Ethics and Jurisprudence for the Physical Therapy Professional Licensed in Hawaii

Learning Outcomes

• Identify 3-4 sources of rules and laws governing physical therapy practice in Hawaii. 
• Explain how to access the most recent Hawaii Physical Therapy Practice Act and apply the clinical scope of practice in Hawaii.
• List the key supervision requirements for physical therapist assistants and physical therapy aides.
• Examine the Hawaii Practice Act to determine requirements for physical therapists and physical therapist assistants to maintain and renew their licenses, including continuing competence requirements.  
• List basic principles of ethics and identify the code governing discipline-specific therapy practice and their application to physical therapy.
• Analyze ethical dilemmas through case scenarios to illustrate how to apply a Code of Ethics to real-world issues.

Introduction

What is jurisprudence exactly?  Jurisprudence is the philosophical study of law, encompassing its nature, origins, interpretation, and application within society.  Jurisprudence requirements for physical therapists vary across states in the United States, with each state's physical therapy licensing board or regulatory agency establishing its own rules and regulations, including any jurisprudence requirements. Jurisprudence courses and/or exams assess therapists' knowledge of the laws and regulations governing physical therapy in a specific state. 

You may ask why jurisprudence?  Why do I need to take a course on this each renewal period?   

Therapists must stay informed about and adhere to their practice acts for several reasons:

1. Legal and Ethical Compliance: Understanding and following the regulations outlined in practice acts ensures therapists comply with legal and ethical standards, maintaining a high standard of professional conduct.

2. Patient Safety and Quality of Care: Practice acts often include guidelines and standards to protect patients' well-being and safety.  Staying updated on these regulations enables therapists to implement best practices for their patients' safety.

3. Professional Accountability: Adhering to the Practice Act demonstrates professional accountability, ensuring therapists can be held responsible for maintaining the highest standards of care through their actions and decisions.

4. Licensing and Certification Requirements: Practice acts govern licensing and certification requirements. To maintain professional credentials, therapists must be aware of continuing education, renewal, and other requirements specific to the state or states practicing in.

5. Professional Development: Staying current with the practice act allows therapists to engage in ongoing professional development, attending conferences or training sessions to enhance their skills and knowledge for optimal client care.

6. Adaptation to Changes: Practice acts may undergo updates or changes over time. Staying informed about these changes enables therapists to adapt their practices, incorporating new evidence-based practices and aligning with evolving standards.

Today, we will go through the jurisprudence and the ethical aspects of physical therapy practice in Hawaii. 

Physical Therapy and the Law

The rules governing physical therapy practice are embedded within the State Practice Act. Additionally, the legal landscape incorporates common law, also known as case law, originating from judicial decisions and encompassing aspects like malpractice cases.

Establishing physical therapy practice guidelines in each state rests upon the State Practice Act, a legislative creation that reflects administrative insights from the state board. These boards, responsible for interpreting and upholding the State Practice Act, oversee physical therapy practice within their jurisdiction. Given the diversity of state regulations, all 50 states possess distinct practice acts shaping the scope of physical therapy within their borders.

The state board relevant to each jurisdiction, such as the Hawaii State Board of Physical Therapy, oversees and enforces the state practice act within their state. The complex mosaic of legal regulations necessitates a tailored approach to each state's laws and regulations, ensuring that the practice of physical therapy aligns with the unique legal framework of that state.

Licensure stands as the primary regulatory mechanism within the domain of physical therapy. This mandates that individuals cannot identify as physical therapists or offer physical therapy services without a valid physical therapy license. The state board, outlined in the state practice act of each jurisdiction, outlines the prerequisites for obtaining and retaining a license.

For instance, in states including Hawaii, acquiring a license typically necessitates successfully completing a licensing examination. Although many states, including Hawaii, opt for the licensing examination provided by the Federation of State Boards of Physical Therapy, this remains a discretionary decision. Presently, licensure remains contingent on adherence to individual state regulations. Reciprocity, whereby a license in one state permits practice in another, isn't guaranteed. While circumstances might enable temporary practice, like being a physical therapist for a visiting performer, the practice authority remains confined to the individual state's jurisdiction.

The realm of physical therapy practice is also influenced by federal laws, which emanate from the central government in Washington, DC. Notably, these federal laws possess jurisdictional impact across all states. Several prominent federal laws are of relevance within clinical practice, including:

1. Health Insurance Portability and Accountability Act (HIPAA): HIPAA is a pivotal confidentiality law. It establishes guidelines for safeguarding patient medical information and personal data. Accompanying HITECH, it ensures the confidentiality of electronic health records.

