Code of Conduct

Ch9part4of5.pdf

Home >Science homework help >Code of Conduct

31305601 - Jones & Bartlett Learning ©

scribed by Dr. deAraujo, the treating physician. She stated that Pecot had added resistive or strengthening exercises to Pontiff’s therapy and that these were not a part of the physician’s prescription, which specified “range of motion and stretching exercises.” Pecot argued that resistive exercises were implicitly part of the prescription, even if her interpretation of the prescription was not reasonable.

Legally, under Louisiana law, a physical therapist may not treat a patient without a written physical therapy prescription. Ethically, the Physical Therapists’ Code of Ethics, Principle 3.4, states “any alteration of a program or extension of services beyond the program should be undertaken in consultation with the referring practitioner.” Because resistive exercises were not set forth in the original prescription, Boulet stated that consultation with the physician was necessary before Pontiff could be advanced to that level. Only in the case where a physician has indicated on the prescription that the therapist is to “evaluate and treat” would the therapist have such discretion. There was no such indication on the prescription written by Dr. deAraujo.

Virginia Davis, a physical therapist in private practice and Pecot’s expert witness, testified that the program that Pecot designed for Pontiff was “consistent with how she [Pecot] interpreted the prescription for therapy that the physician wrote.” Davis, however, did not at any time state that Pecot’s interpretation was a reasonable one. In fact, Davis herself would not have interpreted the prescription in the manner that Pecot did. Davis testified only that Pecot’s introduction of resistive exercises was reasonable based on her interpretation of the prescription.

It is clear that Pecot, as a licensed physical therapist, owed a duty to Pontiff, her client. Pecot’s duty is defined by the standard of care of similar physical therapists and the American Physical Therapy Association. If Pecot found the prescription to be ambiguous, she had a duty to contact the prescribing physician for clarification. The appeals court found that the trial court was correct in its determination that Pontiff presented sufficient evidence to show that this duty was breached and that Pecot’s care fell below the standard of other physical therapists.

31305601 - Jones & Bartlett Learning ©

Resident Neglect The physical therapist in the following case not only failed according to the legal system but also failed to adhere to the professional code of ethics for physical therapists, which provides:

2B. Physical therapists shall provide physical therapy services with compassionate and caring behaviors that incorporate the individual and cultural differences of patients/clients.

In Zucker v. Axelrod, a physical therapist had been charged with resident neglect for refusing to allow an 82-year-old nursing facility resident to go to the bathroom before starting his therapy treatment session. Undisputed evidence at a hearing showed that the petitioner refused to allow the resident to be excused to go to the bathroom. The petitioner claimed that her refusal was because she assumed that the resident had gone to the bathroom before going to therapy and that the resident was undergoing a bladder-training program. The petitioner had not mentioned when she was interviewed after the incident or during her hearing testimony that she considered bladder training a basis for refusing to allow the resident to go to the bathroom. It is uncontroverted that the nursing facility had a policy of allowing residents to go to the bathroom whenever they wished to do so. The court held that the evidence supported resident neglect.

Multidisciplinary Approach to Patient Care

Do patients believe that care is always well coordinated? Are patients at times treated based on short “handwritten notes” by the prescribing physician? Are mistakes sometimes made because of illegible handwriting? Is it helpful to the radiologist if the ordering physician notes on the order sheet why a particular imaging study is required? Do nurses sometimes find it necessary to clarify medication orders? Do pharmacists find it necessary to contact the physician when there are dosing questions? Would it be helpful for the prescribing physician to discuss a patient’s needs with the treating therapist? Would it be helpful if the physician reviewed the imaging studies of his or her patient with

file://view/books/9781284144192/epub/EPUB/xhtml/18_chapter09_25.html#ch9-bib91

file://view/books/9781284144192/epub/EPUB/xhtml/18_chapter09_25.html#ch9-bib92

31305601 - Jones & Bartlett Learning ©

serious neck injuries, prior to treatment by a therapist? Does understaffing affect the quality of care?

