has accompanying technological advances.

Individual Process.  Kate doesn't have the moral sensitivity to recognize that what she did on Facebook was a breach of confidentiality. As to was her decision to read the chart in the first place. She had no professional connection to that patient, why was she reading that chart?

Implications for her action. Joanne obviously is obliged to address Kate's obvious lack of understanding of confidentiality issues,

Type of ethical situation. It's clearly a problem, in that the appropriateness of Kate's actions, is not clear to her.

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.  At this time, we don't know anymore,than what we just talked about. What we do know is that Kate is not treating Ms. Edwards, she is just very curious about her.

Major stakeholders. Kate, Joanne, Ms. Edwards, Kate's friends Sandy. Those are the major stakeholders but again, you can think about anybody who encountered this information on Facebook.

Consequences of action or inaction.  Joanne is obliged to take action and Kate is obliged as a new professional to understand that her personal life and her values are affected by her professional responsibilities.

Laws broken. Probably, the ethical laws for sure. Were there any civil, criminal types of laws? Probably not.

Professional Guidance: Kate would do well to reflect on the principles of the Code of Ethics, regarding, respectively the rights and the dignity of all individuals, and the exercise of sound professional judgment. The core values here that she needs to examine are integrity and social responsibility.

Pass the tests? Does it pass the right versus wrong tests? Is it illegal? Probably not, Does the situation feel wrong? Yes, if even not Kate. Is there discomfort in information, if that information becomes public? Yes, would your parents be likely to take action, in a similar circumstance? Yes, were there violations of the professional code of ethics and documents? Absolutely yes.

Step 3 Decide the Right Thing to Do 

Well, for Kate the barrier to behavior change is getting her to understand that her actions, while perhaps very socially appropriate amongst her peers, are inconsistent with the expectations that her profession has for her and that patients have for her as well as her organization has for her.

Step 4 Implement, Evaluate and Reassess

This situation very well may result, in a change in institutional behavior as Joanne looks at her orientation program and recognizes that she has young staff with social norms that differ from our own. This scenario addresses confidentiality and how therapists manage protected health information at their disposal. Confidentiality is one of the oldest, ethical obligations in medicine. Changes in technology and communication norms are challenging those traditional views of confidentiality. The entire subject needs to be analyzed and perhaps redefined to ensure that the patient is protected as technology and communication continue to evolve.

 

RIPS Model Example 2 - James 

James is an experienced home care PT who enjoys the independence and the variety of his work. One of his current patients named Mike is an active 72-year-old retiree and widower who recently had a left total knee replacement and spent a week at a rehabilitation center before returning home. Now, Mike has a great attitude and is eager to "get back into the swing of things", as he puts it. The payment from Mike's physical therapy is unaffected by the Medicare outpatient guidelines for as long as he remains in home care. This makes James really happy because Mike is a hard worker, an ideal patient, he has very little savings, a very small pension, can't afford to pay for physical therapy beyond what Medicare will allow, and/or his supplemental insurance will cover.
 
James as a physical therapist has a goal to ensure Mike's safety in his home environment and his ability to manage on his own. The goal of discharge is for Mike to be self-sufficient, albeit while still experiencing some residual pain and capable of transporting himself to physical therapy. Based on Mike's limitations at the outset of home therapy, James estimates that this will take about three weeks, three visits per week.
 
The problem arises when James arrives for Mike's third appointment the first week. He notices that Mike's car is in the driveway, rather than in the garage. After Mike answers the door he leads James into the kitchen where Mike is finishing putting groceries away. James, aware that Mike has no family in the area asks who did the driving and the shopping? Mike responds proudly that he did. James is surprised and concerned not only for Mike's safety but also for his wallet. Mike's physical limitations remain significant, in terms of range of motion, strength, and endurance, but in order for him to continue receiving home physical therapy care under Medicare, he needs to be homebound. James emphasizes this to Mike who says he understands but adds he's sure there's got to be at least a little "wiggle room" built into the rules. What harm is there in me trying to do for myself? Mike asks, shouldn't the government be encouraging that?
 
