This content is sponsored by Passy-Muir
A sound understanding of ethical principles lies at the heart of all healthcare professions, and it is a requirement of many licensing and accrediting entities that healthcare professionals participate in regular education on the subject to keep up-to-date ethical practices in the forefront of clinical care. The ethical principles upon which modern clinical practice is based are:
- Patient autonomy – making decisions based on a patient’s own reasons or motives.
- Beneficence – doing what is in the best interests of the patient.
- Nonmaleficence – ensuring a patient will not be negatively affected by treatment.
- Justice – treating all patients in a given situation fairly and equitably.
- Sanctity and dignity of human life – respecting and valuing patients on an individual basis.
- Fiduciary relationship – deserving a patient’s trust that competent care will be provided to meet goals and preserve values. (Olejarczyk & Young, 2019)
Within clinical codes of ethics, there are also consistent principles such as ensuring safe and effective care; establishing parameters of behavior; and promoting an environment of human rights, values, and customs. These standards touch all areas of healthcare. Clinicians in the medical field have a responsibility to provide both evidence-based and ethically based care. However, sometimes the patients and practices of clinical care do not follow clean lines and leave clinicians weighing patients’ rights and the ethics of their decisions. Patient bills of rights vary by state and facility, but nationally protected patient’s rights include:
- Informed consent
- Refusal of treatment
- Confidentiality
- Continuity of care
These rights also extend to patients who have communication difficulties. Of course, they do, right? However, these patients may not have access to the communication needed to actually exercise those rights. The Americans with Disabilities Act calls on us as clinicians to “communicate effectively with people who have communication disabilities” with the goal being “to ensure that communication with people with these disabilities is equally effective as communication with people without disabilities” (ADA Requirements: Effective Communication, 2020). This applies to all patients with barriers to functional communication, including patients with tracheostomies. For this population, using the Passy-Muir® Valve (PMV) to restore normal aerodigestive functions may be part of the ethical and evidence-based considerations for improving communication (and thereby access to patients’ rights) and swallowing.
Communication
Patients have a right to communicate, and, typically, a patient’s preferred method of communication is whatever their typical form of communication is when not under medical care. Clinicians have an ethical responsibility to restore a patient’s access to communication. By restoring the most effective method of communication, a patient will have a say in their treatment and care, possibly decreasing the risk for further treatment dilemmas leading to ethical situations. Misconceptions regarding PMV use that delay access to effective communication may affect ethical treatment of our patients.
| Misconception | Ethical Consideration | Evidence-based Response |
| The PMV cannot be used in-line with mechanical ventilation. | Nonmaleficence: Does delaying assessment deny benefits to the patient such as communication, swallowing, secretion management, positive pressure, cough, weaning, and quality of life? | FDA indicated for in-line use, safe for short-term and long-term use, improved weaning (Sutt et al., 2017 & O’Connor et al., 2021) |
| The patient is not ready for cuff deflation. | Fiduciary relationship: Am I competently managing cuff deflation to the benefit of my patient? Dignity: How is my patient affected by lack of voice? | Primary purpose of inflated cuff is for mechanical ventilation; cuff deflation trials are for assessing airway patency and stability; cuff deflation readiness indicators (Bach et al., 2014 & Pryor et al., 2016) Improved quality of life with return of voice (Freeman-Sanderson et al., 2016) |
| The patient has too many secretions. | Beneficence: Would it be beneficial to improve secretion management? | PMV has been shown to improve secretion management and cough effectiveness (O’Connor et al., 2019). Having a closed system improves EMT (expiratory muscle training) which may improve secretion management. |
| The patient is speaking without the PMV and does not need it. | Justice: Can this patient communicate just as effectively as a patient without a tracheostomy or as a patient with a tracheostomy who uses PMV? | PMV may improve work of breathing, breath support for speech, volume (Wallace et al., 2023) |
Without effective communication, there also is risk associated with assuming a patient’s cognitive capacity. Clinicians must understand the risks in making assumptions about the capacity of patients with communication deficits and the possible consequences if no attempt is made to support communication. The clinician may determine that a communication impairment exists without cognitive deficits and will be able to provide treatment and support for communicating decisions (Kagan et al., 2020). Conversely, an impairment may affect the decision-making process, which requires the healthcare staff to examine the ethics of a healthcare representative and advance directives. Effective communication is needed for accurate assessment. When determining communication strategies, considerations should include:
- Is the patient able to demonstrate autonomy?
- Is the patient able to initiate communication?
- Can the patient utilize this communication strategy without assistance to have a private conversation with medical providers?
- Is the patient able to exercise the right to refuse treatment?
