Identifying Ethical Dilemmas in Practice

You are listening to the AOT podcast. Here is your host, Matt Brandenburg.

All right, today I am joined by Leslie Bennett, the chairperson of the ethics commission at the American Occupational Therapy Association. Leslie, welcome! Welcome to the show.

Thank you so much for having me.

Of course, it's my pleasure. I've been really looking forward to speaking with you and to get a little ethical because you are the ethics commission chairperson. Can you kind of introduce us to the ethics commission and your role as chairperson?

Absolutely. Um, so the ethics commission is part of AOTA, and our—we have three main essential job functions. Uh, most people consider us just the people that they send complaints to, um, and while we do actually answer and respond to complaints and oversee them, two of our bigger jobs and priorities is providing education to practitioners and all of our members across the United States, as well as uh creating educational handouts, um, and uh driving policies and helping um re-create and update the code of ethics. We do that on a five-year cycle. So we honestly, we do—it's a three-dimensional process, and like I said, most people consider us as the place you send a complaint if you're having problems in practice, but I want people to understand that we're more than that, and that we also provide education and we have a hand in helping kind of develop uh policies around the uh code of ethics for the commission and AOTA at large.

I love that. It seems like such an important organization within the field of Occupational Therapy to help and to assist practitioners. How do you really hope that the commission's actions impact the everyday practitioner?

You know, I think that one of the biggest surprises as I got more and more into ethics was the fact that none of us honestly got into Health Care to um be faced with with ethical challenges and dilemmas, but unfortunately, that's kind of the state of our country, including Healthcare right now. And so for those of us who really don't delve into ethical situations and challenges every day, we really don't have a starting point of what is our responsibility in this, what is our role, and how do we negotiate some of these tougher challenges? And so, you know, my point is to be a point person to help educate people on how to handle some of these growing dilemmas and tougher challenges that we are facing in practice as well as outside of practice, but to do it in an ethically responsible way that really meets the needs of everyone that's involved in the situation. So we have a responsibility to help and um treat our patients, but when we're challenged with underlying policy or organizational standards that may be impeding our ability to do our best job, it really has become a challenging culture and environment in the clinic to negotiate that. So I honestly started because of my interest in the rising productivity issues in the clinics um as a clinician, and my confidence and understanding of Ethics grew from that, um, and really just trying to understand some of the—you know, it's understanding that there's so many different contextual facts, and that nothing is black and white. What I joke with my students about is that it's actually 50 Shades of Gray, um, and you never know what you're going to get.

I love that. I love that. And I—I love that your background is in um practicing occupational therapy. The commission really is boots on the ground and and is really trying to help practitioners, which I think is needed. Like you mentioned, um, you know, ethical situations in practice can be daunting. Uh, they can make practitioners feel really uncomfortable, especially when you know something might be wrong, but you're not sure how to handle it, and you're not sure how to deal with those policies and those systems you mentioned, um, which is why I'm so glad we're discussing identifying ethical dilemmas in practice today. Um, they truly can be ambiguous, and what may seem straightforward to one person might be fraught with ethical implications to another, um, as you mentioned to me earlier in preparing for this episode. So we want to help equip practitioners with tools and the mindset to spot and address these dilemmas.

Absolutely. Absolutely. So, so let's—let's get to it. How would you describe medical ethics um to kind of give us a a base level of understanding?

So you know, I put a lot of thought into how to answer this because it can really be complicated, and I think it's a dynamic definition that's constantly evolving and changing, but overall medical ethics is really concerned with the obligations that Health Care practitioners and Facilities have towards not only their clients and the clientele that they serve, but also other professions and Society. So really looking at the different obligations that come in practice and then really starting—the comes from when obligations start competing against each other. So we're constantly kind of looking at what are all the different obligations and how do we meet them when some of them are competing against another obligation that we might have in practice.

That's such an interesting thought to me—when obligations compete against each other—how to find the best um compromise or best scenario where all obligations can be fulfilled without doing any harm.

I think ethics is something—uh, I know I learned about in my curriculum in OT school—um, it's—it's emphasized in the occupational therapy practice framework—um, with principles of autonomy, beneficence, non-maleficence, and Justice. How would you say those principles help to guide ethical decision-making?