2. HITECH (Health Information Technology for Economic and Clinical Health Act): This law complements HIPAA by addressing technology-related confidentiality concerns. It supports the secure exchange of electronic health information while upholding patient privacy.

3. Medicare Rules and Regulations: Guidelines established by the Centers for Medicare & Medicaid Services (CMS) that dictate reimbursement policies, documentation requirements, and standards of care for physical therapy services provided to Medicare beneficiaries.

4. Americans with Disabilities Act (ADA): This law ensures the protection of individuals with disabilities against discrimination in various spheres, including employment and access to public service, healthcare services, and facilities.

5. IDEA (Individuals with Disabilities Education Act). IDEA is a federal law that governs how states and public agencies provide early intervention, special education, and related services to children with disabilities. IDEA covers early intervention services for infants and toddlers with developmental delays or disabilities and their families. Children with disabilities must be educated with non-disabled children to the maximum extent possible. Parents must be included in the IEP process, and older students are also involved in developing their educational plan. The main purposes of IDEA are to ensure all children with disabilities have access to a free and appropriate public education, protect their rights, and provide early intervention services.

6. Stark Law: Prohibits physicians from referring Medicare patients to entities with which they have a financial relationship, which can impact physical therapists who have referral relationships with physicians.

7. Anti-Kickback Statute: Prohibits the exchange of remuneration in exchange for referrals for services reimbursed by federal healthcare programs, which can affect relationships between physical therapists and other healthcare providers.

These federal laws extend their influence beyond state boundaries, making it imperative for physical therapists to comprehend and adhere to their provisions.

HIPAA

In 1996, HIPAA was introduced as a crucial confidentiality law with the central aim of safeguarding patient identifiers and protected health information (PHI). Protected health information encompasses any data that could potentially identify an individual, including details like name, address, social security number, and diagnosis. Even defining characteristics, like in the case of a high-profile patient, can be considered within the scope of PHI. The primary focus of HIPAA revolves around the secure transmission of information and the methods by which such information is shared.

Protected Health Information (PHI) encompasses any information related to a patient's past, present, or future physical and/or mental health or condition, regardless of its form, including written (such as documentation, electronic communication), spoken (like hallway discussions), or even notes left for colleagues. However, spoken and electronic text are particularly prone to causing issues.

For example, consider a scenario where individuals in a public setting, clearly from the healthcare field, inadvertently disclose patient information in conversation, potentially breaching confidentiality. Similarly, online forums, including social media groups, can inadvertently expose PHI when discussing cases. Physical therapists must remain vigilant across all communication channels, ensuring confidentiality and avoiding HIPAA violations.

PHI Identifiers

There are 18 specific identifiers.  Those identifiers include: 

• Name
• Address
• All elements (except years) of dates related to an individual
• Telephone numbers
• Fax number
• Email address
• Social Security Number
• Medical record number
• Health plan beneficiary number
• Account number
• Certificate or license number
• Any vehicle or device serial number
• Web URL
• IP Address
• Finger or voice print
• Photographic images
• Any other characteristic that could uniquely identify the individual ie. tattoo   

How Can We Use and Share Patient Information? 

We can use it for treatment, payment, or operations.

Treatment (T)

Physicians, nurses, therapists, and other providers may access a patient’s record for treatment.  Health information may also be shared with other healthcare providers outside of the facility  to decide on the best treatment or to coordinate care.   

Payment (P)

Health information is shared with Medicare, Medicaid, insurance plans, and other payers to determine claims payments and benefits. 

Operations (O)

Health information is used for quality assurance, training, and audit purposes.  This would include working in an organization where they have a quality assurance committee or performance improvement plans that utilize training, and internally auditing chart reviews. 

For purposes Other than TPO

Unless required or permitted by law, you must obtain written authorization from the patient to use, disclose, or access patient information. Where I see us get into trouble sometimes with this is related to research first and foremost, as well as marketing.

Even positive stories about patient outcomes or new equipment require authorization to be shared publicly, as they are not considered treatment, payment, or healthcare operations. Well-intentioned aggregated data could still indirectly identify individuals, so caution is needed. Sales and marketing teams may propose ideas that breach TPO, requiring therapists to ensure proper protections remain in place. The minimum necessary standard also applies - only essential PHI should be used or disclosed. Openly discussing patients without a job-related purpose violates HIPAA, even if de-identified. When unsure if PHI use aligns with TPO, consult compliance staff rather than risk violations. Their guidance helps therapists avoid missteps while still being able to appropriately leverage data or stories in practice enhancement or referral development. The key is obtaining patient consent and limiting PHI outside immediate care team needs.