Dysphagia
Within the practice of speech-language pathology, dysphagia management presents unique challenges when ethical considerations must be contemplated. From instrumental assessments to diet recommendations, to treatment interventions, this is an area of practice where clinicians may experience the patient’s right to refuse. In any of these situations, it is important that clinicians provide thorough education regarding the available treatment options, the benefits of the recommended services, and risks of refusal so that the patient can make an informed decision. If the patient continues to refuse the service, the clinician may consider, according to competencies and ethical boundaries, what intervention still provides the patient as much benefit as possible within the boundaries set by the patient, rather than discharging a patient. If functional communication has not been restored, patients may not be able to exercise their right to refuse or participate in creating a plan of care that addresses their goals, demonstrating autonomy. Patients with tracheostomies are at increased risk of dysphagia and aspiration. A delay in referral for PMV assessment may prolong negative effects such as decreased laryngeal elevation, reduced subglottic pressure, and impaired airway protection (Prigent et al., 2011). An ethical response may be considerations of beneficence and nonmaleficence with early intervention aimed at providing as much benefit as possible.
Conclusion
The ethical considerations in speech-language pathology are as diverse as the discipline itself. While ethics are continually evolving, the core framework of practicing good ethical principles remains the same. It is important for SLPs to have a firm understanding of the basic principles and to build a practice upon them. To meet these needs, the SLP pursues studying new information and guidelines. As unique patient situations or new diseases and treatment approaches arise, the SLP must rely on their education, training, clinical skills, and competences, and on foundational ethics to make appropriate decisions regarding patients’ care. The SLP should not view ethical concerns as an isolated burden but should feel comfortable with seeking the counsel of others, particularly an ethical committee designed for such a purpose, to discuss complicated situations. Ethical conversations and discussions may be helpful and insightful. After all, SLPs are usually experts at talking about things.
References
ADA Requirements: Effective Communication. ADA.gov. Retrieved November 6, 2023 from https://www.ada.gov/resources/effective-communication/.
Bach, J. R., Gonçalves, M. R., Rodriguez, P. L., Saporito, L., & Soares, L. (2014). Cuff deflation: Rehabilitation in critical care. American Journal of Physical Medicine & Rehabilitation, 93(8), 719–723. https://doi.org/10.1097/PHM.0000000000000112
Ding, R., & Logemann, J. A. (2005). Swallow physiology in patients with trach cuff inflated or deflated: A retrospective study. Head & Neck, 27(9), 809-813. https://doi.org/10.1002/hed.20248
Freeman-Sanderson, A. L., Togher, L., Elkins, M. R., & Phipps, P. R. (2016). Quality of life improves with return of voice in tracheostomy patients in intensive care: An observational study. Journal of Critical Care, 33, 186–191. https://doi.org/10.1016/j.jcrc.2016.01.012
Kagan, A., Shumway, E., MacDonald, S. (2020). Assumptions about decision-making capacity and aphasia: Ethical implications and impact. Seminars in Speech and Language, 41(03); 221-231.
O’Connor, L. R., Morris, N. R., & Paratz, J. (2019). Physiological and clinical outcomes associated with use of one-way speaking valves on tracheostomised patients: A systematic review. Heart & Lung, 48(4), 356-364. https://doi:org/10.1016/j.hrtlng.2018.11.006
O’Connor, L. R., Morris, N., & Paratz, J. (2021). The safety and efficacy of prolonged use of one-way speaking valves. Australian Critical Care, 34(4), 319-326. https://doi.org/10.1016/j.aucc.2020.09.003
Olejarczyk, J. P., & Young, M. (2022). Patient rights and ethics. StatPearls Publishing. Retrieved November 10, 2023 from https://www.ncbi.nlm.nih.gov/books/NBK538279/
Prigent, H., Lejaille, M., Terzi, N., Annane, D., Figere, M., Orlikowski, D., & Lofaso, F. (2011). Effect of a tracheostomy speaking valve on breathing–swallowing interaction. Intensive Care Medicine, 38(1), 85-90. https://doi.org/10.1007/s00134-011-2417-8
Pryor, L. N., Ward, E. C., Cornwell, P. L., O’Connor, S. N., & Chapman, M. J. (2016). Clinical indicators associated with successful tracheostomy cuff deflation. Australian Critical Care: Official Journal of the Confederation of Australian Critical Care Nurses, 29(3), 132–137. https://doi.org/10.1016/j.aucc.2016.01.002
Sutt, A. L., Antsey, C., Caruana, L. R., Cornwell, P. L., & Fraser, J. (2017). Ventilation distribution and lung recruitment with speaking valve use in tracheostomised patient weaning from mechanical ventilation in intensive care. Journal of Critical Care, 40, 164-170. https://doi.org/10.1016/j.jcrc.2017.04.001
Wallace, S., McGowan, S., & Sutt, A. L. (2023). Benefits and options for voice restoration in mechanically ventilated intensive care unit patients with a tracheostomy. Journal of the Intensive Care Society, 24(1), 104-111. https://doi.org/10.1177/17511437221113162
