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Ethical issues arise when the line blurs between therapist and friend
If the doctor doesn’t talk your talk, you may have a problem
KSL Featur
Ethical issues arise when the line blurs between therapist and friend
By Rob Senior
You could say Beth Ryan has quite a large extended family. Ryan, RN, a nurse at Harmony Home Health and Hospice in Murray, UT, has worked in home health for more than 20 years and gotten to know quite a few patients very well. "You spend so much time together," she said, "that you become almost part of the family." Inevitably, over a period of time that sometimes lasts several years, even the most professional of relationships will develop a personal aspect. For the most part, friendliness between a practitioner and client can only be viewed in a positive light. However, it's important for physical therapists in general—and particularly those in home health—to set boundaries and avoid the conflict between professionalism and personal relationships. "The most common ethical issue, and often the most puzzling, is where do you draw the line professionally and personally?" said Ryan. "Because we see our patients in their environment, for such a long period of time, it can be difficult to draw that line."
Dealing with Ethical Issues
Around this time of year, it's customary to exchange gifts with friends, family, even co-workers. But when the gifts are more frequent than once a year, how does a home health PT react?
The very nature of home health in some ways causes the uncomfortable situations in which physical therapists often find themselves, Ryan explained.
"A lot of the patients we see are elderly," she said, "and part of the culture of the older generation is generosity and sharing. Add that to the fact that there is no exchange of money at the time of service, and it only adds to a person's feeling that they should be giving you something."
This is only one of the reasons why some facilities have adopted steadfast policies regarding gift giving. "We instruct all of our visiting staff that they are not to accept gifts from patients or from [the patient's] families," stated Elizabeth Towery, PT, at CarePartners Home Health Branch in Asheville, NC.
For gifts of significant monetary value, this rule is cut-and-dry, and relatively easy for therapists to follow. But what about items that fall into a gray area, such as baked goods or an item personally created by the individual? To refuse these gifts would be to risk hurting or insulting the patient, which could cause unspeakable damage to the professional relationship.
"We're always encouraging our staff to be respectful of the patients," stressed Ryan. "So if I go into a home, and they offer me a cup of coffee or a piece of dessert, I will accept it and enjoy it while I sit and talk with the family. Otherwise, I would risk hurting their feelings."
"If the gift is something small, it's not a problem," agreed Towery. "I will often thank the person, and share it with my co-workers. We're in a rural area, so in summer it's not uncommon to be offered fresh fruits or vegetables from a garden."
While Towery will accept gifts in situations like these, she also makes a point to clarify to the individual that gift giving should not become a regular occurrence. And such a policy is never acceptable for gifts of significant value—or the outright exchange of cash.
"Things get really sticky when someone hands you an envelope, and you just know there is cash inside," Towery admitted. "At that point, you just have to hand the envelope back and say no thanks."
Luckily, CarePartners has developed a way that patients or their families can express their gratitude without creating an ethical dilemma or uncomfortable situation. The organization has opened a "help pot" for those patients who find themselves in difficult financial situations. Patients who insist on giving a gift are encouraged to donate to the help pot.
"It's a way for us to help our less fortunate patients," said Towery. "This way, we can help out a patient who can't afford a piece of equipment, or who runs out of medicine two days before their check comes."
In the past, Towery has encouraged patients who insist on giving a monetary gift to send their donation to the hospital, where it is used for the fund. This way, both parties are happythe therapist has solved her ethical dilemma, and the patient has fulfilled his need to give thanks.
Upon the completion of treatment, the patient is encouraged to write a thank-you note to the hospital or call her supervisor.
"It's not tangible, but supervisors enjoy receiving phone calls complimenting their therapists," said Towery. "Those kinds of gifts are wonderful for us."
Of course, money and gifts are just objects—Towery says if a patient truly wants to thank her, it's much simpler
"I often tell patients the best way they can thank me is to just listen to what I say and continue following the instruction they have received," she said.
Privacy Issues
A different sort of ethical dilemma is created by the patient's right to privacy, and more recently, the HIPAA rules. No matter the situation, the therapist is not permitted to share information about a patient with anyone without that patient's consent.
"If I go into a home and see something that concerns me, I cannot tell anybody about that without the patient's consent," said Ryan. "That puts us in the middle of a situation where we feel obligated to alert someone, even if the patient is asking that we not contact their family."
The aspect of confidentiality between two patients is another tricky issue. "Sometimes, you'll treat people in certain geographic areas where everyone knows each other," said Towery. "Patients know that one of their neighbors is receiving therapy, and they might ask about that person's progress."
To keep within HIPAA guidelines, and to protect the other person's privacy, Towery said she normally compliments the patient on their concern for the other individual, and suggests that a phone call be placed to express that concern.
"That way, you've said nothing, and at the same time encouraged them to be neighborly," she said. "The therapist has done nothing to violate HIPAA or the privacy agreement."