Except for Treatment, the Minimum Necessary Standard Applies

For patient care and treatment, HIPAA does not impose restrictions on use and disclosure of PHI by health care providers. Exceptions: psychotherapy information, HIV test results, and substance abuse information.

For anything else, HIPAA requires users to access the “minimum necessary” amount of information necessary to perform their duties, and only disclose to those that have a need to know. 

You may not discuss any patient information with anyone unless required for your job.

Keep Health Information Secure is Part of Your Job

This includes: 

• Secure Faxing
• Safe Emailing
• No texting of PHI
• Safe Internet use
• Password Protection
• Conversations-Conversations are to be held in a private place
• Department Security
• Social Media
• Discarding Papers
• Computer Security
• Know where you left your paperwork-Check your printers, fax machines, copiers, et cetera. Make sure if you do have soft charts, that those are brought back to the appropriate area.
• Removal of Records-We don't remove records from our facilities for any reason unless it is required or requested by a government agency, an intermediary, or a carrier.
• Storage of Records-Store records a secure location that is not available for public view or access.
• Building Access-How many times have you used your swipe card to go in a facility and somebody comes behind you? If you don't know that individual, don't allow him or her to enter a secure facility if they're not authorized to do so.
• Verification of Requests- Make sure you know your policy on how to verify those requests. Don't disclose PHI unless you have the written authorization to do so
• Sharing PHI
• Disclosure of PHI

Several excellent points for therapists to ensure HIPAA compliance and safeguard protected health information:

• Avoid transmitting PHI via unsecured methods like plain email/text
• Use strong passwords, never share credentials, and properly secure computers
• Have private conversations away from public areas
• Shred documents and utilize locked cabinets/rooms to limit exposure
• Log off computers when stepping away and confirm printer/fax documents aren't left out
• Do not post any patient details or photos on social media
• Verify identity and authorization before releasing records. Make sure you know your policy for figuring out how to verify those requests. We don't disclose PHI unless we have written authorization to do so.
• Do not allow building access to unknown people
• Check state privacy laws, as penalties for violations are substantial

Even when communicating with a patient's friends or family, the patient must have the capacity to consent to disclosing their protected health information. Therapists cannot share details with loved ones without the patient's explicit authorization, even if they intend to keep them informed. It's an important distinction, as family dynamics can make assumptions of implied permission risky. As you noted, HIPAA violations carry substantial penalties, so obtaining express patient consent before any PHI disclosure is essential to avoiding hefty fines or potential legal consequences.

Internet is an Electronic Billboard

You may expect electronic messages to remain private, but once you send or post them, you’ve lost all control over it. 

Deleting an electronic message does not make it invisible or undiscoverable.

NO Social media! Do not post patient-related or sensitive information on a website or social networking site.

Online communications like texts, emails, and social media posts are discoverable even after "deletion." While encrypted networks provide some protection, the best practice is avoiding any patient-related information online. Therapists should operate under the assumption that anything posted could potentially become public, regardless of privacy settings or quick retractions. Violating patient privacy through digital channels can generate HIPAA violations and legal consequences. 

Texting

When is texting appropriate at work?

If your message is urgent or short & sweet:

• “Call Me”
• Say, “I just sent you an email and need a response.”
• Logistical communications: travel information, dates, times, and locations of meetings are ok (if no names).  Make sure not to place protected health information in a text.

Voice Mail 

Don't leave a detailed voicemail unless absolutely necessary.  Never leave substantive patient-related messages on unfamiliar phone numbers.  Instead, just say, "Hey, this is Kathleen from therapy. I need to speak with you. Call me at your earliest convenience. 

Do not use a speaker phone unless privacy is assured.  When using your phone through the car's Bluetooth system, the audio can be heard by people outside of the car. It's important to be mindful of this, especially when parked. To maintain privacy, it's a good practice to use earphones or AirPods if you need to have a private conversation or maintain discretion.

Don't forget that voice mails are easily forwarded, passed along, and otherwise shared. 

Best Practices for Voice Communication

Do not give PHI over the phone unless you confirm the identity of the listener & their authority to receive PHI.  

Be aware of your surroundings and who is around to hear any discussions concerning PHI.     

Refrain from discussing PHI in public areas such as coffee shops, airports, elevators, restrooms, and reception areas. 

Recommendations for Email

Email PHI only to a known party (e.g., patient, health care provider).

Do not email PHI to a group distribution list unless individuals have consented to such a method of communication.

In the subject heading, do not use patient names, identifiers, or other specifics; consider the use of a “confidential” subject line.

Again, I don't put any PHI into my emails. I would say, "Please contact me. I need to speak with you." Oftentimes, I do this within my own organization. If I need to speak with somebody about something that could be compliance-related, I'll email, "Hey, I have that information; I'm following up. Can you give me a shout?" And that's kind of my code to say, I need to talk to you, but I'm not putting that in writing. Always consider what you put in writing.