Jill recently visited a pain center where the medical director had integrated a pain therapist into the hospital’s pain management program. After several visits to the hospital’s pain management program, Jill complimented the staff as to their multidisciplinary approach to her care.

The medical director stated that the success of the hospital’s pain management program was due to the multidisciplinary approach practiced in the hospital. He stated that pain management is often poorly practiced because of the failure of the treating physician to become more involved in the patient’s therapy. A patient’s pain is often exacerbated because of a superficial treatment plan that fails to include the physician, and the failure to provide the images to the treating therapist. Both the physician and treating therapist, and most important the patient’s care, are optimized when there is ongoing communication among caregivers. The medical director further stated that professionalism and satisfaction among caregivers improve when communications flow freely.

Jill again complimented the staff and stated that she would not hesitate to recommend the hospital’s pain management program to her family and friends.

The next time a caregiver treats a patient, the patient should ask: What records have you seen? Have you discussed my treatment plan with my physician? What were my physician’s specific orders? May I see them? What precautions have you been asked to follow with me? Have you seen my imaging studies? Has anyone discussed them with you?

My pledge as a patient: I will ask myself, am I being treated in an assembly-line fashion, assembled in a room like cattle, without privacy in cramped corridors by a caregiver who, because of understaffing, is frantically moving from patient to patient, or am I truly getting individualized care and treatment in a style worthy of the words “I am receiving good quality care”?

Discussion 1. Regardless of your profession or healthcare setting,

discuss how the multidisciplinary approach to patient care might be improved in your organization.

2. Consider and discuss what questions you might ask if you were the patient undergoing treatment.

31305601 - Jones & Bartlett Learning ©

PHYSICIAN ASSISTANT Physician assistants (PAs) are healthcare professionals who “practice medicine on a team under the supervision of physicians and surgeons; there are 123,000 certified PAs nationwide, 70% of whom work in specialty practice and 27% working in primary care.” They are formally educated to examine patients, diagnose injuries and illnesses, and provide treatment. PAs work in physicians’ offices, hospitals, and other healthcare settings. They are subject to the licensing laws within the state they are qualified to practice in. As the role of PAs continues to expand, it is mandatory that they review and understand applicable state licensing laws. In addition, PAs must work within the scope of practice as defined by their employers.

PAs are responsible for their own negligent acts. Further, an employer of a PA can be held liable for a PA’s negligent acts on the basis of respondeat superior. Physicians who delegate tasks to PAs that licensing laws stipulate a physician must perform can be held liable for assignment of an unauthorized task that results in an injury to a patient. If there is no proof that a PA breached the applicable standard of care for a PA, liability will not accrue to the PA. However, if the physician was negligent in making the assignment to the PA that led to the injury, liability could accrue to the physician.

The plaintiff in Cox v. MA Primary and Urgent Care Clinic sued for injuries she allegedly suffered as a result of a PA’s failure to diagnose her condition accurately. The patient was eventually diagnosed with cardiomyopathy. A mitral valve repair and mitral valve replacement were ultimately performed. The patient sued the PA for failure to readily diagnose her condition. The Tennessee Supreme Court, after reviewing the case, held:

The professional standard of care applicable to physician assistants is distinct from that applicable to physicians. Because Plaintiff introduced no expert proof as to any violation of the applicable standard of care, the trial court was correct in its ruling that Defendants are entitled to summary judgment.

31305601 - Jones & Bartlett Learning ©

To limit the potential risk of liability for a PA’s negligent acts, PAs should be monitored and supervised by a physician. Moreover, guidelines and procedures should also be established to provide a standard mechanism for reviewing a PA’s performance.

