[DYSPHAGIA] Ethical Question

[linds@escape.ca (Lindsey McLean)]

Carol

I notice you're posting from Canada....I'm in Winnipeg.  We already have a
similar situation here where us SLPs, including our Senior SLP (no longer a
manager due to program management put in place in 1992).  Our Senior SLP
reports to our 2 rehab mgrs who are a PT and OT team; the PT manages SLP
concerns and the OT manages audiology concerns.  We are under the Emergency
program at our hospital.  I believe our Program Manager is a nurse.  

We haven't encountered your hypothetical situation in quite the same way as
posed yet.  However my position and 1 other full-time adult SLP position
were just added to the department 1 year ago; we also all provide service
M-F.  Before our positions were added, a significant amount of prioritizing
had to take place.  For safety concerns only, swallow evals were done
before communication evals if that situation arose.  Swallow therapy was
not done, other than recommendations.  

Now that 2 additional bodies service adults in our hospital, we can usually
do inpatient evals on a first-come, first-serve basis instead of
prioritizing quite as much and making patients wait.  We also now provide
dysphagia therapy because we have the time.  On occasion we still have to
prioritize if we're really busy and we still look after swallow needs
first.  I know we do this because of safety concerns but it throws all of
us into an ethical dilemma of our own.  We look on ourselves as experts in
communication in the hospital, and this prioritization takes away from
that.  We really encounter some "moral residue" (term from our clinical
ethicist) when the communication needs of our patients get left behind.  

Getting back to your hypothetical...I think if it came down to it, several
of the SLPs I know would rather see another discipline take over dysphagia
service with some extra training on top of what they already know about
feeding/eating, rather than communication.  I would have to feel confident
in the other person/discipline providing dysphagia service as needed, but I
would feel much more confident about communication service being provided
by a SLP rather than another discipline.  Disciplines such as dieticians
and OTs do know a certain amount about eating/feeding anyway; we work
closely with student dieticians to expose them to dysphagia as well as
their own nutrition placement.  Of course I would prefer they receive much
more training on top of the knowledge they already possess, hopefully that
would be allowed to happen in a flexible, non-crash-course manner!  

I'll leave it there for now...
Lindsey, MS, CCC-SLP
St Boniface Hospital

At 07:39 25/06/00 -0400, Carol Wilkins wrote:
>This is a hypothetical question as yet--and I hope it remains so.
>
>Context:  Program management in which SLP's report to program managers
>who are not SLPs.
>
>SLP resources are limited in the Long Term Care program.  In order to
>most effectively use the resource, the SLP has decided to provide
>swallowing services as priority followed by consultation  re
>communication issues (e.g. assessment with management recommendations to
>patient, staff, family etc but not direct treatment).  Program manager,
>staff, and all families are made aware of this model of service.
>
>Scenario:  A family aware of the service model demands direct
>communication treatment for their family member of the SLP and
>subsequently the Program Manager.  The Program Manager decides the SLP
>will provide direct communication treatment to patients.  In order to
>free up her time, the OT will provide swallowing services.  The SLP has
>considerable expertise in dysphagia based on university and ongoing
>continuing education and extensive experience.  The OT has no dysphagia
>training or experience.
>
>Query:  What is the SLP's ethical responsibility to patients with
>dysphagia in the facility?
>
>We assume she will inform the manager of competencies required to treat
>swallowing---but, if the manager continues to insist the OT provide that
>service without appropriate training----what is required of the SLP?
>
>Corollary re choice of service provision:  If an SLP is an employee of a
>facility where dysphagia may be expected, and she has the requisite
>skills to assess and treat dysphagia,  but too limited work time to
>address both communication and dysphagia,  may she opt to treat only
>communication?
>
>I am looking for your thoughts on the ethical situation.
>
>Thanks
>
>Carol
>
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