Medicare Rules and Regulations

Distinguishing between resources for healthcare providers and consumers, inquiries from professionals are directed to the cms.gov website, while patient queries are referred to the medicare.gov website.

Medicare, originally comprised of Parts A and B denoting inpatient and outpatient categories, has expanded to encompass Parts C and D. Part C represents a new version of Medicare resembling an HMO or PPO, and Part D pertains to pharmaceutical coverage. The distinctions among these parts can significantly influence coverage and care. Unlike Medicaid, which is managed at the state level, Medicare is federally funded and administered. The funds originate from federal taxes and are distributed nationwide from Washington, DC.

The American Physical Therapy Association (APTA) is a valuable and comprehensive resource for navigating Medicare rules and regulations. Through their Learning Center, they offer courses to stay updated with updates.  APTA also provides advocacy resources for private practice owners, aiding in optimizing reimbursement. The significance of Medicare regulations on physical therapy practice cannot be overstated. Since many patients treated fall under Medicare, understanding reimbursement policies is pivotal for financial sustainability.

Furthermore, Medicare policies often set the precedent for other third-party payers. For example, the concept of direct access, allowing patients to seek physical therapy without a physician referral, has varying degrees of acceptance by third-party payers. Medicare's stance on reimbursement influences the decisions of these payers. If Medicare were to support reimbursement for direct access care, other payers would likely follow suit, enhancing the financial feasibility of direct access care within the physical therapy practice.

Fraud and Abuse

A critical aspect of federal law that demands attention is the distressing occurrence of fraud and abuse within the healthcare industry. Despite discussions about escalating healthcare costs, an alarming 3 to 15% of these expenses are attributed not to actual medical care but to fraudulent and abusive practices. Unscrupulous healthcare providers exploit Medicare, Medicaid, and third-party payers through deceitful tactics, costing taxpayers billions of dollars.

As professionals in the field, physical therapists and physical therapist assistants (PTs and PTAs) must remain vigilant to prevent their involvement in such activities. It's equally vital to raise awareness about the substantial financial toll this misconduct takes on society. Many federal laws, including those I've previously discussed, such as Medicare, contain provisions designed to curtail instances of fraud and abuse. These laws enforce penalties and fines against those found guilty of such misconduct.

To gain clarity, here are a few examples of fraudulent activities: submitting claims for services that never occurred or supplies never provided, overbilling for time or services, falsely billing Medicare for missed appointments, or manipulating claims for inflated payments. Instances of abuse involve misusing billing codes, charging excessively, or submitting claims for services that lack medical necessity.

Maintaining a clear distinction between ethical practice and fraudulent behavior is crucial. While some may consider pushing the boundaries or being creative as harmless, it's important to emphasize that we must adhere to rules and regulations rigorously. Humorously put, "fudging" is appropriate for brownies, not for therapy documentation.

It's important to recognize that fraud and abuse have federal and state implications. Both levels of government employ civil and criminal laws to prosecute offenders, often resulting in severe consequences such as imprisonment. Perpetrators might face multiple charges, employing both federal and state statutes. Even though professional licenses aren't federally regulated, engaging in fraudulent behavior can still adversely affect one's license. Furthermore, individuals found guilty of Medicare or Medicaid fraud can be barred from participating in these federal programs for the remainder of their careers, resulting in a potentially permanent career setback.

Definitions of Fraud Abuse and Waste

Fraud:

• Involves intentional deception or misrepresentation for personal or financial gain.
• Examples include submitting false claims for reimbursement, billing for services not rendered, or forging patient signatures on treatment documentation.
• Typically involves criminal intent and can result in legal consequences such as fines, imprisonment, or loss of professional license.

Abuse:

• Involves improper or excessive use of resources or authority for non-legitimate purposes.
• Examples include providing unnecessary treatments to increase revenue, billing for services performed by unqualified individuals, or misusing equipment or facilities. Unbundling services and billing or billing services that do not meet professionally recognized standards.  
• May not necessarily involve intentional deception but still constitutes misuse or harm to resources.

In essence, while both fraud and abuse involve actions that are detrimental to the integrity and efficacy of healthcare services, fraud entails deliberate deception with the intent to gain unlawfully, while abuse encompasses actions that are excessive or improper, regardless of intent.

Waste:

• Excessive ordering of supplies or equipment beyond what is needed.
•  Inefficient scheduling resulting in underutilized staff or facilities.
•  Failure to properly maintain equipment leading to premature replacement.
•  Example: A physical therapy clinic purchases expensive equipment that is rarely used, maintains excessive inventory of supplies that expire before use, or schedules patients in a manner that leaves therapy rooms unused for significant periods.

