Course:DHYG400/Group C
Mara Burrows, Fayroon Kandasamy, Jelena Ozanic, Deanna, Navreen Dhudwal
DHYG 400 Group
By: Jelena Ozanic Assignment 2 Ethical Issues in Work and Life Interview with a Registered Dietician'
Relevant Information
In Ontario, the regulatory body for Registered Dieticians is the College of Dieticians of Ontario. Their Code of Ethics for the Dietetic Profession in Canada was developed by Dieticians of Canada. It is the official code of ethics for registered dieticians nation wide adapted by every province and regulatory body.
In Ontario, registered dieticians are educated at the university level and graduate with a baccalaureate degree in either science or applied science. A one year internship follows graduation, and precedes a written registration examination.
Interview Question 1
Where do Registered Dieticians typically practice?
There are five main streams of practice with varying skill sets. There is significant overlap in the various settings.
a) Clinical often in an institutional setting such as a hospital, long term care facility, includes client and family counselling in the food industry concerned with package labelling and nutritional requirements
b) Research May include clinical trials concerned with how nutrition affects outcomes of illnesses or treatments Pharmaceutical companies researching supplements At universities
c) Community Long term care Public health departments Improved community access has been identified as a goal by the profession
d) Administration In institutions such as hospitals Menu planning to ensure nutritionally sound diets are provided to clients in care Human resources Cost control Creating and maintaining nutritional databases Product evaluation
e) Food Sciences Food manipulation such as fortifying foods with vitamins and minerals Genetic modification Product evaluation Product development
Interview Question 2
What are the most common sources of ethical dilemmas/distress for Registered Dieticians?
a) Peers Competency/fitness to practice issues, such as peers who may be emotionally or psychologically challenged which affect their ability to practice. Most dieticians practice in one stream, although there is overlap with the scope of practice, the skill sets required within the various streams may differ. Thus dieticians who are changing practice streams may not be competent to practice due to a lack of experience. Individual values that affect the way they choose to practice, for example a vegetarian dietician who does not distribute the Canada Food Guide because of its inclusion of meat.
b) Interdisciplinary Issues It is not currently within the scope of practice for dieticians to write orders for diets for hospitalized patients. This is the responsibility of doctors. Sometimes the doctors do not chart appropriate orders based on the dietician’s nutritional assessments, or they ask the dieticians to write the orders themselves based on their nutritional assessments. When reading orders that have been transcribed by clerks, that have inaccuracies or inconsistencies, resisting the urge to just change them to what they know to be accurate but are not authorized to do.
c) Administration “cost leadership”, staying within budgets often affects the quality of the food they can provide to the patients
d) Food Sciences Rationalising the reasons for supplementing through food, is it really in the best interest of the consumer? Reformulating recipes to accomplish one nutritional goal, such as reducing fat, but compromising by increasing sugar content to improve flavour
e) Marketing Especially in food packaging; misrepresenting nutritional information or benefits, for example packaging that boasts the product is “low fat” when that product naturally does not contain fat.
f) Client Compliance and Interference from the Client’s Family For example when family members knowingly provide food that is restricted to the patient, such as diabetics whose families sneak high sugar content foods into the hospital because the patient likes it.
Overview of the Code of Ethics for the Dietetic Profession in Canada Based on the Interpretive Guide
The Code of Ethics upheld by Registered Dieticians is comprised of three areas of responsibility encompassing eleven principles.
Responsibilities to the Client
Principle 1. To maintain integrity and empathy in professional practice. Principle 2 To strive for objectivity of judgement in such matters as confidentiality and conflict of interest Principle 3 To work co-operatively with colleagues, other professionals and lay persons Principle 4 To obtain informed consent for our invasive or experimental procedures
Responsibilities to Society
Principle 5 To maintain a high standard of personal competence through continuing educational and an ongoing critical evaluation of professional experience Principle 6 To protect members of society against the unethical or incompetent behaviour of colleagues or other fellow health professionals Principle 7 To ensure that our publics are informed of the nature of any nutritional treatments or advice and it’s possible effects Principle 8 To support the advancement and dissemination of nutritional and related knowledge and skills
Responsibilities to the Profession
Principle 9 To support others in pursuit of goals Principle 10 To support the training and education of future members of the profession Principle 11 To involve myself I the activities that promote a vital and progressive profession
Included is a decision-making framework for guidance to solving ethical dilemmas, similar to that of the CDHA Code of Ethics.