When James arrives a few minutes early, the following Monday for Mike's appointment, Mike's car is gone. About five minutes later, Mike drives up.  Mike stated he had gone to the hardware store for plumbing supplies to fix a leaky sink.  James watches as Mike slowly gets out of the car, makes his way up the front steps safely, but with considerable difficulty. Upon questioning from James, Mike freely admits that he's been out driving several times over the weekend. James feels conflicted, he firmly believes that Mike needs more physical therapy based on, his obvious exhaustion, and the objective measures of his progress that suggests solo errand running, are neither safe nor prudent at this time. But in taking these trips, however, Mike has shown functional independence that defies the definition of homebound. As he follows Mike's slow labored steps toward the house, James wrestles with whether or not to make this visit Mike's discharge from home care physical therapy.
 
An interesting scenario so let's go through the steps: 

Step 1. Recognize and Define the Ethical Issue

Realm. Individual, this is between James and Mike. There is also a societal element because of Medicare reimbursement.

Individual process. There is moral sensitivity here, obviously on James' part what should he do about the scenario?

Implications for action. If James exercises moral courage in this case, Mike is will stop receiving home care that could truly benefit him.

Type of ethical situation. This is an ethical dilemma, Mike is exercising his autonomy, but James is concerned for Mike's safety. James is exhibiting nonmaleficence in wanting to keep Mike on program. James is also concerned about veracity. He believes in being truthful and doesn't wanna lie about the homebound status.

Barriers.  The one big barrier to James taking action here is his concern for Mike's safety if home health physical therapy is discontinued.

Step 2. Reflect

Major stakeholders. James and Mike.

Consequences of action or inaction. If James takes action to discharge Mike, Mike will lose the additional physical therapy that he probably needs. Inaction means that a patient who does meet the definition of homebound will continue to receive home care services.

Are any laws broken? Medicare laws are very specific regarding what constitutes home care status. James is aware of this and he's skirting them obviously at his own peril.

Professional guidance. Principles seven of the code of ethics states that a physical therapist shall seek only such remuneration as is deserved and reasonable for physical therapy services. Also, the professionalism core value of integrity applies here.

Right versus wrong.  Illegal? Yes. Situation feel wrong? Yes.  Is there discomfort if this information becomes public? Yes. Are your parents likely to take action, in a similar situation? Yes.   Are there violations of APTA's professional codes and documents? Yes. 

Step 3 Decide What to Do 

James needs to consider discharge, but he also needs to do all that he can to see that Mike will maintain access to the outpatient services that he needs, in order to ensure his safety.

Step 4. Implement, Evaluate and Reassess

It's unclear that any change, in institutional policy or culture, is warranted here but that policy should be fully explored. The two consistent themes in the comments I have received are the pressure applied to PTs by others and the fact that PTs must provide patients with optimal care within guidelines and then in this particular case, the feedback that is driving home, we need to look at reimbursement. We can't allow reimbursement to drive our clinical practice. Our clinical practice needs to drive our clinical practice.  The patient then reimbursement and in this case, we don't know ultimately what James did but I strongly suspect that James coordinated with an outpatient clinic to make sure that Mike continued to receive services that he needed and James didn't violate that definition of homebound.

Question & Answer

Q: An live audience member posed this question:  Could the considerable and taxing effort as well as negative effects on the patient be considered such as pain, edema, fall risk, etc to keep in home health physical therapy caseload? 
A:  Yes, those can be considered however if you go back to the true definition of homebound, homebound is homebound. That means that the patient cannot access, any sort of services that are outside of the home. They are limited to that home. In this case, this patient was out at the plumbing store, the hardware store, the grocery store, and who knows where else. He clearly doesn't meet the requirements of homebound, so the therapist should certainly recommend outpatient physical therapy. 

RIPS Model Example 3 - Jenna

 
I am not going to give you the answers to this scenario. This one is for you to consider or to use as a discussion topic with your colleagues. This case is based on a true scenario.
 