Hawaii Whistleblower Act: The Hawaii False Claims Act

The Hawaii Whistleblower Act and the Hawaii False Claims Act hold particular relevance for physical therapists as professionals entrusted with the health and well-being of their patients. These acts provide crucial mechanisms for identifying and addressing instances of fraud, waste, and abuse within the healthcare system, ensuring that resources are allocated efficiently and ethically. Physical therapists may encounter situations where they witness fraudulent billing practices, inappropriate patient care, or other misconduct within their workplaces. The Whistleblower Act empowers them to report such violations without fear of retaliation, thereby promoting a culture of accountability and transparency in healthcare settings. The False Claims Act also allows physical therapists to take legal action against individuals or organizations that engage in fraudulent activities involving government healthcare programs or contracts.

Americans with Disabilities Act

The impact of federal laws on our clinical practice extends to ensuring accessibility for all individuals. Common inquiries arise regarding accommodations for patients with specific needs. While the answers might seem straightforward, local and state regulations often influence them. Consider these examples:

1. Accommodations for Deaf Patients: Providing a sign language interpreter is a common accommodation for deaf individuals. While using a family member might not always be ideal, seeking a professional translator is preferable.

2. Service Animals in Clinics: Determining which service animals to permit in outpatient clinics can be challenging due to the absence of clear guidelines. Developing well-defined clinic policies and procedures becomes crucial. Generally, service animals should be accommodated with appropriate documentation from a medical professional.

3. Wheelchair Accessibility in Clinics: While promoting wheelchair accessibility aligns with the principles of physical therapy, the financial feasibility is considered. While full accessibility is ideal if implementing it poses a significant financial burden, complete wheelchair accessibility might not be mandated.

Viewing the Americans with Disabilities Act (ADA) from the perspective of PTs and PTAs involves more than meeting legal requirements. It also serves as a tool for patient advocacy. Our responsibility extends beyond compliance; it's about empowering patients to live life fully in their most accessible communities. By adhering to ADA standards, we ensure legal compliance and champion our patients' rights and inclusivity.

Physical Therapy Practice in Hawaii

Let's delve into the specifics of physical therapy practice in Hawaii and the relevant laws governing it. The Board of Physical Therapy in Hawaii regulates physical therapists and physical therapist assistants in Hawaii.  It comprises 7 members (4 physical therapists, one physical therapist assistant, and two public members. Their primary role involves the interpretation and enforcement of the State Practice Act. They ensure licensure compliance, safeguard public safety, and maintain the standard of care within the state.  On the website for the Board under the Professional And Vocational Licensing Division of Hawaii, you will find licensee renewal information, continuing competence information, links to the licensing laws and regulations for Hawaii, board agendas and meetings, and physical therapy important announcements. 

1. Practice Act (Hawaii Revised Statutes Chapter 461J): This link provides direct access to the official practice act. The Practice Act outlines the legal framework that governs physical therapy practice in Hawaii. Familiarizing yourself with its contents is not just advisable but a professional responsibility. It defines the scope of practice, regulations, and other essential aspects.

2. Hawaii Administrative Rules, Title 16, Chapter 110, Physical Therapy

3. Uniform Professional and Vocational Licensing Act (HRS Chapter 436B)

It's imperative to stress that, as a professional, you have a duty to be well-informed about the content available through these links. Keeping up-to-date with the Practice Act and the State Board's guidelines ensures legal compliance and safe and effective patient care.

Hawaii State Practice Act  

461J-1 Definitions

Board: The governing body responsible for overseeing physical therapy practices.

Competence: The effective application of knowledge, skills, and behaviors required to function ethically, legally, and safely within one's role and environment.

Continuing Competence: The lifelong process of maintaining and documenting competence through ongoing self-assessment, development, and implementation of a personal learning plan, followed by reassessment.

Educational Institution: Public and private schools, colleges, and universities, including the University of Hawaii, where physical therapy education is provided.

Foreign-Trained Person: Someone who has completed a physical therapy educational program outside the United States.

Physical Therapist: A licensed professional authorized to practice physical therapy in the state.

Physical Therapist Assistant: A licensed individual who assists the physical therapist in specific treatment components.

Physical Therapy (PT) Services: Examination, treatment, and instruction to detect, assess, prevent, correct, alleviate, and limit physical disability, bodily malfunction, and pain. PT services encompass:

1. Administration, evaluation, modification, and instruction using physical measures, activities, and devices for preventive and therapeutic purposes. If PT care conflicts with medical diagnoses or prescriptions, the physical therapist must consult with the medical professional for appropriate action in the patient's best interest.