Ethical Dilemma-Excericise
In our discussion I asked the Registered Dietician to suggest a typical scenario/ethical dilemma and suggested we work through the dilemma using their code of ethics decision-making framework.
The Ethical Dilemma
Mr. Thompson is a 90 year old veteran in long term care in the Veterans’ Ward of a Toronto hospital. In this ward, the patients are residents, and have their own refrigerators in their living quarters. Mr. Thompson has Type I diabetes which is poorly controlled. He has already had one leg amputated as a result.
Mr. Thompson is regularly visited by his grown children and grandchildren, who know that he is diabetic. In anticipation of their visits, Mr. Thompson requests that they bring him foods that are not part of his nutritional plan. In particula cakes and beer. Alcohol is not permitted in the ward.
The dietician discovers the contraband food items, and when asked, Mr. Thompson admits that his family members are smuggling food into the hospital for him on his request. The dietician discusses her concerns that his diabetes is not well controlled. He tells the dietician that he is 90 years old, in long term care, and if he wants to eat cake and drink beer, he will eat cake and drink beer. It makes him happy and he is not concerned that his blood sugars are uncontrolled.
The dietician feels it is important to address the issues with the family members, however, Mr. Thompson doesn’t want her to discuss it with them.
Using the Decision Making Framework
1. Identify the problem. The client will is not adhering to his diet restrictions Diabetes uncontrolled Family members enabling his poor food choices Mr. Thompson doesn’t want dietician to consult with the family
2. State how you feel about the problem. Concern for the patient’s well being Frustrated that he is not taking his health seriously Concerned that the family may not be well informed of the consequences
3. Identify ethically relevant issues Stakeholders: Mr. Thompson, his family, the institution, the dietician, the profession
Values in Question
Place clients first the dietician believes Mr. Thompson is at risk of more complications from the diabetes
Respect Client’s Values Mr. Thompson believes eating these foods makes him happy, quality of life Doesn’t want the dietician to speak with family
Respect the Family’s Values The family wants to make him happy
Uphold the standards of the profession The dietician has a responsibility to the profession to uphold the standards of practice Follow Relevant Legislation and Procedures and Policies Professional Misconduct Guidelines Institution policies
Relevant statements from the Code of Ethics Interpretive Guide
Principle 1.1 Place my clients’ best interests as my primary professional obligation Principle 1.2 Respect the wishes of my client and his/her appropriate others within the obligations of the law and the CDO standards of practice Principle 1.3 Make every effort to communicate effectively with others Principle 1.5 Seek out and share information with my client so that they can make an informed decision and take advantage of any resources available to them Principle 1.10 Listen to and appreciate my client’s values, opinions, and ethno-cultural, religious beliefs in order to offer them appropriate services
Principle 2.31 Provide nutrition treatment to my client once informed consent is obtained and respect my client’s wishes when he refuses the treatment Principle 2.32 Divulge confidential information without consent only when authorized or required by law. This would include circumstances of disclosure for the purpose of eliminating or reducing a risk to an individual’s health or safety if there are reasonable grounds to believe the risk is significant….
Principle 3.36 Seek the opinion of an appropriate colleague…. Principle 3.42 Place the needs of my client first but also consider the philosophy and polices of the employer. I will explore solutions that meet the needs of my client and my employer.
Principle 4.45 Recognise that informed consent results from collaborating with my client or substitute decision-maker. This entails fully informing my client of the related treatment and obtaining a clear indication that my client understands. Principle 4.49 Respect informed, voluntary decisions and choices even when they may conflict with my personal opinion.
