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Ethics of Providing Culturally Competent Home Health Care

Ethics of Providing Culturally Competent Home Health Care
Kenneth L. Miller, PT, DPT, GCS, CEEAA, Olaide Oluwole-Sangoseni, PT, PhD, DPT, MSc, GCS
October 12, 2016


Course Learning Outcomes

  • The participant will be able to describe the interrelationship between ethics, culture, and law.
  • The participant will be able to identify the need for cultural competency training in home health practice.
  • The participant will be able to describe at least three ways to incorporate cultural awareness and sensitivity into patient-centered care.
  • The participant will be able to describe at least three ways to provide culturally appropriate care as a means of improving multicultural patient's engagement and adherence with prescribed exercise and intervention plans.

Dimensions of Ethics in Home Health

Ethics Defined

Generally defined, ethics is a systematic reflection on, and analysis of, morality. This definition can be applied to many different areas of practice (medicine, law, business, etc.). Regardless of the discipline, ethics requires the analysis of the circumstances surrounding a particular event and the kind of morality involved in that situation or event. Morality is the standard of right and wrong conduct as defined by one’s society. What I call morality here in the United States, may not be the morality that exists in the United Kingdom. Ethics doesn’t just refer to clinical practice ethics or medical ethics where we focus on compassionate care.  Ethics can also refer to organizational ethics which includes our professional behaviors. Medical ethics extends to the duties and the responsibilities in both social and political realms, to deal with issues in public health as it occurs in our own society.

Ethics has to do with the concept of right and wrong, with regard to human relationships and interactions. Because human relationships are very complex, those concepts of right and wrong, fair and unfair, just and unjust means that the theory of ethics will not be static. It’s always changing, because human relationships are always changing. That means what is ethically unacceptable by our larger society today, may become the norm as the time progresses, as societal thinking becomes more evolved. Some experts tell us that ethics, like the practice of medicine, is about black and white. It is about learning to discern the shades of gray that comes with human relationships. It’s about dealing with uncertainty, and finding the best possible course of action under the circumstances in which you find yourself. In other words, knowing how to determine the difference between right and wrong, wrong and wrong, and even right and the consequences.

When we’re dealing with right and wrong, most of the time that may be easier than when we’re dealing with wrong and wrong. Both of them may be easier than when we’re dealing with right and consequences (e.g., I do the right thing but the consequences may not be good). Normative ethics, according to experts, is said to be prescriptive ethics. There is this aspect of ethics in healthcare, in clinical care, in medical ethics that is said to be prescriptive. That’s based on normative theories, that based on certain ethical standards that have been created. Those standards may use one of these two approaches: A deontological approach or a teleological approach.

Deontological Approach to Ethics

A deontological approach takes into consideration the best way to carry out the duties expected to fulfill one’s obligation. Deontological ethics is based on what is the best possible scenario; not just the outcome alone, but what is the best thing that can be done in a particular situation. Deontological ethics is means-driven; it is focused on duty and the actions that you take to carry out your duty. In order for you to carry out your duty, you have to respect the person that you’re dealing with – their rights, their dignity and their autonomy in making their own decisions. Deontological ethics’ primary focus, and the responsibility of the healthcare provider, is to the patient or the client. Deontological ethics views an action to be right if it is done in accordance to the expectem, or a principle or moral duty. That means people should never be treated as a means to an end; they should be treated as an end in themselves.

Teleological Approach to Ethics

On the other hand, there is the teleological approach. In other words, “the end (or the outcome) justifies the means.” It doesn’t matter how I get there; it doesn’t matter how I get the patients to arrive at the outcome that we’re expecting. What matters is that we achieved the desired outcome; we reached our goal. In teleological ethics, the right and wrong is based on what is best for the general good. That is why you see our policy makers and our administrators or managers focused on a more teleological approach, which some people also call the utilitarian approach in healthcare. How can we get the best thing for the largest number of people? The emphasis is on utilizing and maximizing resources for the greatest number of healthcare consumers. Teleological approach also focuses on the consequences. You may hear the terms teleological, consequentialism, and utilitarian used interchangeably.

Moral Relativism

Another dimension in home care, besides those two major approaches, is how we decide what is right. What is right for you, may not be right for me. That falls under the ethics of moral relativism. Moral relativism is the position that moral or ethical propositions do not reflect objective and/or universal moral truths, but instead make claims relative to social, cultural, historical or personal circumstances. It is relative to the traditions that I follow, to my convictions and to the practices of my culture. It is not absolute. How I judge a situation, how I make my judgment, depends on my background, my professional PT culture, and the guidelines I’m following. It depends on what the employee protocols tell me to do.


Moral relativism says that I can only judge something as true or false based on my convictions. Multi-culturalism is the body of thought in political philosophy about the proper way to respond to culture and religious diversity. The proper way you respond is based on the cultural and the religious diversity of the practice setting in which you are, of the environment in which you exist.

Multi-culturalism is not a mere toleration of group differences. It is said to fall short of treating members of minority groups as equal citizens. You’re recognizing and giving them positive accommodation because of the differences that they may have within your group. In other words, something that you don’t perceive as a big deal may be a big deal to some people. You don’t see it as a big deal because the larger society in which you exist and share the same world view, doesn’t see it as a big deal. However, there is this small proportion of people that don’t feel the way you feel. Multi-culturalism says how exactly do I recognize those people and make sure that I don’t look down on them, and give them positive accommodation.

Ethics and Law

As physical therapists, how do and ethics and law relate to us in our practice? Whereas ethics deals with more personal, individualized set of values, the law is a binding statement of duty for all of us. Ethics is a statement of our personal values and how we have evolved. Law is what we have decided as a society are the rules we are going to abide by.

