Ethics: What Would You Do?

You are working with a 25-year male who suffered a high-level spinal cord injury (and you suspect a mild head injury due to his aggressive behavior but there is no diagnosis) as a result of a hit and run auto accident. He thoroughly expects if he tries hard enough to one day "walk out of this #(U#@) place" and needs a "good" therapist to help him (meaning not you) "learn how to walk". You know that given the extent of his injury, it is very unlikely that he will ever walk and will likely require extensive assistance with most of his ADLs. Every time you try to discuss a realistic level of recovery with him and possible goals, like basic feeding and grooming goals, he gets belligerent and tells you again that he needs a "good" therapist and how much you and occupational therapy "suck". He is currently on anti-depressants and is receiving psychiatric services. He will be discharged from the inpatient rehab facility if he continues to refuse OT services. You have trialed a co-treatment with your PT colleague, a rehab aide, and an OT student where you worked on "standing" which was basically 4 people holding him up. This patient also weighs 300#. His family agrees that he needs to walk. What do you do?

• Silently cry inside each day before you go into his treatment room and speak about pleasantries like the weather while trying AGAIN to get him to work on ADL-related skills.

• Work on "walking" everyday with your PT associates and other helpers you can recruit and not address the OT goals.

• Inform him again if he continues to refuse, that he may be discharged from the facility per insurance regulations.

• Change your OT goals to address functional mobility.

• Other

You are an occupational therapy student and you see a nursing assistant be very rough with one of the residents at the nursing facility where you are doing your observation hours. The nursing assistant is a family friend and is a single mother who is working her way through nursing school. The resident at the nursing facility has advanced dementia and is known to frequently yell out and can become physically abusive with staff.

• Nothing- this makes me very uncomfortable and as a student, I probably don't know enough about the situation.

• I would peek my head in the room and ask her if everything is okay.

• I wouldn't do anything at that moment but would tell my mom about what I observed later that night.

• I would tell the nursing assistant's manager what I saw.

• Other- please explain

You have a 82 year old patient named Sofia who has high complaints of back pain (consistently 9/10 on the Numerical Pain Scale) and is taking high-level narcotics to help control the pain. She has had multiple interventions to control her pain but reports that nothing makes her pain better. Sofia was recently hospitalized with pneumonia and pressure ulcers, largely due to spending most of her day in bed. She currently lives in a senior living apartment and requires moderate assistance with transfers, toileting, lower body dressing and bathing. She has a home health aide that comes in three days a week for 2 hours to assist with those ADLs but often stays in bed the other days and will often not bathe or change her clothes on the days that the home health aide does not come in. Her two sons both work and are not able to afford paid caregivers to meet Sofia's needs. However, they stop in after work and on the weekends to check on her. The sons say that Sofia has always been very dramatic and enjoys getting attention from medical professionals. Sofia's sons say that you should "make her" get up and out of bed and that she is faking the pain for attention. However, every time you approach her about participating in occupational therapy, she adamantly refuses due to complaints of pain. She has mild cognitive deficits but is deemed able to cognitively live independently with minimal support and can make her own medical decisions. Thinking about the principles of beneficence and autonomy, how should you proceed with Sofia?

• My job is to promote good and it is in Sofia's best interests to get up and out of bed. Therefore, I should continue to push her to get out of bed and will attempt to persuade her again to get out of bed.

• My job is to prevent harm and given that Sofia has high complaints of pain, forcing/persuading her to move would only increase the amount of harm to her. Therefore, I should leave her alone.

• Sofia is able to make her own decisions and has the right to choose to refuse therapy. I think she needs to go to a nursing home but she has said multiple times that she will refuse to go.

• Sofia appears to be narcotic-seeking and should be referred to a psychiatric setting. She has also refused multiple times to be seen by "quacks" despite her apparent desire for attention.

• Other: please share with class.