Principle 5.53 Comply with CDO’s Standards of Practice, including regulations, rules, and the Code of Ethics
4. Rank the values in conflict.
First Take care of the client: Related values: respect the client’s wishes The client’s best interests for best health
Second Take care of the institution and the profession Related values: standards of practice and the policies of the institution
Third Take care of the family Related values: respect the family’s values
5. Outline possible courses of action.
a) Counsel Mr. Thompson about the possible catastrophic effects of not following the recommended diet. b) Consult with Mr. Thompson’s physician about possible treatment interventions to stabilise blood sugars c) Consult with the department within the institution responsible for overseeing the import of banned substances. d) Consult with colleagues for advice in the decision making process e) Counsel Mr. Thompson’s family without his consent f) Advise Mr. Thompson’s family that it is against hospital policies to allow alcohol into the ward.
Discuss all possible courses of action with Mr. Thompson
6. Analyze risks vs. benefits of each possible course of action. a) Mr. Thompson may agree that the cake and beer is not worth the risk of morbidity or death or it may not change his mind, he may become angry. b) The physician may intervene and support the dieticians opinion, there may be medical options, Mr. Thompson may refuse any additional consultations or treatments or his status may improve. c) The department will likely confiscate any alcohol and may forbid family from visiting if it doesn’t discontinue, Mr. Thompson may become discouraged, depressed if his family cannot visit, benefit is that he won’t have access to alcohol d) May acquire different perspectives. May make it more difficult to decide. e) Risk breaching the patient’s confidence but under principle 3.32 may be appropriate due to significant risk to the patient. Risk severing the relationship with Mr. Thompson, benefit, the family may begin to understand the gravity of the situation and decide to stop enabling Mr. Thompson f) Mr. Thompson may tell his family to stop bringing alcohol because he is afraid they won’t be allowed to visit, or he may warn them they may be suspected of smuggling alcohol.
7. Evaluate the courses of action based on consideration of the issues and consequences.
8. Document your decision and why this alternative is preferable to other options. Articulate this decision to other stakeholders. 9. Take action based on the decision made.
10. Monitor and evaluate the results of the action.
Decision: The Course of Action Taken by the Dietician.
The Dietician after careful consideration decides on her course of action. She decides to start by counselling Mr. Thompson about the possible catastrophic effects of not following the recommended diet. Mr. Thompson remains undeterred. Following consultation with Mr. Thompson’s physician about possible treatment interventions to stabilize blood sugars, it is confirmed that there are no alternative medical options at this stage. The Dietician consults with her peers and other colleagues and weighs their opinions. She now feels that she must take appropriate actions to resolve the problem. She starts by reporting the discovery of alcohol to the administration. She chooses against the wishes of Mr. Thompson, to contact the family members to discuss the problem with them. Mr. Thompson is angry that she went against his wishes. She advises him that under principle 3.32 she feels justified because there is significant risk to his health. She strongly believes that by doing so she is putting the patient first. If the family agrees to come for counselling, dietician will encourage them to discontinue bringing alcohol to the hospital as it is against policies and offers alternative suggestions for satisfying Mr. Thompson’s requests.
DHYG 400 By: Mara Burrows
Assignment 2
Ethical Issues in Work and Life
Interview with a Paramedic Information:
In Nova Scotia, the regulatory body of Paramedics is the College of Paramedics of Nova Scotia (CPNS). Their code of Ethics is fairly consistent nation wide, although it varies slightly in each province. There is also the “Paramedics Act or Bill 158”.
The College of Paramedics of Nova Scotia (CPNS) operates as a professional, self-regulating College under the laws of Nova Scotia. The CPNS does the following: 1) set the criteria for paramedic licensing and re-licensing, 2) investigate and deal with complaints, and conduct and competency of its members issue paramedic licenses, 3) review paramedic registration, and 4) establish and improve professional standards.