Well, you know, first and foremost, those ethical principles are actually what our code of ethics is founded on. So we actually use autonomy, beneficence, non-maleficence, justice, as well as uh veracity and Fidelity to kind of outline the areas that we need to be conscientious of when we're in practice, um, and so we really start from that and kind of educating people—what—what are those principles? And if you're not in ethics every day, they're pretty ambiguous principles for people to understand, but I try to teach people that on autonomy is about independence and being able to assert our own independence, make our own decisions, and two key pieces of autonomy for us is making sure that our clients are able to provide informed consent as well as their right to privacy and having everything um, you know, maintained confidentiality—that we're maintaining HIPAA with our students—our FERPA laws. So autonomy is a big one; it's—it's definitely one that we strive to address, but a lot of times that can come into competition with the next two uh principles, which is beneficence, which really is looking at the benefit—what kind of benefit does it provide to the individual—versus the second term, which is non-maleficence, which is really about doing no harm. And so a lot of times we get a lot of situations where maybe the individual's autonomy is now directly in conflict with benefits or even um the risks of procedures or um interventions that we want to use. So we really use these to define how we should be interacting, and then the fourth of the main principles is Justice, and that's really to act justly, which means equitably, um, and really making sure that we're providing equitable Services um in practice as well as in our education environment. So I think it's really important that you understand that we have a responsibility to maintain each of these principles, but there are situations that unintended or intended often cause one of these principles to be in direct conflict with another one. So a lot of what I do in ethics is really evaluating and balancing which principle may be the one that we have to address the most and be the one that kind of takes um precedence over some of the other principles when we're trying to make the best decision that we can. So they're honestly—in Ethics—that's how we guide um and make ethical decisions, and we founded our—our code of ethics on those principles, and uh, you know, the essence of them is written into every single one of the standards that we have.

So the principles really are the guiding light to how we examine situations.

I love that. I love that. Much like a practitioner bases their intervention approach and their approach to the OT process on um on Theory and on evidence, um, practicing good ethics also needs a solid foundation and understanding of these principles.

Oh yeah, I mean, ethics school is about the founding of the theories and how we make decisions, and then on the principles, and we have our own set of theories that we use to help kind of guide decision-making. So that's exactly what it is.

So I love that. I love that, and these principles to me, they truly seem fundamental to um occupational therapy practice, um, but occupational therapy operates within a larger system, um, and a non-perfect world, um, so sometimes there's gray areas and there's concerns and there's um ethical dilemmas like we're discussing today. What would you—they are some of the most common red flags that practitioners can really keep an eye out for when striving to practice ethically?

Honestly, I think one of the biggest red flags is an individual's own gut feeling. Um, I think that if someone is being asked to do something that doesn't feel right, that doesn't feel like it's the best course of action for what they should be doing with a client, that um I think we probably should start asking ourselves why we're feeling that way. I have to tell you that those, you know, low-level gut feelings are some of those first red flags because you're being asked generally to do something that maybe is outside of the ordinary, that isn't something that you've been asked for before, um, and some of those examples may be doctoring or changing documentation to say something different for some of those reasons. It's been increasing the amount of time so that um they can go to the next um highest billing level in the facility that they're in to get a higher reimbursement; is it them um being asked to um sign on documents for evaluations or assessments that they didn't do, um that someone else did? So it's often that it's being—they're being asked to do something that is out of the ordinary that doesn't quite seem right, um that may impact your actual um interaction with your client. So does it actually have a long-standing impact on your client care? So I ask, is it impacting quality of care? Is it impacting your own um mental health, and is it causing burnout because maybe you're being asked to work at very high levels of productivity that just aren't sustainable? So to me, it often starts with just kind of that gut-level feeling that this doesn't feel right, and I need to understand something more.

And I think you provided such a wonderful insight there as well, in that you naturally gave an example where a practitioner would start questioning those things, um, because it's—it's one thing to have that gut feeling, to feel like you're put in an uneasy or unsure position, but next it's kind of—okay, what do I do? How do I approach this? Um, what are some recommendations that you would give to a practitioner who maybe notices some red flags and and has a gut feeling that something isn't quite right? What questions can they ask to ensure that they um take appropriate action?

Yeah, so—and the thing is is you do—you need to start by asking questions, and one of the first ones is—what is it about what I'm being asked that doesn't feel right? And I think some of the questions that I ask for people to think of, especially when those red flags start popping up, are things like—is someone's values or rights being impacted? So by what I'm being asked to do, is there going to be an impact on someone else's values or rights by this decision? I also ask people to evaluate and look at external factors, and are those external factors now influencing what you're being asked to do? Like I—I had said before, productivity, I think, is a big one. We get a lot of calls about productivity demands, and that's really a trickle-down effect that comes from insurance policies that then become an organizational policy, and it's trying about making sure that obviously the facilities are making their financial obligations, but when you're being asked to treat at, you know, 110% productivity, we have to really take a look at how that's going to trickle down and impact the individual clients that we're seeing. I often ask people to look at—are there alternative actions or solutions that they might actually be able to look at or seek out and see if there's something else that they can do. Um, I do ask a lot of people to ask themselves—what happens if no action is taken? And believe it or not, what surprises me most is that people would rather just kind of bury their head in the sand and kind of let it just happen and take no action. And one of the things that I tell people is that yeah, the ostrich may bury their head in the sand, but at some point in time, the ostrich has to pull its head out of the sand, and the problem's still going to be there. And so trying to take no action is just as ethically problematic as actually trying to address the um actions. So we actually have statements within our code that say action or inaction can lead to unethical behavior. So we actually call people out and say that if you knowingly know something's going on and you knowingly do not do something about it—you kind of stick your head in the sand—you're also ethically as responsible for what's going on as the other people that maybe have started that. So um it's really important to understand that no action is just as bad as being part of the problem, um, and then I also ask them to evaluate if there's some kind of—of uh potential conflict of interest. So I do—I kind of ask them to evaluate and ask several questions, but I also ask people to go and look at standards, and you know, what does Medicare guidelines currently say about reimbursement? What does um, you know, the different um insurance companies or state laws versus federal laws say about what's going on, so that you at least have some ground to stand on before you start charging forward and saying this is an ethics violation. So I do—I ask people to kind of step back and ask themselves a series of questions to say—is this really arising to the level of an ethical dilemma and a conflict, um, or is this something that maybe is smaller, um, and doesn't really rise to that occasion? So there are responsibilities for people to kind of figure that out before they go to that next um step. So I even tell people—maybe reach out to your corporate compliance office at work; could you reach out to HR, maybe the Title IX office, um, and try and get some clarification on things before you, especially before you come running to the ethics commission. Like it's really a responsibility to try and figure out if this arises to that level before you go all the way up to the ethics commission.