31305601 - Jones & Bartlett Learning ©

PSYCHOLOGY Psychologists are expected to safeguard the welfare and rights of those with whom they interact professionally. They must establish relationships of trust with those with whom they work. They must uphold professional standards of conduct, clarify their professional roles and obligations, and accept responsibility for their behavior. Principle A of the “Psychologist and Code of Conduct” states in part:

Principle A: Beneficence and Nonmaleficence Psychologists strive to benefit those with whom they work and take care to do no harm. In their professional actions, psychologists seek to safeguard the welfare and rights of those with whom they interact professionally and other affected persons, and the welfare of animal subjects of research. When conflicts occur among psychologists’ obligations or concerns, they attempt to resolve these conflicts in a responsible fashion that avoids or minimizes harm. Because psychologists’ scientific and professional judgments and actions may affect the lives of others, they are alert to and guard against personal, financial, social, organizational, or political factors that might lead to misuse of their influence. Psychologists strive to be aware of the possible effect of their own physical and mental health on their ability to help those with whom they work.97

31305601 - Jones & Bartlett Learning ©

Failure to Minimize Harm: Unethical Conduct Sturm, a licensed psychologist who has taught professional ethics since 1985 and who served on the ethics committee of the Oregon Psychological Association for 6 years, testified that testimony about the best interests of children in a custody dispute by a therapist who had not observed both parents’ interactions with the children was unethical. Sturm further stated that a psychologist has an obligation to adopt an impartial stance and to avoid actions that would escalate an adversarial nature of the relationship between the parents. Sturm explained that psychologists have “an ethical responsibility to anticipate the possible purposes” behind a request to prepare an affidavit to be used in a custody dispute in order to prevent misuse of the evaluation and agreed that practices such as making evaluative statements about persons or relationships not observed directly are blatantly unethical. The petitioner’s affidavit made such statements, and it was not until the show cause hearing that petitioner admitted to her bias toward her patient.98

31305601 - Jones & Bartlett Learning ©

Sexual Harassment The Ethical Principles of Psychologists and Code of Conduct, on sexual harassment states:

3.02 Sexual Harassment Psychologists do not engage in sexual harassment. Sexual harassment is sexual solicitation, physical advances or verbal or nonverbal conduct that is sexual in nature, that occurs in connection with the psychologist’s activities or roles as a psychologist and that either (1) is unwelcome, is offensive or creates a hostile workplace or educational environment, and the psychologist knows or is told this or (2) is sufficiently severe or intense to be abusive to a reasonable person in the context. Sexual harassment can consist of a single intense or severe act or of multiple persistent or pervasive acts.

The Board of Psychologist Examiners in Gilmore v. Board of Psychologist Examiners revoked a psychologist’s license because of sexual improprieties. The Board found that:

When a therapist’s emotional state overwhelms the rational decision-making process in dealing with clients, we think it demonstrates a significant personal problem. This personal problem would be very likely to cause loss of objectivity and to therefore result in inferior services to a client who is the object of the attraction. Harm to the client in this situation is also likely, because the client is vulnerable, is in a position to be exploited, yet has placed trust in the therapist.

The psychologist petitioned for judicial review. She argued that therapy had terminated before the sexual relationships began. The court of appeals held that evidence supported the board conclusion that the psychologist had violated an ethical standard in caring for her patients. When a psychologist’s personal interests intrude into the practitioner–client relationship, the practitioner is obliged to seek objectivity through a third party. The board’s findings and conclusions indicated that the petitioner failed to maintain that objectivity.

100

101

31305601 - Jones & Bartlett Learning ©

Reporting Child Abuse Two children were placed in the temporary custody of a foster family. One child was referred to a licensed psychologist for evaluation. After two interviews, the psychologist formed the professional opinion that the child had been sexually molested. Based in part on statements made by the child, the psychologist further believed that the perpetrator of the suspected molestation was the father. At a hearing before the juvenile court, the court determined that the evidence did not support a finding the child had been abused by his father. Custody was returned to the parents. The child’s parents subsequently initiated an action for medical malpractice against the psychologist. The psychologist claimed immunity from liability, as provided by a state child abuse reporting statute. The trial court and the parents appealed, arguing that the immunity provisions of the statute do not apply to the psychologist because she was not a “mandatory reporter” under that statute.