The Code of Ethics is very similar to our CDHA Code. It speaks of responsibilities to the Patient, to the College of Paramedics and the Profession of Paramedics, and the responsibility towards Society as a whole.
In Nova Scotia, Paramedics are educated at the college level and graduate with a diploma. A written and practical exam follows education and is mandatory before entry to practice.
Where do Paramedics generally practice?
1. Pre-Hospital -Rural -Metropolitan 2. Community Events - Sporting Events - Community Awareness - Gatherings such as festivals, fairs etc…
What are the most common sources of ethical dilemma for Paramedics?
1. Co-workers -Issues related to a fellow Paramedics choices/may feel as though the fellow worker may not be following proper protocols. -Question competency of other Paramedics that you work with related to personal issues, differences in ethical practices. -Paramedics that may not work properly within their scope of practice, for example providing services that are in a grey area or which are not technically allowed within the Paramedics code of ethics.
2. Interference from by-standers -Dealing with distraught or angry family members, friends or by-standers who want to be involved in treatment (technically not able to restrain etc…) -Having to act in a ‘policing’ capacity to control crowds before Police can arrive on scene is a difficult decision and there is a fine line that cannot be crossed.
3. Deviation from Scope of Practice Guidelines within Canada/Canadian Provinces
-Example is having trained and worked in many different countries, (in Canada unable to perform numerous procedures). If working in a rural setting where hospital is hours away, would performing a procedure that the Paramedic has done many times be ethically responsible or not? Example: Tension-Pneumo-Thorax needle decompression in certain Provinces is not permitted.
The Ethical Dilemma
Working in a small town setting, with a diverse cultural population. Many residents in the town have serious drug and alcohol addictions, and many of the calls are related to such addictions.
Ambulance is called to a location where a barely coherent (under the influence) individual is being tended to by a number of clearly intoxicated friends.
Friends and the individual himself state that he has not used any type of illegal substance, although the Paramedics clearly disagree. It is unethical for a Paramedic to simply treat for an “unknown” cause and treatments could be fatal if the diagnosis is not true.
The patient is experiencing chest pains, having difficulty breathing etc… and does not want to co-operate with the Paramedics. Meanwhile, the friends are still attempting to give the patient a bottle of beer to drink and the patient is trying to smoke a cigarette.
The Paramedics need to establish crowd control without provoking a fight, maintain patient consciousness and treat for the overindulgence in illegal drugs and alcohol. The issue of what to treat for is a problem when patient is not being honest.
The Process:
1. Establish crowd control, contact the Police, as violence could easily and frequently does occur in such situations. Try to isolate patient in ambulance to remove from the harmful environment. 2. Consult with patient to realize the true nature of substances abused. 3. Identify issues and treat accordingly without provoking the underlying medical problem.
The Paramedic who I interviewed says that these types of calls are very dangerous and difficult because the patient’s frequently abuse strange substances such as Lysol (drink it), and Hairspray (drink it). In addition many of them are crack cocaine addicts and have other severe chemical addictions. These substances can be (obviously) fatal and if the Paramedic treats the issue at hand, there are also many times other underlying medical problems. The family and friends of the patient also many times become extremely violent and out of hand.
Paramedics use careful decision making skills and decide their course of action given the circumstances and their best analysis of the situation. They consult with fellow Paramedics on the scene and take the appropriate actions.
Interview with a Nurse Practioner by Fay Kandasamy
The entry to practice for nurses in Ontario currently is a degree in nursing. The professional I interviewed is a nurse practioner. She holds a masters degree in nursing and works in the community, assessing patient needs with regards to nursing services in their homes.
In Ontario nurses have a choice of associations they can belong to’ which includes the RNAO (registered nurses of Ontario), CNA (Canadian nurses association), ONA (Ontario nurses association. DH’s in Ontario also have a choice of which association they can belong to. Also, like dental hygienists their profession is regulated by the CNO ( College of nurses of Ontario).
