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May 1999

A Case Study Illustrating Professional Care Judgement Within an Ethical Framework, by Julia C.  Jean-Pierre, PT, MSH, PHD

Physical Therapy in the long term care setting is a challenging profession. Because the occupation is called physical therapy, most people would assume that decisions about moving and positioning of individuals are the most crucial. However, sometimes even more important professional decisions can result from moral and ethical contemplation about whether to continue treatment or not with a particular patient.

Recently at my workplace, a favorite resident of our facility suffered a majorly debilitating cerebral vascular accident. Prior to this episode, the resident was conversive, ambulatory and independent in all activities of daily living. After the event, the resident was virtually non-responsive and dependent for all mobility skills and care. All three disciplines Occupational Therapy, Physical Therapy and Speech Therapy received orders from the resident's physician for evaluation and treatment as indicated. After a three day evaluation of the patient, it became obvious to me, having seen many individuals with similar medical backgrounds, age and cerebral vascular accidents that the prognosis for the patient was very poor. My decision was to set up a comprehensive range of motion and positioning program for the patient and to discharge him from physical therapy services in one week, when all nursing staff had been inserviced on the patient's program. Occupational and speech therapy decided to treat this resident on an on-going basis, seeing more potential in the patient's outcome and possibly not wanting to "give up" on this once vibrant resident of our facility. Part of my decision was that the physical therapy department would continue to communicate with occupational and speech therapy and personally screen this patient every two weeks to see if the condition improved to warrent re-initiation of physical therapy services. The decision to discontinue physical therapy treatment in this individual presented a conflict between my personal moral and professional codes, making it a difficult decision.

My personal moral code includes the principle of not depriving any individual of beneficial skilled physical therapy intervention. In this case this belief was intensified by the individual's high level of activity prior to the cerebral vascular accident. Another facet of the dilemma reflected the rights of the individual since my moral code also includes the belief that all people have the right to receive the best care possible. Even though nursing could perform the patient's range of motion and positioning program, a skilled physical therapist would most probably do a superior job. In another way, the principle of nonmaleficence was called upon. By not providing the daily skilled physical therapy service, was this ultimately goig to harm the patient by not allowing him to improve with a more vigorous program? The final moral principle that influenced me was justice. My feeling that all individuals, no matter what age or diagnosis should receive the same degree of healthcare made it difficult to decide whether the individual should continue to receive physical therapy services or not.

On the other hand, my professional code of ethics presented some opposing views. Although all of the moral principles apply to my professional code of ethics as well, the professional ethic of beneficence was applicable. Although the patient may benefit from continued physical therapy treatments, would the outcome from these treatments balance the cost? Even fifteen minutes of physical therapy treatment is very costly, and it isn't professionally ethical to keep a patient on a caseload for financial or personal reasons, even if you have the reasonable expectation that the patient will receive some benefit from these treatments. Additional professional direction is provided through the Medicare system in this instance. Medicare states clearly that the rehabilitation services should not be performed unless there is documentable progress in each case. This is an important part of the physical therapy code of ethics as well which implies we must not provide unneeded services just to increase financial gain. One final part of my professional code of ethics played a role in my decision, and this is discernment. It was very important that I was able to problem solve and reach my decision without being unduly influenced by personal attachment to this favorite resident or his rather assertive family which was resistant to the idea of discontinuing the resident's treatment.

There was a rather obvious conflict between moral code and principles and professional principles. In summary, morally I was drawn to the ideas of providing skilled service to this patient so that he might receive the best possible treatment, but professionally I knew that the cost versus benefit issue made continued treatment unreasonable.

Further conflict arose when occupational and speech therapy decided to continue daily treatment with this individual, both of these disciplines felt my decision was incorrect, even though the resident would continue to be considered for re-initiation of treatment, if any improvement in status was recognized. The conflict was resolved by realizing that part of my motivation for wanting to keep the patient active in occupational and speech therapy felt my decisionwas hasty and was not compassionate enough. There were several antagonistic discussions regarding the reasons and ramifications of my decision. Secondly, the patient did not receive the amount of range of motion exercises that I had deemed minimally necessary from nursing. This resulted in several frustrating attempts to increase carryover of my instructions, knowing had I kept the patient on my caseload the proper instructions would been followed. Thirdly, five weeks later, the patient died. This reaffirmed the fact that my decision was the appropriate one. Occupational therapy continued to see the patient until the end, showing what I perceive as misuse of silled therapeutic intervention.

In this instance, after being temporarily caught between apparently equal but conflicting principles, I was able to deliberate about the situation to come to a successful justification of my decision so that the patient received appropriate medical care for this particular situation. However all decisions of this sort are ethically very difficult since moral, emotional and professional factors come into play. Each new situation requires new deliberation.  

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