The Georgia Court of Appeals held that the statute’s grant of immunity from liability extended to the psychologist. The evidence did not establish bad faith on the part of the psychologist so as to deprive her of such immunity. The statute provides that any person participating in the making of a report or participating in any judicial proceeding or any other proceeding resulting in a report of suspected child abuse is immune from any civil or criminal liability that might otherwise be incurred or imposed, provided such participation pursuant to the statute is made in good faith. The grant of qualified immunity covers every person who, in good faith, participates over time in the making of a report to a child welfare agency. Proof of negligent reporting or bad judgment is not proof that the psychologist refused to fulfill her professional duties out of some harmful motive or that she consciously acted for some dishonest purpose. There was no competent evidence that the psychologist acted in bad faith.

102

31305601 - Jones & Bartlett Learning ©

RADIOLOGY Medical imaging–related lawsuits include ordering unnecessary tests, physician kickbacks, patient falls, the negligent handling of equipment, improper lead shielding, and misdiagnosis. Lawsuits against radiologic technologists are rare. It has been reported “fewer than nine malpractice payments involving an x- ray technician are awarded each year. In more than half of these cases, payments do not exceed $50,000. These findings come from analysis of x-ray technician malpractice payments reported to the National Practitioner Data Bank over 18 years.”

Radiology technologists are expected to conduct themselves in a professional manner, respond to patient needs, and support colleagues and associates in providing quality patient care. The radiologic technologist, as with all healthcare professionals who care for patients must within their scope of responsibility, exercise care, discretion, and judgment; assume responsibility for professional decisions; and act in the best interest of the patient.

The technologist failed to exercise discretion in the following case by not making sure the patient was secured to the table prior to the examination to prevent the patient from falling.

103

31305601 - Jones & Bartlett Learning ©

Failure to Restrain Causes Patient Fall The plaintiff in Cockerton v. Mercy Hospital Medical Center was admitted to the hospital for the purpose of surgery. Her physician ordered postsurgical X-rays for her head and face to be taken the next day. A hospital employee took the plaintiff from her room to the X-ray department by wheelchair. A nurse had assessed her condition as slightly “woozy” and drowsy. An X-ray technician took charge of the plaintiff in the X-ray room. After the plaintiff was taken inside the X-ray room, she was transferred from a wheelchair to a portable chair for the procedure. After being moved, the plaintiff complained of nausea. The technician did not use the restraint straps to secure the plaintiff to the chair. At some point during the procedure, the plaintiff had a fainting seizure. The technician called for help. When another hospital employee entered the room, the technician was holding the plaintiff in an upright position. She appeared nonresponsive. The plaintiff only remembered being stood up and having a lead jacket placed across her back and shoulders. The technician maintains that the plaintiff did not fall. At the time the plaintiff left the X-ray room, her level of consciousness was poor. The plaintiff’s physician noticed a deflection of the plaintiff’s nose but had difficulty assessing it because of the surgical procedure from the day before.

The following day, the deflection of the plaintiff’s nose was much more evident. A specialist was contacted, and an attempt was made to correct the deformity. The specialist made an observation that it would require a substantial injury to the nose to deflect it to that severity.

The plaintiff instituted proceedings against the hospital, alleging that the negligence of the nurses or technicians allowed her to fall during the procedure and subsequently caused injury. The jury concluded that the hospital was negligent in leaving the plaintiff unattended or failing to restrain her, which proximately caused her fall and injury.

The X-ray technician testified that during the X-ray the plaintiff appeared to have a “seizure episode.” She also testified that she left the plaintiff unattended for a brief period of time and that she did not use the restraint straps that were attached to the portable X-ray chair. Using the restraint straps would have secured the plaintiff to the portable chair during the X-ray examination.