The code of ethics that a nurse practioner is guided by is as follows: -to promote health and well being -to provide safe, competent care (This is equivalent to beneficence in the DH code of ethics) -maintaining dignity -preserving privacy and confidentiality (Same as in DH) -promoting justice -being accountable (Same as in DH) -promoting and respecting informed decision making Similar to autonomy in DH code of ethics - truthfulness and fairness
We see a huge overlap with the code of Ethics for both professions.
Dilemma: An 80 year old patient has just been diagnosed with terminal cancer. The patient speaks no English, only Italian. The daughter is present to interpret for her mother. When told of the diagnosis, she requests that her mother not be informed of the diagnosis because she will “give up” on living. This presents an ethical dilemma(#1) for the nurse practioner because she believes that with- holding the diagnosis from the patient is a violation of the patient’s right to know. The daughter then informs the nurse practioner that she will not consent to any homecare by the community nurse if her mother is informed of her diagnosis. This creates ethical distress for the nurse practioner and she is aware that if she agrees with the daughter she will commit an ethical violation(#2). The daughter is instrumental in all matters related to her mother. Also, the language barrier does not help. The daughter believes that sharing this news will catapult her mother into a state of depression, with no end in sight.
Resolution: The nurse practioner takes the time to explain the nature and progression of the cancer and the available palliative care options. She then requests that the other siblings be informed so that a joint decision can be made. Also, that the daughter should not commit to any one choice until she has thought about all the issues clearly, so to give herself a few days and then get back to the nurse practioner. The nurse practioner has realised that her ethical reasoning may not result in an ethical action, but she is hoping that this not be the case. It is evident that the nurse practioner does not want to upset the most important decision maker, the daughter. However, she is also cognitive of the fact that her main concern is the palliative homecare that the patient needs. The nurse practioner feels that she will abandon the patient if she is unable to get through to her daughter. So she relays her greatest concern as the patient being deprived of the essential care she needs, and the enhanced quality of life the patient can enjoy in the days remaining in her life. This illustrates that the nurse practioner is posing an alternative way for the daughter to think of the issue. The siblings eventually decide not to inform the mother of her diagnosis, but agree that homecare can be provided. They explain to the mother that the homecare nurse is there to administer medication to help her sleep.
So, the ethical issue we are dealing with here includes:
- 1. Truthfulness and fairness- the nurse is not being truthful and fair to the patient by with-holding information from her because of a request by the daughter.
How is the nurse practioner dealing with the ethical dilemma and the possible ethical violations?
- 2. The nurse wants to promote justice by discussion and education ( informed decision making) with the daughter, so that the mother is given a chance to be autonomous in her health care. The nurse is trying to create an environment where dialogue will be possible.
The nurse wants to provide home care services so that the client’s well-being and welfare is given priority over any other family matters. However, we have to also consider cultural issues in these circumstances. It can be difficult to decide what is best in a particular situation, but the decision can be based on beneficence, ie providing care for the good of the client. However, not all instances of ethical dilemmas can be resolved successfully, as values may differ.
Refences/ resources used: http://www.cna-aiic.ca/CNA/practice/ethics/code/default_e.aspx http://www.cno.org/docs/qa/44023_fsQa.pdf http://www.cno.org/docs/prac/41034_Ethics.pdf http://www.cna-aiic.ca/cna/documents/pdf/publications/Ethics_Pract_See_Silent_November_1999_e.pdf
We can see many similarities with in the professions:
They all have a regulatory body who is responsible for public safety, and therefore provides a code of ethics for it's professionals. This provides a guideline for the professionals to work within. We see that beneficence, autonomy, confidentiality, accountability and professionalism all have a role in the guidance of these professions, although it may be called by a different name. Quality assurance seems to also be a common yardstick to address ares of concern. A commonanity amonst these professionals indicate that many of them voice their concerns initially amongst co-workers, and if a suitable solution is not available then they consult with supervisors or managers.
None of these dilemmas needed any union involvement or any sort of arbitration. I have heard of some that go that far if coworkers or managers are involved .