Those are such wonderful recommendations and and um well-versed points, um, and I—I'm thinking how important it is for practitioners to be educated on policies and laws in order to practice ethically, um, and and I'm also imagining how a practitioner must feel when they have this gut feeling and they know something's wrong, and I can imagine that the question might arise that—well, do I say something? Do I educate myself? Do I take action? And if I do, am I going to be at risk of losing my job and my livelihood? What would you say to practitioners who are worried about their own job security and are kind of fearful of bringing up an ethical dilemma to their employer or someone else within their company?

That is an extremely valid worry anytime that you need to report an incident; anytime you kind of are the one that needs to step up and um say something. So um the good news is that there is a larger amount of states that now have enacted whistleblower laws that protect people when they actually um file or make complaints against either their employee or employer or specific people within their health care facilities. So different states have different whistleblower laws, so you actually do want to be familiar with what your state says as far as protections for you, because losing your job, being fired for stepping up and saying something, is a real possibility. And you know, at the end of the day, it's a choice that you may need to make. Some states may provide some kind of um paid benefit for actually being the whistleblower; um, some states do not; some states still don't really recognize whistleblower laws. So you do want to know um starting with your state um whether there are whistleblower laws that protect you. The second thing is is that a lot of health care institutions now also have um anonymous phone tip lines, hotlines where you can call and actually make anonymous tips about something that you're seeing. So if you're truly worried about losing your job, if you really do want to try and um make sure that someone is aware that there is something happening, there are anonymous tip lines now where you can reach out and report instances, and your name does not have to be involved in that. So I do think this is one of those tricky lines because we are asking people to behave ethically, and that requires them sometimes acting in a way that in all essence, while responsibly, ethically, and doing the right thing, could result in the potential loss of their own job. And so people have to really decide if that is something that they're willing to risk. They have to obviously look at their own family life; are they the breadwinner? Um, can they afford to have a loss of a job like this? I also ask people—if this is happening and it's not changing, is staying in that job worth it at the end of the day? And not saying something when it could end up becoming your license and your job at the end of the day if someone else catches up with it. So I—I have to tell you that's probably one of the hardest decisions anyone will have to ever make, especially if it's a significant ethical uh situation, and everyone has to make the decision that's obviously best for them, but I think there's pros and cons to both sides, and I think the only best thing that you can do is try to consult the resources that you have, try to reach out and find some answers, and then find out what protections your state as well as your facility might have for you if you do choose to step up and say this is an issue and I'm not going to let it keep continuing, and I'm going to say something. So that, unfortunately, is one of those hard parts because to step up and to say something could result in a potential negative, you know, side effect or impact on you, and so I don't have an easy answer. I think the only thing I—I've ever been able to say to people is—I'm not sure that I would want to continue working for a facility where that continues to play out and things aren't changing. I think that I would want something better for myself, and that I would want to be changing jobs anyways.

Yeah, and and that's an excellent point. Uh, we've mentioned how having that gut feeling is—is stressful, um, and if the place you work is making you feel that way on a daily basis, it might not be the healthiest spot to be at right.

Yes. Yes. Um, you mentioned the importance of education and learning about these laws that are already enacted and enforced within um your State, uh, or different uh systems that an organization might have, like that anonymous tip line. Can you highlight maybe some more resources or ways that you would recommend a practitioner discover these types of um resources or information that's available to them related to ethics?