104

31305601 - Jones & Bartlett Learning ©

RESPIRATORY CARE Respiratory care involves the treatment, management, diagnostic testing, and control of patients with cardiopulmonary deficits. A respiratory therapist (RT) is a person employed in the practice of respiratory care who has the knowledge and skill necessary to administer respiratory care. As with other healthcare professionals, respiratory RTs are expected to comply with their professional code of ethics. The American Association for Respiratory Care, in its Statement of Ethics and Professional Conduct, requires that RTs:

Demonstrate behavior that reflects integrity, supports objectivity, and fosters trust in the profession and its professionals.

That code was violated in State University v. Young. In this case, the RT was suspended for using the same syringe for drawing blood from a number of critically ill patients. The therapist had been warned several times of the dangers of that practice and that it violated the state’s policy of providing quality patient care.

Although an RT is responsible for the negligent acts, the employer can be held responsible for the negligent acts of the therapist under the legal doctrine of respondeat superior.

Case Studies Restocking the Code Cart In Dixon v. Taylor,111 N.C. App. 97, 431 S.E.2d 778 (1993), Dixon had been admitted to the hospital and was diagnosed with pneumonia in her right lung. Dixon’s condition began to deteriorate, and she was moved to the intensive care unit (ICU). A code blue was eventually called, signifying that her cardiac and respiratory functions were believed to have ceased. During the code, a decision was made to intubate by inserting an endotracheal tube into Dixon so that she could be given respiratory support by a mechanical ventilator.

105

106

31305601 - Jones & Bartlett Learning ©

As Dixon’s condition stabilized, Dr. Taylor, Dixon’s physician at that time, ordered that she be gradually weaned from the respirator. Blackham, a respiratory therapist employed by the hospital, extubated Dixon at 10:15 p.m. Taylor left Dixon’s room to advise her family that she had been extubated.

Blackham decided an oxygen mask would provide better oxygen to Dixon but could not locate a mask in the ICU; thus, he left ICU and went across the hall to the critical care unit. When Blackham returned to Dixon’s room with the oxygen mask and placed it on Dixon, he realized that she was not breathing properly. Blackham realized that she would have to be reintubated as quickly as possible.

A second code was called and Shackleford, a nurse in the cardiac critical care unit, responded to the code. Shackleford recorded on the code sheet that she arrived in Dixon’s room at 10:30 p.m. She testified that Blackham said he had too short of a blade and he needed a medium, a Number 4 MacIntosh laryngoscope blade, which was not on the code cart. The code cart is a cart equipped with all the medicines, supplies, and instruments needed for a code emergency. The code cart in the ICU had not been restocked after the first code that morning; thus, Shackleford was sent to obtain the needed blade from the critical care unit across the hall.

When Shackleford returned to the ICU, the blade was passed to Taylor, who had responded to the code and was attempting to reintubate Dixon. After receiving the blade, Taylor was able to quickly intubate Dixon. Dixon was placed on a ventilator, but she never regained consciousness. After the family was informed there was no hope that Dixon would recover the use of her brain, the family requested that no extraordinary measures be taken to prolong her life.

A medical negligence claim was filed against Taylor and the hospital. The jury found that Taylor was not negligent. Evidence presented at trial established that the hospital’s breach of duty in not having the code cart properly restocked resulted in a 3-minute delay in the intubation of Dixon. Reasonable minds could accept from the testimony at trial that the hospital’s breach of duty was a cause of Dixon’s brain death, without which the injury would not have occurred. Foreseeability on the part of the hospital can be established from the evidence introduced by the plaintiff that the written standards for the hospital require every code cart be stocked with a Number 4 MacIntosh blade. This evidence permits a reasonable inference that the hospital should have foreseen that the failure to have the code cart

stocked with the blade could lead to critical delays in intubating a patient. Accordingly, there was substantial evidence that the failure to have the code cart stocked with the proper blade was a proximate cause of Dixon’s fatal injuries.

Ethical and Legal Issues 1. Describe the ethical issues involved in this case. 2. Explain how the elements of negligence are met in this

case. 3. What steps could be implemented to prevent similar

occurrences in the future?

