Ethical Case Study Physical Therapy

“With increasing professional autonomy and independence in clinical decision making and judgments, physical therapists face increasingly complex ethical issues in their professional practice.”1In an attempt to ensure that physical therapists (PT’s) engage in legal and ethical practice, most states require PT’s to pass a jurisprudence examination as a part of obtaining licensure.I have worked as a licensed physical therapist since 2009 and have taken jurisprudence exams for the states of California, Maryland, Georgia, and the District of Columbia.Each state has their own variations of what constitutes the professional practice of the PT.Additionally, the American Physical Therapy Association (APTA) (physical therapy’s professional organization) has developed a specific code of ethics that they encourage and recommend all PT’s to abide by.I would like to go through each of these principles and provide examples from everyday PT practice regarding how these principles may be either employed or violated.

APTA Code of Ethics2

·PT’s shall respect the inherent dignity and rights of all individuals

oExample: Patient A has come in to the PT clinic for an evaluation of his shoulder.The PT requests that Patient A remove his shirt for better access to his shoulder.When Patient A asks for a gown as a covering, the PT laughs at Patient A and exclaims, “Men can roam around shirtless.”

§This is a clear violation of Patient A’s dignity and rights.PT’s are taught to properly “drape” a patient when removal of clothing is necessary whether they are male or female.

·PT’s shall be trustworthy and compassionate in addressing the rights and needs of patient/clients

oA PT would violate this code if patient confidentiality were breached.

§Example: 2 patients are in a PT gym at the same time.Patient A is completing therapeutic exercise, while Patient B is receiving manual therapy by the therapist.Patient B asks “what’s wrong with Patient A?”If the PT discloses the diagnosis or even the “injury story” without Patient A’s consent, then the PT has breached Patient A’s confidentiality.

·PT’s shall be accountable for making sound professional judgments

oExample: Patient D was seen by the physical therapist’s co-worker Jane during the last treatment session, and received dry needling to her left upper trap due to cervical pain and headaches.However this week Patient D is seeing PT Kelly.PT Kelly has only been trained in dry needling of the lower extremities, but is qualified to perform manual techniques in the cervical region.PT Kelly makes sound professional judgment by choosing not to dry needle an area she has not received training in, explains this to Patient D, and proceeds with manual treatment to the cervical spine.

·PT’s shall demonstrate integrity in their relationships with patient/clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public

oExample: Patient F has been treated by a spectrum of health care providers including massage therapists, chiropractors, orthopedic doctors and podiatrists and is not happy with the treatment she has received from chiropractors and orthopedic doctors.As a result, Patient F proceeds to bad mouth and swear off ever utilizing these professionals again.The PT is able to maintain professional integrity in this situation by listening and being attentive to patient F’s concerns, while also respectably choosing not to agree with Patient F, recognizing that everyone makes mistakes.

·PT’s shall fulfill their legal and professional obligations

oExample: PT Dane happens to be double-booked with 2 patients who have Medicare as their primary insurance.If Medicare patients are seen together during a PT session, the session must be billed as a group therapy session.PT Dane however, chooses to bill each patient separately as reimbursement payments are more for individual sessions.PT Dane has violated this ethical code and in doing so has completed Medicare fraud.

·PT’s shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors

oExample: Every state requires continuing education typically of 30-40 hours every 2 years.

§PT Sonya has had a child over the past year and though she has 20 hours of continuing education, she has not had the time to take additional continuing education classes before the due date of her license renewal.If Sonya does not renew her license, she cannot work until her license is renewed.In order to continue to work to support her family, Sonya decides to lie about her continuing education hours stating that she has completed them, with hopes that the state board will not audit her this year.Sonya has just violated this ethical code and has jeopardized her licensure.