Oh, absolutely. Um, I think one of the biggest things you can do is when you're seeking out continuing education courses, um, especially some of the courses or continuing events that are National, kind of like AOTA's National um conference, they will always have sessions dedicated to federal and state level legislation and sessions dedicated to talking about current insurance trends. So one of the best ways is probably to try and stay up-to-date through some continuing ed events. Um, most State associations will also provide state-level events that will specifically focus in on your state level and some of the legislation and the billing and insurance trends going on within your state. So I would say seeking it through continuing education is a really great option. I do think even just reaching out to your state-level Association or your National Association like AOTA are really good starting points. Um, most, if not all of them, have a political action committee of—as of some level—who is so um involved in what's going on at the state and federal level, and they can tell you what's going on with bills, what's changing in different practices, and so they can—

Give you updates as well. The other thing you can do is go to, like, the Center for Medicare and Medicaid, um, and really look at what they’re saying about current trends as far as reimbursement requirements for Medicare and Medicaid. They really kind of lead the other insurances, private and public, as to how things are reimbursed. So often, if Medicare and Medicaid are doing it, then you will also see that happen—not all the time, but you will see it kind of carry down into the private insurances. So, you know, doing some research online, like I said, reaching out to your state and your federal agencies, um, doing continuing education is a really good start. And then even within your facility, um, like I said, there should be some kind of corporate compliance officer; there should be lawyers that can help you kind of address what some of the current laws and regulations are, especially around billing and reimbursement. So yeah, we don’t really go to school to learn all of that, and I know that we do generally have a class dedicated to talking about some of those logistical pieces, but I would really advise people to try and at least stay current with the practices that are specifically implicated in the area of OT that you’re practicing.

Outpatient is one crazy hubbub of insurance systems, and every insurance has a different requirement: length of stay, number of visits, co-payment, what you can and can’t do. And so being able to really stay up to date on what the trends are will be that first big piece for you, um, so that you understand what should or shouldn’t be happening. So it honestly starts right at that internal level, and then there’s several ways that you can step up and reach outside of your organization to ask for help and clarification. So there’s always resources. I think the hard part is, is what are those resources you want to reach out to? And like I said, I think your state level and then your National level organizations are a good place to start. And then any kind of continuing education events where they’re talking about policy updates and that type of thing will really be beneficial to letting you understand what is up, what is changing this year, what type of things do I need to be aware of. And thank you for highlighting some of those; I think that is so valuable.

Um, as a young practitioner myself, I feel like so much of my energy is put into improving my intervention approaches and focusing on improved outcomes for my clients. And I think this is an area of practice that is essential for practitioners to increase their knowledge, um, for how to handle ethical situations and dilemmas should they occur. Because if they do pop up, it’s going to be stressful and intimidating and overwhelming. And it is so reassuring to know that there’s State organizations and our National Organization who has already prepared so many resources that are available for practitioners who may feel that way and be in a situation like that. Absolutely. Absolutely. I think, you know, I think that’s one of the big benefits of being members of State and national organizations is you have some of the direct access to some of these resources. While some of them are free and easy to gather, some of them you may need, um, a membership to get the information. But for the most part, I think really being able to lean on those organizations because I don’t think anyone at any given time can know everything, and I certainly can say not someone that knows the insurance system and the regulations very well. And I’m constantly re-relying on other resources, um, and partners to give me that information, even when I’m looking at ethics cases. So yeah, that’s on the great point: no one can know everything, and it’s reassuring as a practitioner to know that there’s entire organizations that can support and help. Because being faced with an ethical dilemma, I imagine, makes a practitioner feel very alone, um, and unsure.

Are you an occupational therapy practitioner ready to make a real impact? AOTA membership unlocks the knowledge and inspiration you need to implement best practices, explore opportunities, and reach your professional development goals. Don’t miss the AOTA Inspire annual conference and Expo, the profession’s largest gathering every spring, and specialty conferences throughout the year. AOTA members save up to 35% off registration and get unlimited access to over 200 online continuing education courses. Elevate your career. Elevate lives. Join AOTA today at aota.org/membership. And we’ve mentioned how these dilemmas can be intimidating, overwhelming, and stressful. I want to now present a few scenarios that practitioners may encounter and ask how you would recommend they begin to think through how to approach each situation and maybe provide some recommendations on possible courses of action that practitioners could take. Absolutely. So let’s start with: what would you recommend to a practitioner who is being asked to continue an occupational therapy plan of care when the client is not expected to make any further progress?

Yeah, so this is actually one that we get asked quite frequently, um, and can definitely be a challenge depending on the situation and the setting that you might be in. I have had a lot of, um, some of my students that have recently graduated reach out to me sometimes with these type of questions and ask, you know, “I don’t think they’re making any more progress; um, I’m being asked to keep them on program; what should I do?” Um, and I think there that we have to get a little bit more of the bigger picture. Um, I’m thinking a lot of times we get these questions out of nursing homes. Um, there’s a lot of times, um, residents who may be put on program for a short period of time, maybe because they got sick, they had pneumonia, they had COVID, they were hospitalized, um, but they’re not someone that’s going to be on long term, um, and at some point they need to come off. Um, but I have heard and I’ve gotten calls and questions about, “Well, my facil is asking me to keep them on for a longer, um, time to just kind of keep trying to work with them.” And so the first thing you do, really have to establish is: is there really further progress to gain? And so we often can do that by knowing and understanding diagnosis; obviously knowing the resident—you know, we are very holistic practitioners—and if this is someone that has end-stage dementia, this is someone that has been in and out of the hospital over the course of the year numerous times and is just debilitated beyond debilitated, um, you know, it may not be appropriate to be keeping them on programs. So discharging them is definitely something that you need to do. And so you really have to be able to show, um, your manager and whoever it is coming to you and asking you to keep them on program and say, “Look, there are no more realistic, achievable goals, um, that I can make with this client that would be functional, um, and help impact or improve their occupational performance. And I don’t feel comfortable keeping them on program just for the benefit of the hours.”

