Recent Good Practice articles have utilized the work on the draft Standards of Practice and how they have been modified to address questions received by the College and issues physiotherapists deal with in daily practice. The Code of Ethical Conduct is an equally valuable document that creates a moral anchor for the physiotherapist and works alongside the Standards of Practice to establish expectations for physiotherapists to abide by.
This article will look at several of the draft Standards of Practice and provide an in-depth look at the Code of Ethical Conduct and how it can shape difficult decision making in clinical practice. The following scenario will hopefully create a realistic look at how the Code and the Standards work together to establish expectations regarding re-assessment, prolonged care plans, and discharge.
Carlos is a physiotherapist working in a small-town clinic and has been treating Lada since she had a fall and injured her ankle. Initial x-rays were clear, but Lada’s ankle is six weeks post-injury and Carlos has concerns about the limited improvements thus far in her condition and her elevated pain levels with weight-bearing.
Re-assessment
Carlos has appropriately used outcome measures in the early stage of physiotherapy. When he re-assesses Lada at the six-week mark and compares the findings to the initial assessment completed two weeks after Lada’s injury, and the re-assessment at four weeks post-injury he realizes that there hasn’t been any significant change and Lada’s ankle isn’t responding as expected. Carlos also reviews his chart notes to evaluate the treatments to date and if any of them may have been too aggressive for the nature of the injury and acute timeline.
Note: The performance expectations referenced in this article are based off the draft Standards of Practice circulated in January 2023. There are differences from the version that is currently in effect. The draft standards indicate the future direction of the College of Physiotherapists of Alberta. The Code of Ethical Conduct has not recently changed, nor is it awaiting any revisions.
Code of Ethical Conduct
1. Practice in a safe, competent, accountable and responsible manner during the provision of services.
2. Take all reasonable steps to prevent harm to clients. Should harm occur disclose it to the client and others as required.
Assessment, Diagnosis, and Treatment Standard of Practice
1. Uses standardized measures as available to assess and reassess the clients condition and progress.
2. Applies treatment procedures safely and effectively.
3. Re-evaluates and monitors clients’ responses throughout the course of treatment.
Referral
After re-assessment Carlos is suspicious that there may be a fracture that was missed or some other issue driving Lada’s slow recovery. Due to the lack of progress and his concerns regarding Lada’s injury, he decides it is best to order ankle x-rays (as he has his authorization to do so) and also refers Lada back to the physician for consultation.
The x-rays suggest something could be going on in the ankle joint but further investigation is needed. Carlos phones the physician and the physician agrees to send Lada for a CT scan to provide better imaging of the ankle. Lada comes back two weeks later after obtaining a CT scan. The CT scan was able to show a talar dome fracture that was missed on the initial x-ray and Carlos adjusts his treatment and timelines for recovery to deal with the new information.
Code of Ethical Conduct
1. Work in partnership with clients to improve, support and/or sustain their health status and well-being.
2. Work effectively within the health-care system and manage resources responsibly.
Assessment, Diagnosis, Treatment Standard of Practice
1. Makes appropriate referrals when clients’ needs are best addressed in collaboration with or by another provider.
2. Promotes continuity in service by collaborating and facilitating clients’ transition from one health sector or provider to another.
Concurrent care
Some time has passed and Lada has struggled to improve. She is now fully weight-bearing but is struggling with pain levels, continued mild swelling, and she does not tolerate prolonged periods of standing or walking. She is frustrated with the recovery and Carlos has been noticing changes in Lada’s condition and outlook over the past several weeks that are flags for chronic pain and depression. Carlos has recently met with a more senior clinician in the clinic to discuss Lada’s treatment plan and has agreed to alter his approach to Lada’s care to better address the concerns around her mental health and chronic pain. He has also had good success with referring patients to a local mental health care worker and decides to have a conversation with Lada regarding her mental health and how a mental health care worker could help her with coping strategies and address some of her frustrations.
Code of Ethical Conduct
1. Communicate openly, honestly and respectfully with clients at all times.
2. Respect the principles of informed consent including by explaining service options, risks, benefits, potential outcomes, possible consequences of refusing treatment or services, and by avoiding coercion.