Jenna is a respected PT who has been working at Pondview Medical Center for six years. Jenna is known for her wound care expertise and she has been a clinical instructor for the past four years. She recently completed the CI credentialing course. She supervises at least three students a year as they rotate through their clinical experiences. Jenna enjoys the interactions, particularly introducing students to the clinical challenges of wound care. This is a next-to-last clinical rotation for Brendon, a third-year DPT student at the local university who has made a career change from the corporate world. Brendon is a little bit older than the typical students who generally rotate through Pondview. Brendon is working with another PT named Mary for the first part of his affiliation and then will have Jenna as a supervisor midway through his 12-week rotation.
 
One day, three weeks into Brendon's affiliation, he stays late to finish some paperwork and ends up leaving the building at the same time as Jenna who also worked late. They have a long conversation while standing in the parking lot and Brendon states he is very interested in wound care. He asks Jenna a lot of questions about what he'll be seeing and doing while working with her in just a few short weeks. They also exchange small talk during which Jenna mentions that her birthday is coming up next week. As the conversation winds down 20 minutes later, Brendon asks if Jenna would let him buy her a birthday drink at a bar that is within walking distance of the clinic. She responds that she appreciates the offer but then it strikes her as inappropriate, given that she'll be his supervisor in just a few weeks. Brendon responds that having worked in a corporate environment, he is sensitive to the issues of perception and propriety but he adds that he sees the situation as innocuous. It's just one birthday drink, he says, and I also want to pick your brain about some cases that I've been seeing while working with Mary.
 
This sounds reasonable to Jenna because having a single drink with Brendon while engaged in a professional dialogue does not seem so wrong. Brendon waits for an answer.
 
As you analyze this situation, ask the following questions:

Step 1: Recognize and Define the Ethical Issue

Realm. Into which realm or realms does this situation fall? Is it individual? Is it organizational? Is it institutional? Is it societal?

Situation. What does the situation require of Jenna, and of Brendon?

Individual process.  Which individual process is most appropriate? Is it moral sensitivity, moral judgment, moral motivation, or moral courage?

Implication for action.  Are there implications for actions on the part of anyone besides Jenna and Brendon?

Type of ethical situation. What type of ethical situation do you think this is - a problem, a dilemma, distress or temptation?

Barriers. Are there any barriers to Jenna taking action?

Step 2: Reflect Upon the Situation 

Background. What do you know about the legal obligations that Jenna may face, and how can you find out about those?

Stakeholders. In addition to Jenna and Brendon, who or what else might be affected by this situation?

Consequences of action or inaction. What are the consequences of action or inaction on Jenna's part?

Any laws broken? Might the action or inaction break any laws?

Professional guidance:  What ethical principle or principles might be involved?  Do any of the following resources, provide professional guidance: the APTA Code of Ethics, the APTA Guide for Professional Conduct and/or Professionalism and physical therapy, or the Core Values? For example, do you see a relationship between this case and any other principles of the code of ethics?

Pass the tests?  Finally, consider how this scenario stacks up, against all of our tests: the tough choices, the legal tests, the stench test, the front-page test, the mom test, and the professional ethical violation test.  In other words, consider if something illegal is going on, or if the situation feels wrong. Think about whether you would feel uncomfortable if you were Jenna and the details of the situation were to become public. Would your mother or your parents do the same thing, if faced with similar circumstances? Can you detect any ethical violations, within the APTA resources?

Step 3: Decide What to Do

If the scenario fails any of the previous tests, this step is superfluous and case action must be taken. The question becomes what kind of action? If, however, you believe this scenario passes each of the tests, it is time to look at the three possible approaches: Rule Base, Ends Base, and Care Base. Do you do rule base, so you follow the principle you want everyone to follow? Is it ends base, where you do whatever produces the greatest good, for the greatest number of people? Or is it care-based? Do unto others as you would have them do unto you.

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

In this step, reflect on the course of action chosen and think about whether a change in the clinic's organizational policy or culture might prevent the scenario from re-occurring.