But there are situations where maybe you are a newer practitioner or maybe someone’s seeing something that maybe you don’t, that maybe they could potentially benefit from. So maybe they just need to be kept on one or two more weeks in order to try and increase their strength so that they’re doing more independently for themselves in their room, reducing the burden of care for the nursing staff and the aide staff, and maybe you need to keep them on. I think the big thing would be able to, you know, provide proof that this person is really not making functional gains. And to me, that starts with your documentation and your constant evaluation of the individual. And and if you can show that they’ve truly plateaued over the last couple weeks and that they’re not moving forward, that they’re really kind of staying still, that should be the ultimate evidence that what you’re saying is true. If they’ve just started plateauing and it’s just been a minimal plateau, you know, sometimes I tell people, “It won’t hurt you to keep them on for another one week, maybe two weeks, and see if you can get anything more out of them.” But then say—and this is where you compromise—“I’m willing to try, you know, one more week, two more weeks with them, but if they’re not making any more gains, they’re coming off. This is not a functional therapeutic intervention anymore; this is not benefiting them in any way, and I will not continue to treat them.”

So it can be hard because it does require you to be an advocate for yourself as well as the client or the resident. It requires you to really look at your assessments and your evaluation materials and your progress notes: Have I really documented that this person is plateaued and they’re not making progress anymore and they should be taken off program, or have I not really shown that well enough and maybe I need to give it one more week or two more weeks? And then say, you know, “That’s it; if they don’t make any more gains, they’re coming off program.” And then there’s, you know, the situation where they really are being asked to keep someone on longer than they shouldn’t, and that’s you being able to take a stand and say, “This isn’t ethical; this isn’t how we go about doing this; um, this is not a functional program for someone; they do not have goals that can be achieved, um, by keeping them on longer, and there’s no benefit.” And being able to say that you don’t feel as though this person is a good rehab candidate and should remain on program. It’s a really hard one; um, it is; it does require you to kind of re-evaluate your own progress notes and take a look at things; it does require you to have a little bit of an understanding of that resident’s case, um, but it also does require you to be confident enough to stand up and say, “It’s not okay to keep them on program any longer; there’s no active benefits, um, and I’m not going to keep them on program just, you know, to make a buck.” So it can be really hard; it you really have to kind of see where that person’s coming coming from and what their thoughts are because I will say as a new practitioner, there was a couple times I thought I should discharge a resident, and after speaking with my supervisor more, I could see what they were saying about what we needed to work on. So it was more of a, “I just didn’t see some of the deeper skills that needed to be worked on,” but there’s also times where, “No, I’ve really done everything that I can, and this is no longer beneficial to the resident.” And if it’s not beneficial to them and you know that there’s not going to be any gains, then saying that you’re taking them and discharging them from program should be what’s going on, um, and I hopefully your rehab manager will hear you when you say that.

Thank you so much; that’s such a wonderful example. And I’ve never considered how having kind of that gut feeling and and maybe thinking that a situation is an ethical dilemma is an opportunity to reflect on your own practice, an opportunity to introspect and ensure that you’re providing the best quality care, maybe reassess goals, make sure that they really are, uh, a best fit for your client’s own person factors and environmental factors and and what they find most meaningful to them. And then having the courage to rely on your own clinical reasoning and your own knowledge base to speak up and say, like, “Hey, this isn’t right.” I I think those are wonderful recommendations. Thank you. I do think, um, especially with newer practitioners but even older ones, it can be hard; it can be hard to have that courage, but I do think a lot of times it requires some self-reflection but also communication and making sure that you’re communicating exactly what you’re thinking so that you do have a leg to stand on when someone asks you to extend care and you don’t think it’s appropriate. Wonderful. What would you recommend, Leslie, to a practitioner who’s being pressured to treat through group interventions when they really aren’t appropriate for the client?

