These findings suggest why CIMT may not have been effective for Mr. Donovan, who is still in the acute stage of recovery. When Scott evaluated Mr. Donovan’s hand and wrist, there was no active movement. Knowing when to start an intervention program is as important as knowing how. Additional considerations are the number of hours per day the hand is restrained, the total length of treatment, and client satisfaction. Although clients who receive CIMT improve, the technique is not a cure. Scott needs to be sure that he “provides the information necessary to allow patients or their surrogates to make informed decisions about physical therapy care” (APTA, 2010b, Principle 2C). Explore the practical alternatives Exploring practical alternatives is important to determine whether another approach or other approaches might provide the same or similar results. For Scott, seeking the assistance of a more experienced practitioner might have helped avoid the pitfalls encountered. CIMT is most useful in the chronic stage of stroke and in clients with active wrist extension movement. Scott may have overlooked those details. Complete the action The state ethics committee is charged with looking at Scott’s rights and privileges as a member of the APTA. The state board of physical therapy is charged with looking at Scott’s license and right to practice. The state physical therapy association’s ethics committee, in consultation with its president, have suggested that he consider identifying and consulting with a more experienced clinician who has used CIMT as an intervention approach or attending continuing education courses on CIMT. Scott has a choice of actions. Doing both may be the best course of action. Note that no sanctions were applied by the state ethics committee with respect to his rights and privileges as a member of the APTA or by the state board of physical therapy with respect to his license status. This was because none were warranted since Scott complied with the suggestions offered to him. Scott may have misled Mr. Donovan into thinking that CIMT would be beneficial in the early stage of recovery. If so, Scott would have violated Principles 2C and 2D (“Physical therapists shall collaborate with patients/clients to empower them in decision about their health care”) and Principle 4A (“physical therapists shall provide truthful, accurate, and relevant information and shall not make misleading presentations”; APTA, 2010b). However, the information provided did not suggest that Scott intended to mislead. Rather, he wanted to accommodate Mr. Donovan’s request and proceeded. Mr. Donovan was not harmed physically and arrangements to reimburse the costs of treatment had already been made. Had Scott elected to refuse to follow the suggestions provided to him, he could have been sanctioned. Generally, the APTA Ethics and Judicial Committee waits until the state board acts before applying sanctions because the state board usually has more resources available locally to collect and analyze data, such as by interviewing clients, managers, and associates (APTA, 2012a). Evaluate the process and outcome The state board required Scott to inform them that he complied with the ethics committee recommended course of action. He must report the number of hours on consultations received and submit evidence of continuing education courses completed on CIMT. Evaluating the process and outcome is important to determine whether the unethical behavior is corrected and a method is in place to prevent the behavior from occurring again. Scott must also reflect on the situation. What did he learn? What will he do differently when faced with a similar situation? Applying the six-step process: Case vignettes Several case studies are included to provide additional practice in analyzing potential ethical problems encountered in clinical
practice. The following case vignettes illustrate both the ethical principles and the application of the six-step process. Beneficence Sara has received a referral from an internal medicine physician to initiate physical therapy for a client diagnosed with carpal tunnel syndrome. The referral states, “Make carpal tunnel splint and educate client on prevention.” However, on the basis of the client’s history and her evaluation, Sara believes the diagnosis is incorrect and that a carpal tunnel splint is contraindicated. The client has stated that he wants it anyway because that is what the doctor ordered. ● Relevant information: Diagnosis and plan of care (treatment, intervention) are not congruent. To better understand the case, Sara might discuss her findings and concerns about the client’s diagnosis with the physician. ● Type of ethical problem: Moral distress. Sara knows the right thing to do, but there is a barrier. ● Ethics theories and approaches: ○ Beneficence: APTA Code, Principle 3A (“Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings”). ○ Deontological/duty theory. ● Practical alternatives: Sara is obligated to treat the client based on her physical therapy diagnosis. If there is a conflict with the medical diagnosis, the practical alternative would be to provide the physician with evidence-based literature that justifies her plan of care and get the physician to change his order. Then it can be presumed that the client will no longer insist on the splint because the physician has discontinued that order. ● Complete action: Provide the referring physician a complete summary of her evaluation findings and ask whether a change in diagnosis is warranted. Sara may also suggest to the internal medicine physician that a referral be made to a physician specializing in hand injuries to help establish a definitive diagnosis. ● Evaluate process and outcome: Monitor client’s name for a revised referral. Nonmaleficence Leslie suspects that a coworker may be practicing physical therapy while under the influence of alcohol because she can smell liquor on her coworker’s breath in the morning. However, if Leslie reports her coworker to her supervisor, Leslie will have to treat some of her coworker’s clients, which will add to Leslie’s treatment load. ● Relevant information: Presumed impaired professional. Leslie’s coworker is performing duties while under the influence of a substance known to alter the brain’s ability to function. Leslie should try to gather relevant information to confirm her suspicions. How certain is she that her coworker is acting under the influence of alcohol? What evidence does she have? Is she basing her suspicions on the behavior of her coworker or a direct observation of drinking? Why does Leslie assume that she would have to treat some of her coworker’s clients? ● Type of ethical problem: Moral distress. Leslie knows the right thing to do, but there is a perceived barrier. ● Ethics theories and approaches: ○ Nonmaleficence: APTA Code, Principle 7E (“Physical therapists should refrain from employment arrangements that prevent physical therapists from fulfilling professional obligations to patients/clients”). ○ Procedural Justice: APTA Code, Principle 5E (“Physical therapists who have knowledge that a colleague is unable to perform their professional responsibilities with reasonable skill and safety shall report this information to the appropriate authority”).
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Book Code: PTNJ0824
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