Evaluate this scenario either on your own or with colleagues, and determine what should or should not happen. 
 

Avoiding Ethical Dilemmas: PROTECT

With all of the potential pitfalls in healthcare today, how can you protect yourself from falling victim to ethical problems?  Remember this acronym: PROTECT. Protect your patients and yourself.
 
P = Put a copy of your licensure law in your desk and read it. This painless step can prove invaluable for any practitioner. Again, many professionals have never seen their own licensure law, let alone take the time to read it. Read it, digest it and when you finish reading it, don't file it away, keep it there and refer back to it.
R = Report ethical and legal violations to your manager and potentially the ethics and/or licensure board.
O = Open your eyes - If it doesn't seem right, it probably isn't right. Sometimes in practice supervisors and administrators, tell us to do things that just don't seem right and consequence arise that we do not anticipate. Don't follow blindly. Pay attention to your gut reaction and look into it further.
T = Tell them you want it in writing or in an email if it doesn't make sense to you or you find yourself questioning an order or directive.  If you don't like the way it seems, get it in writing, electronically through email. The person requesting the action is probably not going to put it in writing if it is illegal or unethical.
E = Encourage ethical behavior always.
C = Cover yourself with complete and thorough documentation. Keep in mind that documentation plays probably the most significant role in protecting yourself and your patients. Document as close to the treatment session as possible so your notes don't become a work of fiction. Make sure the notes are complete, that they discuss the type of treatment that the patient received, the evaluation you performed, and the patient's response to that treatment. Don't change your documentation after the fact and don't allow others to influence you to change it or to include untruths. Do not document something today that you plan to do tomorrow because tomorrow may not turn out the way you plan. Remember, if you didn't document it, it didn't happen. Stay current with documentation. Don't allow yourself to fall behind because that frequently sets up a situation where the facts about the treatment are not easily recalled and the note is either full of holes or fully fiction.
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, do not let problems situations fester. As time marches solutions and choices are more difficult than those that are made at the inception of the problem.
Y= Yearn to learn. Take advantage of all continuing education opportunities, made available to you.
 
P= Plug into your professional associations 
A = Ask a lot of questions if you're unsure of an action or task that someone wants you to perform 
T = Train and supervise all subordinates properly 
I   =  Internet sources guide you to stay on top of changing information 
E = Establish a relationship with a mentor or a peer
N = Never fall behind 
T = Take a good look at the professional literature
S = Surf the internet for regulatory changes, for the situation in which you work. Is your professional responsibility to ensure you know all the rules. 
 
T = Take the time to read your professional code of ethics and Standards of Practice
H = Handover patients to those with more expertise, if you don't have it yourself
Y = Yield to the dictates of the Medicare regulation, workers compensation guidelines and other rules or regulations of payers with whom you work on a regular basis
S = Save a copy of all written correspondence and electronic correspondence.
E = Explore all of the alternatives
L=Look at professional association and licensure or certification board homepages, on a regular basis for changes and finally
F = Fill out all forms accurately and timely.
 

Resources to Help

As I've already said, there are many resources that can help you. There are the core documents from APTA that are mentioned in this course, the code of ethics, the Guide to Physical Therapist Practice, the Guide for Conduct and Professionalism. On top of that from APTA, there are coding and billing resources, compliance resources, the managed care contracting toolkit, PT in motion which is truly an ethics publication that you can rely on so a lot of different resources.
 

Ethical Scenarios to Review on Own

In our last few minutes, or so I'm gonna go through a couple of other ethical scenarios. These I think maybe obvious but they're things that you can talk about and then go back against your principles to determine where or what or how something was violated. 
 