I I would say that this is also a pretty common question that’s brought to us, um, at the commission, and I, um, would say that I have also faced, um, situations similar to this. Um, I think in an effort to try and get all, um, clients seen throughout the day, especially in rehab facilities, when you’re trying to meet minutes or, um, number of hours of treatment, that people will try to get creative in trying to make sure that everyone is seen for, you know, their three hours or the 90 minutes that they need. And so I have seen situations where clients were kind of, um, grouped together, thinking, “Well, they have similar diagnosis, so they can work together,” and they really weren’t; they weren’t appropriate because of their level of functioning, because of their mobility needs, because of their cognitive needs. And so there is a point in a time to use groups, but groups are not the end-all be-all. Um, in my own personal situation, when I was scheduled a group, um, that clearly the level of each of the patients was not in a position where they were all on the same thing and I could be working kind of along the same lines with them, I actually broke the the group apart and treated them individually, and, um, so that I could really make sure that I was treating the individual patient in their needs. Now I am very much aware that people are being pressured into running those groups; um, I am aware that people have been pressured to run groups and then, um, charge people at an individual level, and those are not legal; those are not things that are actually actually okay to do. We are supposed to be using groups for educational purposes; we need to show that by using the group that participants are getting gains from watching other participants do what they need to do, by listening to their examples, by modeling, and that that group is meant to be used as a collaborative experience where they can learn from each other. If a group is only put together because we’re trying to make minutes, that we’re trying to fit everyone into that therapy schedule because we realistically are short-staffed, then that’s not an appropriate use of a group, and it does require you saying, “This is not an appropriate group, and you need to break it apart; I will not treat them as a group,” um, and that can really really be met, um, harshly; that can be met with, “I just need you to do this; they need to get their minutes.” And the truth is is, “I’m sorry that you need to get their minutes, but I am not going to to run a group just to give everyone their minutes; that’s not going to benefit every single person in that group; um, that’s not legal; that’s not ethical; and that should not be happening, and they need to figure out themselves how they’re going to get these minutes in a different capacity.”

I do honestly—I hear this one a lot, um, sadly—and I do hear that, you know, there is a real dilemma, like you’re being pushed and asked to do this, and you know that all the patients need to be seen and that there’s really not enough clinicians on, but at the same time, are you benefiting those patients in the 30 minutes or the 60-minute hour treatment that you have with them when some maybe need a lot more hands-on assistance than others? So some of them aren’t really getting any benefit from that that treatment session if your concentration and attention is all on one person or maybe two people. So you honestly have to go back to those questions I asked from the beginning and really look at: Is there alternative, um, solutions? You know, who who is benefiting from this? Who’s not benefiting from this? And really look at all the factors at play. Because as as much as a group is easy to throw together, if it’s not an appropriate group that’s going to be useful to every single person in that group, then there’s no reason to be combined in them except for that they’re trying to get the minutes of that person, and that’s not legally or ethically okay to be doing. And again, it’s having the moral courage and the voice to step up and say, “I shouldn’t be doing this; I don’t feel comfortable doing this; these two need to be broken apart.” And yeah, that’s hard, especially when we lack practitioners right now, um, and that’s where, um, you know, we really need to look at some of these requirements for minutes and therapy come from, because I think there’s legitimate reasons when we can’t make minutes in our rehab facilities, and as long as we’re documenting the legitimate reason, maybe we’re not always getting the minutes, um, I think that that’s better than pushing someone through something that’s honestly has no therapeutic benefit to them. Absolutely. Absolutely. And and I’m beginning to realize more and more as we, um, talk about this topic how much, um, or how closely connected, uh, best practice and ethical practice are, um, and it really is, uh, part of a practitioner’s ethical duty to to know what types of interventions are going to be best for their clients and to really enable themselves, maybe through continuing education courses or, um, you know, continued study, to know what the best approach to help certain clients and diagnoses and populations may be. Absolutely. Absolutely. Yeah, you know, I think we just don’t realize how much understanding of policy and reimbursement and, you know, facility guidelines and stuff really impact our how we provide therapy and how when we’re not, um, doing something that’s legal, I mean, it’s directly connected to ethical, um, and so it can get really complicated really fast for people. Absolutely. And what would you recommend to a practitioner who, let’s say, is on a travel therapy contract, um, and they’re being asked to sign old progress reports or discharge reports, um, for previous, um, practitioner, and the current practitioner who’s being asked to sign these reports never saw the client? What do you recommend to someone in this situation?

My recommendation is to absolutely never sign those notes. Um, you are not the clinician overseeing those evaluation and assessments, daily notes, progress notes, whatever they are; it is not your responsibility to be signing them, and the fact that you don’t know anything about those situations makes it even worse for you if you were to sign them. So it’s the facility’s problem, and they need to decide how they’re going to get those signatures—where they reach out to that contracted OT that traveled and asked if they can still electronically provide a signature, whether they reach out to the insurance reimbursement people and say, “This person has moved on; we don’t have someone that can sign it.” Um, at the end of the day, the facility needs to take ownership for that; that is not on the OT practitioner that’s now in there to be backdating or back signing things that they have no involvement in. Remember, at the end of the day, it’s your license; it’s your license on the line, and if you’re signing things that have nothing to do with your supervision and oversight, then you are knowingly putting your name on a document that you don’t know about the situation that could become a legal situation down the road. And God forbid there is a reason that someone, um, challenges billing and it goes to the court of law, your name, your signature is now on that document, and you’re going to be the one called, um, to be talking about that document, and you do not want to be caught saying, “Well, I was asked to sign it, but I don’t know anything about this case.” That is definitely not a position that you want to put yourself in. So I can tell you that’s a straight-up legal, um, issue, and you do not want to be putting yourself in that position where you’re signing, um, documentation that you have nothing to do with. Absolutely. This is one of those scenarios that’s a red flag, and it’s, you know, an airport conductor with the glowing sticks, like, jumping up and down, like, “Do not do it!” Absolutely.

