Ethical Dilemmas in Home Healthcare
Whether you're a social worker, therapist, visiting nurse or another type of home healthcare practitioner, you will undoubtedly face an ethical dilemma at some point in your career.
These quandaries can relate to a patient's safety, competency or confidentiality, reimbursement or a host of other issues that force home healthcare workers to act. Three home healthcare professionals shed light on issues they must consider when dealing with these ambiguous day-to-day home-care predicaments.
Patients who put themselves at risk pose a dilemma for social workers, says Lisa Yagoda, LICSW, ACSW, a senior policy associate for the National Association of Social Workers. These patients may refuse medical treatment or services or reject common-sense advice.
"Patients have a right to refuse treatment or services, but there are risks associated with doing so," Yagoda says. "If the patient is supposed to use a walker and won't, if the patient refuses to eat the home-delivered meal, if the patient can't remember to take medication, then the social worker has to decide what is the appropriate action."
The dilemma lies in determining whether the patient is competent, Yagoda explains. And the social worker is responsible for assessing whether the patient understands the consequences of his behavior.
"A team approach to solving ethical dilemmas is ideal," she says. "We work with other disciplines, like nurses or physical therapists, to give the client a different perspective and explain to them why the rug or the pile of books on the floor is dangerous. If the patient still refuses and is at a great enough risk, it should be reported to the primary-care physician."
Yagoda touches on a dilemma that occupational therapists frequently encounter -- that of patient confidentiality versus patient well-being.
"If you have concerns about a patient's judgment, is your obligation solely to that client?" asks Janie Scott, director of practice and ethics for the American Occupational Therapy Association. "Or is the obligation to the family as well? Or to the referring authority? Do you breach confidentiality by sharing those concerns? Where does the client's protection enter into the discussion?"
Occupational therapists should question a client's judgment when, on a home visit, they see inadequate lighting, environmental hazards or bathrooms not equipped with proper safety features. Other signs that should call the client's judgment into question include poor motor skills or poor short-term memory.
"If the client denies the opportunity to make remedies to dangerous situations, then you have a difficult decision to make," Scott says. "It gets even more challenging when you understand that ethical issues can also turn into legal issues. Each practitioner needs to understand their scope of practice and their competency to intervene in a way that promotes well-being."
Time vs. Money
For visiting nurses, dealing with all patient needs in the short time that managed-care providers and Medicare/Medicaid allot for a visit can lead to ethical challenges as well, says Lynda Van Dyke, a division manager for the Colorado office of the Visiting Nurse Associations of America.
"You have to be very creative in terms of time management," Van Dyke says. "You have to identify additional resources in the community, like church and family members and volunteer workers, to assist the patient. Other disciplines, like social workers, can also be brought in to help."
That's all well and good until a situation occurs that requires immediate attention -- just as the visiting nurse's shift has ended. That's when the real ethical dilemma hits. For example, what should the nurse do if a patient has a sanitary accident and needs help? Clock out or clean up?
"We often go above and beyond the call of duty on our own time," Van Dyke says. "But that's another issue, because then you are not covered in terms of liability. But we will not abandon our patients. I am going to stay until the patient is safe."
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