Example-Use of Ultrasound by PTA Not on Plan of Care

You,  the therapist have delegated treatment of your 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, the physical therapist or the physician and they don't have a script or an order to do so. So do we have an ethical issue here? Absolutely, there without a doubt. I think we have a couple of issues. We need to be trustworthy with what we're doing so this person obviously was not trustworthy with the physical therapist. The other piece of this is that we did not practice, within the scope of our practice. This is a violation of the practice act. This is a violation of the code of ethics, this is a violation of the scope of practice. One of your very pertinent principles, under the APTA code of ethics. What do you do? I don't know, at a very minimum, I think you need to have some reeducation and some counseling but that would obviously be something that you would do within your organization. Possibly this person needs reported to the licensure board, but not sure about that.

Example-Assistant Changing Goals

Another scenario, you discover when reading the daily notes of the assistant that you're supervising that he is adding and changing goals for the client, without consulting you. So is there an ethical issue here? Yes, again, this is an issue with a supervisory process that will go back to your ethical principles, in your code of ethics, and your code of professionalism. This is not a scenario where we are advancing the goal, within the long-term goal. This person is truly changing the goals, they are establishing a plan of care that is clearly within the scope of practice of the PT, not the assistant. So again, what are you going to do about this?  You will obviously consult your supervisor within your own facility and then potentially take that up the food chain as well.

Example-Billing for Physical Therapy Aide Services in Outpatient Clinic

You're working in an outpatient clinic that deals primarily with Medicare Part B as a payer.  You have a physical therapy aide in your clinic and you ask the physical therapy aide to complete the therapeutic exercise program with the client and you bill for these services. If you work in that situation, you know that that's not allowed. This is fraud and abuse of the Medicare program. It is a violation of the practice act.

Example-Billing A Different Code for Monetary Reasons

This one's a very real scenario. I just read about this one online a few days ago, You have been told as a physical therapist to begin billing your patients' sessions under CPT 97535 which is self-care. You realize that this code pays more than therapeutic exercises which you typically bill and you wonder if this is the reason? The issue here is upcoding.  This is a huge violation. This is fraud and abuse and it is strictly prohibited by any sort of billing entity.

Example-Continue Treating a Patient for Family Reasons

You've been told as a PT to continue treating your patient, just three more sessions so the facility can continue to obtain skilled reimbursement and because the family is not quite ready at home for the discharge. This is an ethical consideration, but it is a tricky one. I think we need to get more information. Are there still goals that the patient could achieve? Is there still something that the patient, should be working on? What we don't know here is if the PT had already, discharged the patient or was planning to discharge the patient. There might still be something that needs to be worked on and if that's the case then obviously that would be okay.  If that's not the case, you can't just keep the patient on just because.  That's not skilled care.

Example-Lack of Insurance coverage

A 56-year-old man is referred to physical therapy for sciatica, degenerative disc disease, and degenerative joint disease. He's the sole caretaker for his disabled wife. Over the last month, he lost his capacity to bend, lift, work.  Medicaid is only going to pay for the eval and no follow-up. The PT recommends follow-up services, twice a week for four weeks. What do you do? You might be tempted in this situation, to deliver those services to give those services free of charge because it seems like the right thing to do and again, there might be a pro bono opportunity here.  I don't know, that's something you can investigate. But can you just give free services to this person but not somebody else? Obviously not.  In this case, the PT will need to look at alternative sources to frequency and duration, and education. 

Example-Jeremy and Cheryl, Receiving Gifts

Jeremy a PT has been treating a patient, for two months and has been receiving expensive gifts, on a regular basis from the family of an elderly woman. Cheryl, his co-worker has co-treated the patient, for the last month and has noted in the chart, the patient has met all of the goals and is ready for discharge. Well, since then, the elderly woman has been attending rehabilitation with Jeremy three times per week, and Jeremy states, he just doesn't have the heart to discharge her. Obviously, there is an ethical issue here, he's receiving gifts, there's excessive treatment and he could possibly be falsifying a record. There are a lot of issues going on here. Again, what do you do? You consult the PT supervisor. Ideally, the supervisor will consult Jeremy and come to an ethical solution. It might be one of those things that have to go to the PT board. If billing has been submitted for this patient, but it's not medically necessary, it may need to be backed out of.  