·PT’s shall promote organizational behaviors and business practices that benefit patient/clients and society

oExample: Company A utilizes both PT’s and licensed physical therapy assistants.PT John, and PTA Sally both are respectable practitioners and patients love them.PTA Sally has a good friend that needs treatment and makes an appointment on Sally’s schedule.PTA Sally does not tell PT John about this visit until 30 minutes into the session and asks PT John to perform a quick evaluation so that Sally can continue treatment with the appropriate documentation.

§If management from Company A, allowed PTA Sally to continue this without repercussion, this ethical code is violated, as PTA’s are not allowed to perform any treatment unless a patient is properly evaluated by a licensed PT.This type of activity threatens PT John’s licensure.

·PT’s shall participate in efforts to meet the health needs of people locally, nationally, or globally

oExample: This code can be responsibly employed by the PT by offering occasional pro bono services to patient’s with financial hardship, by extending hours so that patient’s who have to work still have access to PT services, or by participating in local and national health events such as fairs and/or conventions.

Physical therapists are skilled professionals in movement science and face ethical issues every day in clinical practice.The above examples are just some of the ways APTA’s code of ethics can either be employed or violated.It is imperative that PT’s continue to strive for excellence in their ethical and moral conduct, while it is also imperative that educational programs continue to teach and stress the importance of ethics in practice.

1.Clare M. Delany, Ian Edwards, Gail M. Jensen, Elizabeth Skinner, “Closing the gap between ethics knowledge and practice through active engagement: An applied model of physical therapy ethics,” Phys Ther, (July 90, 2010): 1068-1078.

2.Code of Ethics for the Physical Therapist.apta.org

Tags: code of ethics, Physical Therapy

Background and Purpose

Constrained practice is routinely encountered by physical therapists and may limit the physical therapist's primary moral responsibility—which is to help the patient to become well again. Ethical practice under such conditions requires a certain moral character of the practitioner. The purposes of this article are: (1) to provide an ethical analysis of a typical patient case of constrained clinical practice, (2) to discuss the moral implications of constrained clinical practice, and (3) to identify key moral principles and virtues fostering ethical physical therapist practice.

Case

The case represents a common scenario of discharge planning in acute care health facilities in the northeastern United States.

Methods

An applied ethics approach was used for case analysis.

Results

The decision following analysis of the dilemma was to provide the needed care to the patient as required by compassion, professional ethical standards, and organizational mission.

Discussion and Conclusions

Constrained clinical practice creates a moral dilemma for physical therapists. Being responsive to the patient's needs moves the physical therapist's practice toward the professional ideal of helping vulnerable patients become well again. Meeting the patient's needs is a professional requirement of the physical therapist as moral agent. Acting otherwise requires an alternative position be ethically justified based on systematic analysis of a particular case. Skepticism of status quo practices is required to modify conventional individual, organizational, and societal practices toward meeting the patient's best interest.

Constrained physical therapist practice is encountered when the clinician understands the patient's legitimate needs and, while acting to meet those needs, may be compelled to provide less than the necessary care.1–3 The process for determining legitimate patient needs is defined by the profession.4 Acting to meet patients' needs requires sufficient assets such as the expertise5 and moral courage6 of the physical therapist, sufficient financial resources, and supportive laws, regulations, and institutional culture.7 As an example, care may be constrained if a physical therapist determines a patient needs a particular intervention but a third-party payer does not reimburse for physical therapy or only reimburses for a different intervention. In this situation, if the physical therapist chooses to provide less than the needed patient service, the physical therapist's actions may be unethical.

The physical therapist is in a helping relationship, with the primary moral responsibility “to stand alongside” the patient.8 This manner of relating is crucial, as the patient is vulnerable and needs the help of the physical therapist to become well again.9 Due to this vulnerability, patient need carries a moral obligation for the physical therapist to act.10 Chronically constrained physical therapist practice erodes this helping relationship, moving the physical therapist toward moral disengagement11 and a loss of the commitment to stand alongside the patient.