Patient Self-Determination Act of 1990

As an American society, we uphold that people have rights. We believe success occurs at the level of the individual. The government strives to protect the rights of the individual. In the realm of healthcare, patients also have rights which must be protected. As such, the government enacted the Patient Self-Determination Act of 1990 (PSDA). The purpose of the Patient Self-Determination Act is to inform patients of their rights regarding decisions toward their own medical care, and ensure that these rights are communicated by the health care provider. In other words, the intent of PSDA was to encourage everyone to think about what kind of treatment we would want to receive if we became incompetent. Experts define competency as the mental ability and cognitive capability to execute a legally recognized act in a rationale manner. If we ever were to become incapable of making that decision for ourselves, to what extent would we want medical care to be administered? In order to protect our rights, and ensure that our wishes are honored in the event that we become incapacitated, it is prudent to create some sort of document to specifically outline our decisions (e.g., a living will, a durable power of attorney, etc.). Such documents are also known as an advance directive. In order for people to exercise that right, the PSDA requires all healthcare agencies (including home health agencies) to recognize the directives that the patient may have created. It mandates that, especially if you are getting paid by Medicare and Medicaid, you must ask the patient about their advance directives. If a patient does not have written documents already established, the agency or healthcare provider must be given information about their rights. That’s one of the relationships between ethics and law.

kenneth l miller

Kenneth L. Miller, PT, DPT, GCS, CEEAA

Dr. Ken Miller, PT, DPT, is a board-certified geriatric clinical specialist and advanced credentialed exercise expert for aging adults. Dr. Miller is an assistant professor at the Medical University of South Carolina in the Division of Physical Therapy and serves as the founding director of the USC Geriatric Residency Program. His clinical focus is on best practices for use with the older adult population. Dr. Miller is the Director overseeing Practice for the Academy of Geriatric Physical Therapy. He has spoken nationally and internationally on topics of gerontology, including pharmacology, primary prevention, frailty, outcome measures, best practices, and pain management for the older adult.  Dr. Miller has over 20 years of clinical expertise in risk mitigation and error prevention and is currently researching well-being, mental health, and burnout in physical therapists.  


olaide oluwole sangoseni

Olaide Oluwole-Sangoseni, PT, PhD, DPT, MSc, GCS

Olaide Oluwole-Sangoseni PT, PhD, DPT, MSc, GCS is an assistant professor of physical therapy at Maryville University of St. Louis. She teaches professional issues and practice management courses in addition to core exercise science courses. She is a co-owner of a multispecialty clinical practice in the St Louis area. She has been a physical therapist for 25 years holding various clinical and management positions in various practice settings, including part-time home health for the last 20 years. Dr. Sangoseni is a regular presenter at the Combined Sections Meeting of the American Physical Therapy Association and other national and international conferences on manual therapy, geriatrics, and evidence-based practice. She is an APTA credentialed clinical instructor. Her areas of interest include advocacy, manual therapy, evidence-based practice and research with a special focus on active aging issues.

Related Courses

Updated Strategies for Designing Exercise Therapy for the Older Adult Home Health Patient
Presented by Olaide Oluwole-Sangoseni, PT, PhD, DPT, MSc, GCS
Recorded Webinar
Course: #4135Level: Introductory2 Hours
Evidence-informed patient-centered care requires that home health physical therapists set achievable goals by avoiding the underdosing of exercise intensity for older adults. Patient-specific approaches to exercise prescriptions are cost-effective in reducing re-hospitalizations and promoting an early return to functional activities. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

Maintenance Therapy in Home Health: Revisited
Presented by Kenneth L. Miller, PT, DPT, GCS, CEEAA
Course: #3136Level: Introductory2 Hours
The Medicare Benefit for Home Health under Part A includes both restorative care and maintenance therapy. The Benefit Manual clearly states that coverage determination for maintenance service provided is not dependent on any "improvement standard" but, rather on whether there is a need for skilled care. The purpose of this course is to provide the CMS regulations regarding maintenance therapy in home health define rehabilitation and maintenance level care and provide examples of appropriate maintenance episodes.

Optimizing Patient Outcomes: Navigating Medical Errors and Preventing Harm and Readmissions
Presented by Kenneth L. Miller, PT, DPT, GCS, CEEAA
Recorded Webinar
Course: #4908Level: Introductory2 Hours
This course defines what medical errors are, how they happen, and what can be done to improve the quality of care, patient safety, and reduce readmissions. Many errors are preventable when safeguards such as procedural checklists are put in place and situational awareness is enhanced.

Learning to Lead
Presented by Kenneth L. Miller, PT, DPT, GCS, CEEAA
Recorded Webinar
Course: #4426Level: Introductory2 Hours
This course will provide the participant with a roadmap for developing or refining leadership skills in whatever role they serve as clinician, academician, or administrator. The roles of manager and leader will be explained in terms of motivation, productivity, and engagement.

Interdisciplinary Approach To Stroke Rehabilitation: Outpatient, Home Health, And Community Rehabilitation Phase
Presented by Alaena McCool, MS, OTR/L, CPAM, Katherine George, PT, DPT
Recorded Webinar
Course: #4609Level: Intermediate2 Hours
The unique relationship between the occupational and physical therapist when treating an acute, subacute, or chronic stroke diagnosis will be distinguished in this two-part series. Part two will focus on the subacute and chronic stroke, differentiating the home, outpatient, and community phases of rehabilitation, as well as examining the evaluation, evidence, and interventions in each setting to optimize independence for the patient.

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