2. Consultative, educational, and advisory services aimed at reducing physical disability, bodily malfunction, or pain.

Practice of Physical Therapy: Includes, but not limited to, the utilization of:

1. Physical agents such as heat, cold, water, air, sound, compression, light, electricity, and electromagnetic radiation.

2. Exercise, joint mobilization, mechanical stimulation, biofeedback, postural drainage, traction, massage, splinting, locomotion training, correction of posture, body mechanics, and gait.

3. Tests and measurements including muscle strength, joint motion, reflexes, sensation, perception, mobility, stability, activities of daily living, cardiac, pulmonary, vascular functions, prosthetic, orthotic devices, posture, body mechanics, limb strength, and breathing patterns.

Unit: A measure of continuing competence activities where one unit equals at least fifty minutes of classroom or hands-on instruction.

Section 461J-2, Practice of Physical Therapy and Qualifications, Use of Titles

No individual shall engage in physical therapy practice, whether for free or for compensation, offer physical therapy services, or hold oneself out publicly or privately as a physical therapist or physiotherapist without possessing the appropriate licensure in Hawaii.

It is prohibited for any individual to use the terms "licensed physical therapist," "physical therapist," or "physiotherapist," or the abbreviations "RPT," "LPT," "DPT," "PT," or any similar words, letters, abbreviations, or symbols suggesting or implying that the individual is a physical therapist unless duly licensed.

No individual may use the title "physical therapist assistant," the abbreviation "PTA," or any other words, abbreviations, or symbols implying or suggesting that the individual is a physical therapist assistant without possessing the appropriate licensure.

Practice as a physical therapist or physical therapist assistant is only permitted for individuals licensed according to the state of Hawaii regulations and rules established by the board.

Section 461J-2.3 Physical Therapist Utilization of Support or Auxiliary Personnel

A physical therapist is authorized to enlist support or auxiliary personnel, including licensed physical therapist assistants, to aid in the delivery of physical therapy services, with the stipulation that such personnel:

1. Only undertake duties delineated in the regulations established by the board.
2. Execute these duties under the supervision and guidance of a licensed physical therapist.

Physical therapists and physical therapist assistants must furnish evidence of adherence to this provision upon the board's formal request in writing.

This language makes the PT responsible for their physical therapist assistant (PTA), aide, or technician. Interestingly, the term "aide" or "technician" is never specifically named or given specific duties. Another noteworthy point is that the State Board of Physical Therapy in Hawaii can request proof of compliance from clinics regarding supervision and direction. Explicitly stated, they can request documentation, such as a schedule, to demonstrate that PTAs are being appropriately supervised and that the PT is directing the patient's plan of care. This emphasizes the importance of ensuring proper compliance with supervision and direction requirements within clinical settings.

Section 461J-2.5 Prohibited Practices

A physical therapist is prohibited from performing invasive procedures. In this context, an invasive procedure refers to the act of breaking or puncturing the intact skin of an individual, such as through surgical interventions or injections.  This would include dry needling.  

Section 461J-3 Exceptions

This section does not restrict anyone from operating within the bounds of a license issued to them under any other law. However, these individuals are prohibited from asserting that they are physical therapists or physical therapist assistants or that they are administering physical therapy or related services.

Students enrolled in physical therapy educational programs, whether for physical therapists, physical therapist assistants, or support personnel, are permitted to engage in program-related activities under the direct supervision of a licensed physical therapist.

Individuals licensed as physical therapists or physical therapist assistants in another state or foreign country may practice physical therapy in Hawaii if they are participating in educational demonstrations, instructional programs or seminars sponsored by authorized entities solely for the duration and purpose of those programs.

This chapter does not prevent individuals from serving as athletic trainers under Hawaii regulations chapter 436H.

Physical therapists or physical therapist assistants employed by the United States Armed Services, United States Public Health Service, or Department of Veterans Affairs under federal regulations for state licensure of healthcare providers are permitted to practice within their federal employment. However, if they engage in physical therapy practice outside their federal duties, they must obtain licensure in Hawaii.

Licensed physical therapists from the United States or other countries may practice physical therapy in Hawaii if contracted or employed to provide services to individuals associated with established athletic teams, organizations, or performing arts companies temporarily operating in the state for up to sixty days per calendar year.

Section 461 J4-J5, Board of Physical Therapy-Establishment, Appointment, and Membership; Powers and Duties

The Department of Commerce and Consumer Affairs establishes the Board of Physical Therapy, which has seven members: four physical therapists, one physical therapist assistant, and two consumers. All members must be residents of Hawaii and at least eighteen years old.