Example- Lauren and Hal

Lauren a PT is the only witness to a patient fall in the clinic gym. The patient has balanced 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 the situation. Is this unethical? Yes. Hal is hiding or falsifying documentation. He is falsifying what actually happened.  The bigger problem here and go back to your ethical principles, He is placing his own needs of not being discovered but not following the facility policy above the patient's and there is obviously an issue with nonmaleficence or patient beneficence here.

Example - Jim 

 
Jim is a PT who 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 called Jim and asked him to call a previously scheduled new patient and have him reschedule.  The reason for the rescheduling is because the VIP shareholder has been referred to the clinic and wants to be seen as soon as possible. Jim is uncomfortable. Is it an ethical dilemma? Yes - the issue is prioritizing patient care based on nepotism or favoritism. They could possibly be providing unnecessary care to this person; maybe the person doesn't even need services. What if Jim says no to this request? He could be fired. What if he says yes? He's uncomfortable. The other thing to consider is whether this is really a patient request to be treated or is there a business issue behind it such as a contract cancellation?  This is an ethical dilemma that needs to be addressed.

Example - Sarah 

 
Sarah works in private practice and her year-end bonus is directly related to maximizing return visits. Her boss has been heard to say that other staff members treat patients to the maximum and it just requires being creative. The boss has also been overheard encouraging therapists to discontinue treatment early for those patients with poor reimbursement. Sarah is uncomfortable with this situation but counting on her year-end bonus. It's clearly an ethical dilemma here as they are putting reimbursement before the patient. Sarah is in a difficult situation because she doesn't want to put her own needs or requirements above those of the patient.
 

Summary

When we look at ethical dilemmas, the most important takeaway message is, if you see something, say something. To whom do you say something? It depends - maybe it's the manager, maybe you have a compliance department, maybe you have a quality hotline, or maybe it's human resources. It may be that you need to go to APTA or to your state association. Where you don't go is on Facebook, Twitter, or other social media platforms. There are groups on social media where oftentimes I see people bringing up ethical dilemmas and issues in their workplace that have no place on social media. Thank you for participating in this course.  Please refer to the handouts and references for more information and resources on this topic.
 

 

References

A complete reference list for this course is included in the course handouts.

 

Citation

Weissberg, K.D. (2019). Ethics in rehabilitation: A clinical perspective for therapists. PhysicalTherapy.com, Article 4281. Retrieved from www.physicaltherapy.com


kathleen d weissberg

Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, OTR/L

Kathleen Weissberg, OTD, OTR/L, in her 25 years of practice, has worked in adult rehabilitation, primarily in long-term care as a clinician, manager, researcher, and most recently as Education Director with Select Rehabilitation where she oversees continued competency and education for close to 12,000 therapists. In her role, she conducts audits and provides denials management and quality improvement planning training for more than 700 LTC sites nationwide. She also conducts compliance, ethics, and jurisprudence training to therapists.  Kathleen has authored several publications that focus on patient wellness, fall prevention, dementia management, therapy documentation, and coding/billing compliance.  

 



Related Courses

Supervising Assistants, Students, and Aides: Upholding Your Ethics in a Challenging Health Care Environment
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This presentation reviews the definitions of supervision as well as APTA guidance related to supervising assistants, students, and aides in various healthcare environments. Documentation guidelines for Medicare are reviewed as these relate to what an assistant can complete versus a therapist. The use of students and rehab aides in long-term care is reviewed in accordance with Medicare guidelines. Real examples of common supervisory ethical dilemmas from the field, including the appropriate action steps to take in each one, are highlighted. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA

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PTs and PTAs practicing in the state of Indiana are required to complete a two-hour course on ethics and jurisprudence for license and certificate renewal respectively. This course reviews the principles of ethics, common ethical dilemmas, and methods for analyzing ethical dilemmas. Jurisprudence components as outlined by the Indiana Board of Physical Therapy, Indiana Physical Therapy Practice Act and The Indiana Administrative Code is also discussed.

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