3. Respect and support the autonomy of the client to participate in the management and decision-making relating their own health.
4. Respect the confidentiality, privacy, and security of client information in all forms of communication.
5. Practice collaboratively with colleagues, other health professionals and agencies for the benefit of clients.
Assessment, Diagnosis and Treatment Standard of Practice
1. Makes adjustments and discontinues physiotherapy services that are no longer required or effective.
Concurrent Care Standard of Practice
1. Only participates in concurrent treatment of the same or a related condition when approaches are complementary, clinically indicated, of benefit to clients, and an appropriate use of human/financial resources.
Maintenance
Lada has done well dealing with some of the issues that were addressed by the mental health worker but is finding it difficult to get back to the activities she enjoys. She can do most things but finds her ankle gets tighter if she doesn’t attend physiotherapy treatments with Carlos. Carlos has continued to use outcome measures with Lada and is finding that Lada’s ankle has hit a plateau with range of motion and function. He notes that Lada continually refers to a “tightness” in her ankle that is alleviated by physiotherapy, but the pre- and post-treatment measurements do not show any changes.
Carlos is a bit conflicted as he is seeing little in the form of progress from his treatment at this stage of rehabilitation, but Lada has been coming regularly for the past few months and is insistent on continuing treatment. She is willing and able to continue to pay for physiotherapy treatment, but Carlos is unsure if he should continue to provide care to someone who isn’t demonstrating measurable changes.
This can be a common scenario in both public and private systems. Physiotherapists must make decisions on how much time and resources they have available to treat a patient. In private practice there is also the financial consideration as they often get paid a fee split for each treatment session they deliver. Therefore, if they continue to see patients they continue to be paid. There isn’t necessarily a conflict of interest as physiotherapists should be paid for the work they do, but if a physiotherapist is prolonging treatment plans or is encouraging a patient to continue care without reasonable grounds to do so, it can become a conflict of interest. Decision making with regards to ongoing treatment should be shared with the patient and should be supported by objective outcomes and evidence.
Code of Ethical Conduct
1. Assess the quality and impact of their services regularly.
2. Act honestly, transparently and with integrity in all professional and business practices to uphold the reputation of the profession.
Duty of Care Standard of Practice
1. Facilitates shared decision-making by taking the time to provide education regarding the client’s condition, supporting health literacy and facilitating the transition to self management.
2. Does not provide a physiotherapy service when the client’s condition indicates that commencing or continuing the physiotherapy service is not warranted or contraindicated.
Discharge and duty of care
Carlos has been working steadily with Lada and her mental health therapist to create self-management strategies and provide ongoing support for her recovery. Carlos decided to develop a maintenance plan for Lada to continue physiotherapy treatment once every two to three weeks for four visits. He felt that ongoing sessions had value as he could monitor her self-management strategies and slowly transition to more active treatment strategies with Lada being in control of pushing herself.
At the end of the four maintenance visits Carlos is confident that Lada can be discharged from physiotherapy. Lada is not so sure and has continued pressuring Carlos to continue treating her. She feels like ongoing treatments are necessary for her to maintain her level of function. She is apprehensive about the plan and fears she will lose ground after all of her and Carlos’s hard work. After a challenging conversation where Lada expressed these concerns and Carlos expressed his confidence that Lada can manage her ROM and reassured Lada that she is always able to return if needed, Carlos and Lada agree to a trial discharge. Carlos feels this is a good balance of discharging a patient but leaving the door open for her return so Lada does not feel abandoned, keeping in mind her long journey to get to this stage.
Conclusion
Carlos and Lada’s patient care journey hopefully highlights the Code of Ethical Conduct and performance expectations related to a common challenging patient care scenario. The decisions made while in practice should reflect an ethical and empathetic approach to care while following the legislative requirements and meeting the expectations found in the Standards of Practice. When faced with challenging decisions, it may be helpful to review the Code of Ethical Conduct to create a grounding in “what is best for the patient.”
Sean FitzGerald, PT, Practice Advisor