Each physical therapist member of the board must hold a valid permanent license as a physical therapist and have a minimum of three years of full-time experience or equivalent in clinical physical therapy services, administration in physical therapy or related health fields, or teaching in a physical therapy educational program post-graduation.

The physical therapist assistant member of the board must possess a valid permanent license as a physical therapist assistant and have at least three years of full-time experience after graduating from an accredited physical therapist assistant program or an accredited physical therapy program.

The governor is responsible for appointing and filling vacancies on the board according to the applicable section.

The board is authorized to:

1. Adopt, amend, or repeal rules as outlined in Chapter 91 to fulfill the objectives of this chapter.

2. Recommend denying or withdrawing accreditation from educational programs that fail to meet prescribed standards.

3. Conduct hearings concerning allegations necessitating disciplinary action against a licensee or the denial, suspension, limitation, or revocation of a license.

4. Issue subpoenas, compel witness attendance, and administer oaths to individuals providing testimony during hearings.

5. Enforce compliance with this chapter and the rules established accordingly.

6. Maintain comprehensive records of all its proceedings and any other powers and duties granted by law

Section 461J-10 Biennial Renewal; Failure to Renew

Licensees are required to renew their licenses biennially by December 31st of the even-numbered year. Failure to pay the renewal fee to the Department of Commerce and Consumer Affairs by this deadline results in automatic forfeiture of the license. However, there's a window of opportunity to reinstate the license within one year from the date of forfeiture. To do so, one needs to submit a written application, pay the delinquent fee plus an additional 50% of the delinquent fee, and provide proof of completing the required continuing competency units. Staying on top of these requirements is crucial to maintain an active license.

Section 461J-10.1 to 461J-10.15 Continuing Competence Requirements, Exemptions

Every licensed physical therapist must accumulate a minimum of thirty approved continuing competence units within each two-year license renewal cycle. Each unit equals at least fifty minutes of classroom or hands-on instruction. 

During the initial license renewal, if the initial license issuance occurs within twelve months before the renewal date, no continuing competence units are required for the first renewal period. However, if the initial license issuance occurs more than twelve months before the renewal date, fifteen approved continuing competence units are necessary for the first renewal period.

Each licensee in Hawaii must provide evidence of completing the required continuing competence units to the board during renewal. Failure to provide this evidence at renewal results in license forfeiture, which can only be restored through a written application, payment of a restoration fee to the board, and proof of compliance with continuing competence requirements.

Continuing competence units must cover subjects relevant to the professional practice of physical therapy or patient/client management. The "professional practice of physical therapy" encompasses professional accountability, behavior, and development, among other areas. "Patient/client management" entails examination, evaluation, diagnosis, prognosis, plan of care, implementation, education, and discharge, among other components.

For each renewal period, continuing competence units must consist of:

• Two units covering ethics, laws, and rules (jurisprudence), or a combination thereof.
• Four units that focus on life support for healthcare professionals. This training must be equivalent to, or more advanced than, the American Heart Association's basic life support healthcare provider course.

Continuing competence units must be obtained from a provider or agency approved by the board. Approved sources include, but are not limited to:

• Continuing education courses, including home and self-study options, which are offered by agencies recognized by the board.
• College coursework from an educational institution accredited by the United States Department of Education or another agency acknowledged by the board
• Other competence-related activities endorsed by the board or a recognized agency.

Exemptions

Licensees may request an exemption from the continuing competence requirements outlined in this chapter by submitting a written request to the board before the renewal period expires. 

Exemptions are limited to one renewal period. If a licensee cannot fulfill the continuing competence requirements within two years after receiving an exemption, the licensee may only renew the license on an inactive status.

In cases where a licensee is absent from the state due to military service for a period of one year or longer during the two-year renewal period, which prevents completion of the continuing competence requirement, the board may grant an exemption from the continuing competence requirement for more than one renewal period.

Exemptions can be requested for the following: 

1. You can request an exemption by providing evidence that you were living in another country for one year or longer during the two-year period before your license expired, which reasonably prevented you from completing the continuing competence requirements.
2. You can request an exemption by providing evidence that you were ill or disabled for one year or longer during the two-year period before your license expired. This evidence must be documented by a licensed physician, surgeon, or clinical psychologist, and it must show that your illness or disability prevented you from completing the continuing competence requirements.
3. You can request an exemption by providing evidence that a dependent family member was ill or disabled for one year or longer during the two-year period before your license expired. This evidence must be documented by a licensed physician, surgeon, or clinical psychologist, and it must show that your family member's illness or disability prevented you from completing the continuing competence requirements.