SOCIAL WORK Social workers in the hospital setting assist patients and families with psychosocial issues; obtaining insurance coverage; making difficult care decisions; and assisting the patient and family in planning for post-discharge care. As with many professionals, social workers are often overlooked and underused when it comes to the team approach to health care. It has, over the years, been a low priority with hospitals to hire an effective team, adequately staffed to address the myriad of issues that need to be addressed in the delivery of patient care.

The National Association of Social Workers Code of Ethics specifies the following six purposes:

1. The Code identifies core values on which social work’s mission is based.

2. The Code summarizes broad ethical principles that reflect the profession’s core values and establishes a set of specific ethical standards that should be used to guide social work practice.

3. The Code is designed to help social workers identify relevant considerations when professional obligations conflict or ethical uncertainties arise.

4. The Code provides ethical standards to which the general public can hold the social work profession accountable.

5. The Code socializes practitioners new to the field to social work’s mission, values, ethical principles, and ethical standards.

6. The Code articulates standards that the social work professional itself can use to assess whether social workers have engaged in unethical conduct. NASW has formal procedures to adjudicate ethics complaints filed against its members. [For information on NASW adjudication procedures, see NASW Procedures for the Adjudication of Grievances.] In subscribing to this Code, social workers are required to cooperate in its implementation, participate in NASW adjudication proceedings, and abide by any NASW disciplinary rulings for sanctions based on it.

As with any profession, legal and moral issues concern social workers as well, as noted in the following news clipping.

107

Caseworker Fired after Baby Dies

A District of Columbia social worker was fired Tuesday following the death of a baby who was reported as neglected, city officials said.

The city’s Child and Family Service Agency received a call about the 6-month-old boy in March, but the social worker assigned to the case never visited the child, interim Attorney General Peter Nickles said.

—Nikita Stewart, The Washington Post, July 8, 2008

CERTIFICATION OF HEALTHCARE PROFESSIONALS The certification of healthcare professionals is the recognition by a governmental or professional association that an individual’s expertise meets the standards of that group. Some professional groups establish their own minimum standards for certification in those professions that are not licensed by a particular state. Certification by an association or group is a self-regulation credentialing process.

LICENSING OF HEALTHCARE PROFESSIONALS Licensure can be defined as the process by which some competent authority grants permission to a qualified individual or entity to perform certain specified activities that would be illegal without a license. As it applies to healthcare personnel, licensure refers to the process by which licensing boards, agencies, or departments of the several states grant to individuals who meet certain predetermined standards the legal right to practice in a healthcare profession and to use a specified healthcare practitioner’s title. The commonly stated objectives of licensing laws are to limit and control admission to the different healthcare occupations and to protect the public from unqualified practitioners by promulgating and enforcing standards of practice within the professions. Health professions commonly requiring licensure include dentists, nurses, pharmacists, PAs, osteopaths, physicians, and podiatrists.

The authority of states to license healthcare practitioners is explicit in their regulatory powers. Implicit in the power to license is the right to collect licensing fees, establish standards of practice, require certain minimum qualifications and competency levels of applicants, and impose on applicants other requirements necessary to protect the general public welfare. This authority, which is vested in the legislature, may be delegated to political subdivisions or to state boards, agencies, and departments. In some instances, the scope of the delegated power is made specific in the legislation; in others, the licensing authority may have wide discretion in performing its functions. In either case, however, the authority granted by the legislature may not be exceeded.

SUSPENSION AND REVOCATION OF LICENSE Licensing boards have the authority to suspend or revoke the license of a healthcare professional found to have violated specified norms of conduct. Such violations may include procurement of a license by fraud; unprofessional, dishonorable, immoral, or illegal conduct; performance of specific actions prohibited by statute; and malpractice. Suspension and revocation procedures are most commonly contained in a state’s licensing act; in some jurisdictions, however, the procedure for suspension and revocation of a license is left to the discretion of the licensing board.