Other Dangers
Roger Herr, PT, president of the APTA's Home Health Section, acknowledges the importance of a strong relationship between therapist and patient. However, he also maintains that the basis of that relationship should be professional before becoming personal. One way Herr does this is by addressing his patients formally, as in "Mrs. Smith" or "Mr. Jones" until they ask him to do otherwise
"Only when they say, 'Oh, you can call me Betty,' will I do so," said Herr.
Overly personal relationships can lead to a dependency Herr refers to as "learned helplessness," in which a patient will become increasingly reliant on a physical therapist. While Herr admits he has done favors for a patient in the past, he is also quick to clarify to the patient that it is the humanitarian in him doing these favors—not the physical therapist.
"You want to establish a group therapeutic rapport with the patient, so you'll do things for them," said Herr. "I might take out the trash for them, or give them a ride to the store after we're done therapy," he said, "but I make sure they understand that I'm doing so out of the goodness of my heartnot because of a professional obligation."
Being outside of a typical health care environment blurs the barriers between therapist and friend. The transition to a person's home gives the encounter more of a social feel than a professional one.
In the end, however, home health PTs enjoy a great deal of independence—with no supervisor on site, they essentially serve as their own boss while performing therapy. While the independence factor is an inspiration to many to get into the business, by the same token it has scared off a number of PTs who've decided they simply couldn't handle it.
"People usually know right away if home health isn't for them," Herr confirmed. "Most of our therapists are very happy—but those who aren't usually leave within the first six months on the job."
Legislative Advances
The year 2004 has been a great one for the home health field, a trend Herr hopes will continue in the future.
"More people are becoming aware of home health now," he said. "And the role of the physical therapist is increasing. Agencies are utilizing more therapists—not only in providing care, but also in their OBQM [Oasis-Based Quality Management]."
This is in no small part due to the Medicare Prescription Drug Act, signed by President Bush earlier this year. The bill allows patients to receive home health visits without co-pays, and increases reimbursement for home health providers in rural areas. Over time, the hope is that these changes will lead to greater exposure, and subsequently a greater interest in home health among physical therapists.
So as we reach the end of what many view as the first year of home health's resurgence, the adage from the old song holds true—there's no place like home (health) for the holidays.
Rob Senior is on staff at ADVANCE, and can be reached at rsenior@merion.com
Copyright © 2005 Merion Publications
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If the doctor doesn’t talk your talk, you may have a problem
By Greg Lavine
Navigating the health care world can be challenging enough for those who speak English, but new immigrants often face the added confusion of language barriers.
Kingi Langi, a physician’s assistant and medical technician originally from Tonga, is trying to reach out to the medically underserved Polynesian community. On Saturday, he helped out at a free clinic for the Polynesians in West Valley City.
Langi said Tongans and other Polynesians are at greater risk for diseases such as obesity, hypertension, diabetes, arthritis and high cholesterol. Many times, these medical problems go undiagnosed in the immigrant communities. "We want to identify these high-risk groups and get them to treatment," he said.
Cindy Clark, a community education specialist with Harmony Home Health and Hospice, said Tongans living here are likely to wait until a health problem reaches a serious level before seeking help. There is a cultural tendency to avoid outside aid for heath problems.
"They just don’t have the resources to take care of themselves healthwise," she said. Clark’s company, which co-sponsored Saturday's screening, provides home health care services and participates in events that reach out to underserved communities. Clark hopes that these types of events let immigrant groups know that it is not a bad thing to let doctors come in and take care of medical problems.
Langi said language and financial problems contribute to the difficulties for some members of the Polynesian community. Taking health care to these communities, such as Saturday’s event at the Tongan South Stake Center of the Church of Jesus Christ of Latter Day Saints, can help.
Langi has participated in several such clinics in the last few years, but hopes to start holding these events every three months. Along with his medical partner, physician Lombardo Palma, Langi would like to expand these clinics to underserved Latino groups.
Health care providers at these events offer free blood pressure and blood glucose tests, in addition to taking weight and pulse measurements. The data can reveal potential medical problems.
Each participant sits down with a physician’s assistant or a doctor to discuss the results of the test as well as tips for living healthier, Clark said.
On October 21st Harmony was featured on KSL’s segment speaking on business, to read or listen to the segment, click the link below.
smallbiz.ksl.com/speak-11201i.php
• September 14, 2004 - A philosophy of living - http://www.transcriptbulletin.com/20040914philop.html
• August 26, 2004 - Utah ranks #1 in nation for best places to die - http://tv.ksl.com/index.php?nid=39&sid=115777
• August 25, 2004 - Utah is “best place” to die - http://deseretnews.com/dn/view/0,1249,595086631,00.html
• April 22, 2004 - Young pianist shares gifts with appreciative seniors - http://deseretnews.com/dn/view/0,1249,595057759,00.html
&bull: October 10, 2003 - Many ways to help others - http://deseretnews.com/dn/view/0,1249,515037775,00.html
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