Impacting Patient Care and Ethical Considerations
Kristin King, PhD, CCC-SLP
Ethical considerations are constantly evolving as medical care changes and advances. Because of the ever-changing state of medical care, being aware of the current research must be maintained at an international level as researchers from around the globe contribute to the standard of care for patients with tracheostomy and mechanical ventilation. However, a challenge to healthcare professionals is clarifying their role in the decision process for medical care and determining appropriate interventions for patients. The ethical standards that should be addressed in practice go beyond individualized, personal professions; they also incorporate the rights of patients and the consideration of a patient’s ability to access communication and to participate in their medical care. The efficiency and efficacy of the communication method provided is a primary aspect to patient care.
The articles in this issue provide support for both team management and early intervention with patients following tracheostomy to provide best practice. In the article by Hans Schwegler and Bischof, he follows the care of one patient over a year and provides perspectives on team management and complex problem solving with unique patient issues. The complexities of managing this patient population become evident through this patient case study. Each article provides a perspective on advances which are occurring in care management, from advanced treatment interventions to such practices as phrenic nerve stimulation.
However, as advances are made in medical care, an examination of ethical standards emerges on many levels to meet the demands of proper patient care and professional practice. Ethics in medical healthcare include the consideration of bioethics that deal with decisions related to both old and new practices in healthcare. An evolution of traditional ethical standards is being observed because standards for new issues are created – and then challenged and revised. The conversation is often sparked by new developments in patient care and it is constantly evolving. Kummer and Turner (2011) discussed that because the practice of medicine and medical speech-language pathology affects the health, well-being, and quality of life of individuals served, adherence to a code of ethical conduct is critically important in the healthcare environment.
One question that arises to challenge healthcare professionals on the medical front is what role each team member has in the decision process when determining appropriate interventions for patients with tracheostomy and mechanical ventilation. When patients are in the intensive care unit of a medical facility, one patient population to manage are those who are intubated, requiring mechanical ventilation to support their respiratory function. However, a dilemma arises with the decision of whether or not to pursue a tracheostomy tube and the timing of that placement. Desai and Chakrabarti’s article in this issue addresses the question of prolonged mechanical ventilation and the complications that arise. They walk the reader through the team concept and the members of a multidisciplinary team. While historically, Speech- Language Pathologists (SLPs) would not be involved at this level of care (prior to a patient’s ability to access communication and swallowing), because of the negative impact of intubation on swallowing and communication and the research which shows the significant benefits of early intervention – SLPs have a role in this decision process which Desai and Chakrabarti explore. This earlier intervention leads to the direct care of the patient with a tracheostomy and many questions arise as to the Scope of Practice of an SLP of working with these patients and the ethics behind conducting tasks that some see as more medical in nature versus “speech.”
Another aspect regarding the care of patients in the critical and acute settings is their ability to participate in their medical care and to make decisions, both of which are a basic human right. When a patient is intubated, they have lost their voice. However, various regulations, such as the ADA (American Disabilities Act), require that a patient have access to the least restrictive means of communication and access to participation in their medical care. “The ADA applies to all hospital programs and services… Wherever patients … are interacting with hospital staff, the hospital is obligated to provide effective communication… Effective communication is particularly critical in healthcare settings where miscommunication may lead to misdiagnosis and improper or delayed medical treatment.” While in the United States, the ADA provides support for access to communication, internationally; each country has their own system to address patients’ rights. The research that has best illustrated the impact that a loss of voice has on multiple aspects of a patient’s life is shared within the research article summaries.
Freeman-Sanderson et al. (2016) found that patients who were intubated or on mechanical ventilation without a means to voice had a higher incidence of depression and anxiety. The findings from this study indicated that patients with return of voice, by using a no-leak speaking valve, had decreased anxiety, improved mood, and shorter lengths of stay in the ICU. Another consideration to early voicing is that the AMA (2016) stated that is a fundamental requirement both by law and ethics for patients to have access to informed consent. Patients have the right to receive information and ask questions about recommended treatments, so that they can make well-considered decisions about care. Another aspect of care that is covered within the research article summaries and by Schwegler and Bischof is how poor access to communication or a lack of voice impacts a patient’s ability to notify and interact with medical staff effectively as it relates to their direct care.
It also has been reported that patients who cannot communicate are in more pain. Not only is there a link to the degree of pain, but it has been reported that difficulty communicating with healthcare practitioners remains a significant barrier to accessing pain relief (Limaye & Katz, 2006; Wiltshire, Cronin, Sarto, & Brown, 2006). Several authors have reported that decreased access to communication also may partially explain why pain continues to be frequently undiagnosed and mismanaged (Limaye & Katz, 2006; Wiltshire, Cronin, Sarto, & Brown, 2006). Due to the private and subjective nature of pain, it is necessary to communicate about the pain and the level of its impact, if others are to be aware of its presence and nature. It also has been shown that adverse events are three times more likely to occur when communication between medical professionals is not correct and efficient. In United States medical facilities, review of and adherence to standards is often overseen by JCAHO (Joint Commission: Accreditation, Healthcare, Certification). Meeting JCAHO’s goal is not the only reason to encourage patients to have a voice in their care though: patients who are actively involved in their care often have better outcomes (Metules & Bauer, 2006).
Briggs, E. (2010). Assessment and expression of pain. Nursing Standards, 25,35–38.
Freeman-Sanderson, A.L., Togher, L., Elkins, M.R., & Phipps, P.R. (2016). Quality of life improves with return of voice in tracheostomy patients in intensive care: An observational study. Journal of Critical Care, 33, 186-191. doi:10.1016/j.jcrc.2016.01.012
Kummer, A. and Turner, J. (2011). Ethics in speech language pathology in the health care setting. Seminars in Speech and Language, 32(4), 330-7
Limaye, S.S., & Katz, P. (2006). Challenges of pain assessment and management in the minority elderly population. Annals of Long Term Care, 14(11), 1–5.
Metules, T. & Bauer, J. (2006). Patient-inclusive care: Encouraging patients to be active participants in their care. JCAHO’s patient safety goals: a practical guide. Part 1. RN Journal, 69(12), 21-6.
National Cancer Institute (2011) Pain Assessment. Available: http://www.cancer.gov/cancertopics/pdq/supportivecare/pain/HealthProfessional/page2
Swann, J. (2010) Pain: Causes, effects and assessment. Nursing Residential Care, 12, 212–215.
Wiltshire, J., Cronin, K., Sarto, G., & Brown, R. (2006). Self-advocacy during the medical encounter. Medical Care 44(2), 100-109. doi: 10.1097/01 mlr.0000196975.52557.b7