The causes of constrained clinical practice may be internal or external, and the effects of constrained care may be weak or strong. A physical therapist's clinical practice is internally constrained when he or she possesses less than sufficient moral intent, expertise, or moral courage to help meet the individual patient's needs. Laws and regulations may be a source of external constraint on the physical therapist's practice. When professionals follow just laws, they contribute to a well-ordered society.12 However, professionals must be vigilant and not follow unjust laws or regulations not in the patient's best interest.13 The effect of constrained clinical practice on the patient varies from weak to strong. Weak constraint may have no discernable effect on a patient's care, whereas strong constraint always results in harm to the patient.

Evidence of constrained physical therapist clinical practice was identified by Guccione1 and Treizenberg,2 indicating physical therapists may not have sufficient resources to meet patients' needs. Greenfield and colleagues' qualitative study of 7 novice physical therapists also reported constraints on practice, including barriers to caring and the culture of the practice setting.14 Purtilo3 declared scarce resources to be an ongoing reality of the physical therapist practice environment. The medical profession is debating how to ensure patients' needs are met in an environment of constrained practice that attempts to limit professional autonomy.15–18 Morreim19 proposed deceptive documentation, so-called “gaming,” as a justifiable response. In the physical therapy profession, Nalette20 reported a case of a physical therapist gaming third-party payers to ensure patients received needed care and later reported anecdotal information from graduate student physical therapists who were involved in gaming.21

Jette et al22 proposed a clinical decision-making model used by occupational therapists and physical therapists for recommending placement of patients being discharged from an acute care setting. In the model, a clinician's initial discharge recommendation may be constrained by various regulations. This routine constraint of practice seemed to be recognized by these occupational therapists and physical therapists as a practice reality and an accepted condition for altering an individual's professional judgment. Moral concerns were not expressed about the acceptance of this routine constraint.

The processes used by physical therapists to make good moral decisions regarding a patient's legitimate needs are described in the physical therapy literature23–27 and are interwoven into expert clinical practice.28 The physical therapy profession defines this moral intent through its code of ethics. The American Physical Therapy Association's (APTA) Code of Ethics (Code) “[p]rovide standards of behavior and performance that form the basis of professional accountability to the public.”29 This public professing of a moral intent creates a normative foundation from which physical therapists ought to assess their moral actions. As an example, the physical therapy profession recognizes that third parties may attempt to constrain the physical therapist's ability to meet patient needs. However, its Code obligates physical therapists to “be accountable for making sound professional judgments” (Fig. 1, principle 3) while acting in “the best interests of patients/clients” (Fig. 1, principle 2A) and being “responsible stewards of health care resources and shall avoid overutilization or underutilization of physical therapy services” (Fig. 1, principle 8C). The physical therapist is morally obligated for meeting patients' needs.

When all is calm, the physical therapist understands a patient's needs and is able to meet those needs. This moral calmness ought to be interrupted when the physical therapist is unable to meet patient needs. Under conditions of constraint, the physical therapist is not fulfilling the profession's moral ideal, may not be fulfilling his or her personal moral intent, and may be practicing unethically as a physical therapist. During professional (entry-level) education, student physical therapists are taught to meet patients' needs and to do so in an ethical manner.30 At entry to clinical practice, the physical therapist is competent to meet patients' needs, is capable of assessing the ethics of practice, and is legally bound by the state jurisdiction to practice within ethical boundaries. A physical therapist then is professionally obligated to apply an ethics comprised of the agent's “personal philosophies, metaphysical beliefs, the virtues, communities, narratives, rules, principles, circumstances, consequences, feelings, intuitions, codes of ethics training and workplace norms” to the resolution of specific cases31(p147) to ensure morally good actions on behalf of patients. Ethical analysis, what Purtilo referred to as “tools for developing ‘habits of thought' for reflection,”32(p1114) and moral action then are required when the physical therapist encounters a situation of constrained practice. After all, as Frankena stated, “being without doing, like faith without works, is dead.”33(p66)

Constrained physical therapist practice is routinely encountered by physical therapists. Swisher34

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