Um, Leslie, thank you so much for providing these recommendations. I find these case studies, uh, really helpful to our listeners and, um, how they can, you know, consider how it might approach their day-to-day, um, and and their own scope of where they’re practicing right now. Um, what additional case studies or or personal examples related to ethical practice of Occupational Therapy, um, would you like to share with us? You know, I think I was trying to sit on this, um, and think about some of the, um, different case scenarios and stuff that maybe we’ve been privy to. Um, I think that we just want to be careful. I think there’s been some questions about overbilling and use of private pay with clients and patients, um, it has actually led, um, nationally to some facilities being shut down when they’re not billing correctly. So you want to be careful that you’re not being asked to overbill—again, not bump your minutes because someone asked.

You to. If you didn't provide 45 minutes, but you provided 36 minutes, then you need to be documenting 36. Um, there are people, too, that can afford private pay and people that can't, and that can really become, uh, a really kind of challenge as to how you continue continue that. So you know, do you have a patient that can afford private pay, but the only reason they're using that private pay is for you to continue the exercises with them? Because at the end of the day, when they go home, they're they're not doing anything; they kind of look at you as the person that does it for them. And is that really the best use of your time? Um, and then I think of the patients who can't private pay, but then run out of insurance benefits, and they truly need more therapy, but because they can't afford to private pay, they can no longer come into therapy. So I do think we have to be very careful when we offer private pay and who we're offering private pay to. For people that can't afford it, do we have scholarships available for them? Is there, um, pro bono services that you know about? Is there a local college that maybe has a free clinic that you could send them to? We have a responsibility to really decide, um, when that end and termination of services should be. And as much as I appreciate that people look at us as the expert, there is a point in time where you know, carry over and maintenance of your needs needs to continue at home. You know, if you want a private pay, maybe you private pay to have an aid or someone come in to do that for you, but we have to be careful that we don't let them private pay just because it's a money maker, just because it'll bring in some more money for the facil facility.

Um, I've definitely heard some conversations with that. I've also heard of people being asked, and I think I've mentioned this during the, um, course of our conversation today, about changing documentation, um, to kind of make it look, um, more reimbursable. One of the big ones that we've heard is parental choices for their child. So this can be really hard if a parent is pushing, um, interventions or wanting us to do things that one really don't have a proven evidence-based research-backed, um, benefit to that particular case, um, but the parents are pushing for it. Um, I think sometimes two parents will do anything they can to help their child, to make their child better, and so sometimes parents, not intentionally, but are just trying to do anything at this point in time to kind of save their child. And we have a responsibility to really help them hear that you know, there's nothing left in that category that we really can help them, uh, beneficially or therapeutically. And so sometimes we have to be able to tell parents, no, we can't do that intervention; no, that intervention is not appropriate for your child, um, especially if they see that we're using it with someone else. Um, a lot of parents are willing, like I said, to delve in and find any of the L and greatest research, but at the end of the day, we have to weigh the risks and the benefits to the child, and we have to ask if it's really therapeutically beneficial to that child, and will the benefits outweigh the harms? Because if it's the other way around, then we should not be doing that. So it can be hard; it can really be hard, um, with parents who have very medically fragile children, um, with parents who maybe are losing a child, um, because of their illness, to really be able to reason and tell them that I understand and I can hear how much you want to help your child, but this is not the option.

We get that even sometimes in OT with them wanting and pushing and pushing for more therapy or the newest and latest greatest thing that they saw, um, and I think we just have to be able to to draw that line, and you know, sometimes that means being hard, um, you know, and just saying, you know, this is not helping your child, and we cannot do this. Um, so those I think are some of the tougher cases that we've we've had, but I have to tell you the one that has grown, um, definitely since Covid and seems to be on the Moun rise is our ability to communicate with one another, whether it's our communication with patients and their family, it's our communication with other healthcare professionals, our communication with our colleagues. One of the biggest challenges that we're facing ethically is how we're communicating with each other and doing it in, um, a respectful manner that respects culture, race, identities. So I would encourage people, too, to also think about how their communication can become, uh, an ethical dilemma, um, and can actually cause communication problems that end up with, you know, an ethical complaint towards them. So, uh, that's been a new one that's really been kind of coming out of the woodwork, and one that we've really been trying to address appropriately as they come in and really talking about the challenging nature of the situations and respecting the diversity of thought and the, you know, the ability to communicate appropriately. And one of the biggest breakdowns that we're seeing right now is just ability to manage the conflict for themselves and have conversations before they kind of start coming to the commission and saying to us, you know, they, you know, challenged me, and you know, they really, um, they went against the code, and this is an ethical violation. Um, I think that we need to step back and really start with trying to reduce, um, and address conflict on our own at that level before it gets raised up to the ethics commission.

