Ethical Consideration from a Legal Lens - A Case Study

Mora Pluchino is instructing her ethics course, Ethical Considerations from a Legal Lens, which is scheduled for June 3, 2023. This remote course covers ethical considerations from a legal lens for professionals working in the area of Pelvic Health. Health Care Professionals have many day-to-day ethical considerations to “do no harm” including basic decisions for billing, patient care, safety, and compliance. Pelvic Rehabilitation comes with additional layers of vulnerability and ethical challenges, and the legalities of pelvic health can add further complications for patient care, business, and clinical practice decisions.

The patient is a 70 cis-gender female:

• Primary complaints - Painful sitting, terrible tailbone pain x 2 years
• Secondary complaints - SUI, fecal urgency, mild POP
• Prior therapy - multiple, most recent Hospital Based OPPT 3 x per week x 8 weeks (24 visits)
• Progress - minimal to none, the patient actually thinks her symptoms are worsening, pain is unbearable
• Other diagnoses - Parkinson’s Disease, HTN, high cholesterol
• Primary Insurance - Medicare

SEPTEMBER
The patient presents to the provider for specialized pelvic floor therapy. The patient is seen 1 x per week for a total of 6 visits. The patient reports a 75% reduction in symptoms, adheres to her HEP, and attends all scheduled visits.

Treatment Included:

• Internal rectal musculature work (Instructed in Pelvic Floor Level 2A)
• Body mechanics and coccyx mobilization - internal and external (Instructed in Coccydynia & Painful Sitting)
• Sacral nerve release techniques (Instructed in Sacral Nerve Manual Assessment and Treatment) 

NOVEMBER
The patient is now able to participate in her ADL, regular exercise routine, and her social life and she has noticed how her endurance and balance have declined as she tries to return to normal. She starts to come in 2 x per week, one day a week focusing on her pelvic floor complaints and one day a week focusing on her endurance, balance, and Parkinson’s symptoms. She completes an additional round of therapy 2x per week for 8 weeks. She progresses slowly but objectively measures small therapy gains.

Additional treatment:

• General strength and endurance training and conditioning
• Large amplitude movement program
• Education for a home walking program
• Connection to a Parkinson’s boxing program in the community

FEBRUARY

The patient gets sick, misses 2 weeks of therapy, and has a return in her coccyx pain and an exacerbation of her Parkinson’s symptoms. Her tremors became so bad that she has to cancel multiple sessions at the last minute. She is now also having swallowing and speech problems. She finally gets in with her neurologist who explains her Parkinson’s has progressed. They recommend changing her medications, assessment for a brain stimulator, and trying an intensive LSVT BIG Program 4x per week for 4 weeks. 

Please pause and take a moment to think about a few things that may pop up for a provider from an ethical or legal lens!

SOME ETHICAL + LEGAL CONSIDERATIONS FOR THE CASE

1. Prior to beginning the LSVT BIG program, the patient is already at 46 visits in total 
2. Your practice is a small, niche market practice that specializes in Pelvic Health - this patient only ended up with you due to her tailbone pain - your location is small and does not have “big gym” equipment or space
3. You do have two providers that have prior LSVT BIG training
4. This patient has worked with and reports feeling safe and comfortable with both providers
5. Sitting in the car for more than 45 minutes is again a challenge for the patient and you are the closest qualified provider to her home
6. You are the only Pelvic Floor clinic within the 15-mile radius
7. To accommodate this patient’s scheduling needs will make your waitlist longer for others
8. Medicare has an annual cap for services which changes based on practice setting. Physical therapy and Speech therapy share this cap. 
9. This patient has been plateauing/ possibly worsening as her Parkinson’s progresses and sessions are feeling like maintenance therapy.
10. There are hospital-based LSVT BIG programs 55 minutes away from the patient's home.

The fun and challenging part about ethics is that the possibilities and scenarios are many and ever-changing. This is a real live case and an example of what therapists have to navigate on a day-to-day basis. Sadly, there is no right or wrong. Ethics and Law are areas of more gray than black and white. 

Ethical Considerations from a Legal Lens has the following goals:

1. Define basic Ethical Framework topics
2. Perform Core Values Self Assessment
3. Identify the components of the RIPS model and the Model Rules of Professional Conduct
4. Explore Pelvic Health from a Legal Lens
5. Apply the RIPS model to real-life legal scenarios
6. Devise a plan of action or solution to legal and ethical scenarios 

The hope is that with this understanding of things like beneficence (balance harms and benefits), non-malfeasance (do no harm), justice (fairness), and autonomy (respect for self-determination) as well as being well-versed in patient care topics like consent, abuse, misconduct, discrimination, and our individual practice acts, providers will feel more comfortable in their ethical decision making. 

Ethical Considerations from a Legal Lens and Ethical Concerns for the Pelvic Health Professionals both offer the information needed to have these conversations and start problem-solving these decisions. It is encouraged as part of the precourse work to send in the ethical concerns that have you stuck in the clinic or keep you awake at night!

Ethical Considerations from a Legal Lens

Price: $175.00          Experience Level: Beginner          Contact Hours: 6 hours

Course Dates: June 3 and November 12

Description:  This one-day remote course covers ethical considerations from a legal lens for professionals working in the area of Pelvic Health. In general, Health Care Professionals have many day to day ethical considerations to “do no harm.” This includes basic decisions for billing, patient care, safety and compliance. Pelvic Rehabilitation comes with additional layers of vulnerability and ethical challenges, and the legalities of pelvic health can add in further complications for patient care, business and clinical practice decisions.

Ethical Concerns for the Pelvic Health Professionals

Price: $175.00          Experience Level: Beginner          Contact Hours: 6 hours

Course Dates: September 16

Description:  This one day remote course covers ethical considerations for professionals working in the area of Pelvic Health. In general, Health Care Professionals have many day to day ethical considerations to “do no harm.” This includes basic decisions for billing, patient care, safety, and compliance. Pelvic Rehabilitation comes with additional layers of vulnerability and ethical challenges due to the anatomical areas being treated, topics being discussed, and intimacy of sessions.