Yeah, that's such a great point. Like you mentioned earlier, the importance of kind of reflecting and, um, introspecting and and asking those questions about whose values or rights are being impacted or considering the external factors and and alternative actions, um, all important things for for practitioners to keep in mind. Absolutely. Um, and then, of course, finding a way to commun unicate those concerns and those questions in in an effective and, um, appropriate way. Absolutely. Um, I think that you know, giving the the changing diversity of our culture, um, and I think it's just a a a national, um, kind of challenge that we're seeing is the inability or loss of ability to handle conflict, and it really starts with just communication and being able to communicate, and that really has to start at your level, um, and it has to start with you and you taking the power and control to try and address the issues before you raise it up and start challenging the ethics of the situation. Um, so you know, as much as that seems like a very different one from practice, which it is, it is one that is becoming more prominent, believe it or not, um, so I just really encourage people to start with just stepping back and, you know, using the questions that I've presented today and really evaluating the situation and say, how have I tried to address this, um, before raising it to the level of an Ethics complaint.

That's wonderful advice, Leslie. Are there any additional resources you'd like to recommend to our listeners? Um, I know you mentioned a few earlier, um, any additional ones you'd like to highlight? Yeah, so I actually, um, would encourage people to even just go to AOTA's website. There's a whole, um, page and area of the website dedicated to ethics, including the access to the code of ethics, but we have 27, um, papers that we've written, um, called ethics advisory opinions, and they are written specifically because of situations that we've faced over the, you know, last 10 to 20 years. And so they are the the papers are rise from challenges that were actually brought to the ethics commission. So everything from billing and productivity to fieldwork ethics to Covid management, um, so those are really great resources as well to help you if you guys are really feeling challenged and not sure if this raises to that level of an Ethics challenge or if it's something maybe you can answer on your own. So I do think there's some really great resources on AOTA's website, and so I would encourage you guys to go on there as well and look around because we have tried to build a page that provides resources, FAQs, and stuff to help kind of guide you guys as you're trying to negotiate some of these challenging situations.

I love that. I love that if a practitioner finds himself facing an ethical dilemma, odds are another practitioner at some other point in time has faced the same dilemma, and I love that those resources and, uh, ethics advisory opinions are available, um, for people to to read and to learn from and, um, hopefully impact their own decision-making. Absolutely, Leslie. It's time for our golden nugget segment. We end every show with this question: If there was one piece of advice or knowledge that you could share with our listeners, what would you say? I honestly have to say that it would be: Don't be afraid to ask. If you're questioning whether something has risen to the level of an ethical dilemma or a violation, don't be afraid to reach out and ask to consult with a peer in your facility or even reach out to the ethics commission and just ask, you know, this is the situation; would you consider an ethical issue that is enough for a violation or not? I think if we don't ask, we don't know, um, but the key is being able to back up what you ask with facts, documenting evidence to show, um, what's been asked of you and what you con your concern is. So don't be afraid to ask, and also Al have the moral courage to question, um, when you don't feel like something is correct. And I hope that you guys can use those pieces to kind of help you as you move forward.

Absolutely. I love that. I think so much of the fear and stress that a practitioner experiences when faced with an ethical dilemma comes from feeling like they're alone and facing that dilemma, um, oh absolutely. Yeah, and knowing that there are organizations and an entire commission that you can ask for assistance, um, is really encouraging. Definitely, definitely. Well, Leslie, thank you so much for being on the show today. It's been wonderful talking with you, um, and I want to thank you for all your efforts, uh, as chairperson of the commission. Thank you so much for having me. Actually, kind of have an exciting announcement that I'll make really quick is that we are currently going to be collaborating and working with the DEI jaab commission, um, to develop a socially responsive model for ethical decision-making, and our hope is that we'll be able to make an infographic that all practitioners can use when they're managing and handling conflict to help them try and start locally and resolve it internally before they have to come all the way up to the ethics Comm commission. So we're really excited about this project because we're addressing the DEI jaab needs within that new model and, um, really hoping that we can create something that everyone can use, um, before they even have to bring it to the ethics commission. So I hope people will be on the lookout for that because I'm really excited about it, and I hope that, um, people will be able to use it as they move forward in practice.

Absolutely. That is exciting, a whole new model for ethical decision decision-making and a new resource for practitioners. Um, do you know a timeline for when that would be released? So we are just starting to work on it, so my guess is it'll probably take about 2024 to get it together, um, and so I would say early 202, probably late 24, early 2025, you guys can hope to see, um, that infographic released, um, and we'll be able to use it and let us know what you think. Absolutely. We'll on the lookout for it, and I think Leslie that we're going to have to have you on the show again when it is formally released and we can highlight all the wonderful work and results that went into it. Oh, absolutely. We would love to do that. Perfect. Well, thank you again so much, um, it's really been a pleasure speaking with you. You as well. Thank you. Thanks for listening to the AOTA podcast. Tune in again next time. [Music]