Record-Keeping Requirements for Licensees

 As a licensee, you are responsible for maintaining records demonstrating the completion of each course or activity for which credit is claimed. The course or activity title, completion date, and participation evidence must be included. Upon request, you must provide copies of this documentation to the board or its designated representative within fourteen calendar days.

You must keep documentation of course completion for seven years after the conclusion of the course or activity.

Section 461J-12 Revocation, Suspension, Probation of License; Part V 436B18-25 Licensing Sanctions

The board reserves the right to revoke or suspend any license issued for various reasons, including:

• Misleading patients with false promises of curing incurable diseases for a fee.
• Breaching patient confidentiality deliberately.
• Making false or improbable claims in advertising.
• Engaging in deceptive advertising practices.
• Demonstrating excessive drug or alcohol use, addiction, dependency, or habitual drug use.
• Practicing physical therapy while impaired by alcohol, drugs, or mental instability.
• Obtaining a license through fraudulent means or allowing unlicensed practice.
• Showing professional misconduct, gross carelessness, or incapacity in practice.
• Behaving in ways contrary to the ethics of the physical therapy profession.
• Violating terms or limitations of temporary licenses or exemptions.
• Breaking rules outlined in this chapter, licensing laws or rules set forth by the licensing authority.

Additional education or training may be required to reinstate a suspended license or grant licensure to a previously revoked licensee, or proof of competency may need to be provided.

Instead of revoking or suspending a license, the board may choose to place the licensee on probation, which may involve supervision by a relevant group or society of physical therapists.

The Board can add conditions or limitations to a licensee's license following a hearing. Violating these conditions or limitations could result in further sanctions against the licensee. Unless specified otherwise by law, any fine imposed after a hearing shall be a minimum of $100 for each violation, and each day of violation may be considered a separate offense.

In addition to the above, the Board may refuse to renew, reinstate, or restore, or may deny, revoke, suspend, or condition in any manner, any license for the following: 

• Failure to meet or maintain the conditions and requirements necessary to qualify for the granting of a license.
• Failure to maintain a record or history of competency, trustworthiness, fair dealing, and financial integrity
• Revocation, suspension, or other disciplinary action by another state or federal agency against a licensee or applicant for any reason provided by the licensing laws or this section
• A criminal conviction, including those resulting from a plea where the accused does not contest the charges, for a crime directly related to the qualifications, functions, or duties of the physical therapist or physical therapist assistant. 
• Failure to promptly inform the licensing authority in writing of any disciplinary decisions made against the licensee or applicant in another state within thirty days of the decision
• Employing or attempting to employ anyone without the required license where licensure is mandated by the licensing laws

Suspension or Denial of License for Noncompliance With Child Support Order (436B-19.5)

The licensing authority won't renew, reinstate, or restore a license if they get confirmation from the child support enforcement agency that the licensee or applicant hasn't followed a support order or ignored a subpoena or warrant in a paternity or child support case. They'll only renew or reinstate the license if they get permission from the child support enforcement agency, the office of child support hearings, or the family court unless the law says something different.

Suspended License (436B-20)

The licensing authority can't suspend a license for more than five years. If someone's license is suspended, they can apply to get it back as allowed by law and after meeting all the requirements set by the suspension order. To apply for reinstatement, they need to pay all the required fees, such as reinstatement fees, compliance resolution fund fees, and recovery fund assessments.

Revoked License (436B-21)

If a person's license has been revoked, they can apply for a new license after five years from the revocation date. They must file a new application and meet all current requirements for new applicants. However, the licensing authority may waive any applicable education or exam requirements if satisfied the applicant has maintained equivalent knowledge, competence, and qualifications through work experience, training, or education.

Relinquishment No Bar to Jurisdiction (436B-22)

If a licensee forfeits, does not renew, surrenders, or voluntarily relinquishes their license, it does not prevent the licensing authority from proceeding with any investigation, action, or proceeding to revoke, suspend condition, limit, or fine the licensee's license.

Summary suspension (436B-23)

Regardless of other laws, the licensing authority or its delegate can immediately suspend or restrict a license, subject to later notice and hearing, if specifically determined that failure to do so may result in:

1. An immediate and unreasonable threat to personal safety or
2. Fraud or misrepresentation of consumers

And that for public protection, the licensee's license should be immediately suspended/restricted.

The summary suspension can be up to 20 days initially. The suspension order and notice of disciplinary hearing must be served on the licensee at the same time. The hearing must be scheduled before the 20-day suspension expires unless the licensee requests a reasonable continuance to prepare their defense.

Any attempt by the licensee to continue the licensed activity during the summary suspension is grounds for permanent license revocation and subjects them to all penalties under the applicable laws/rules.

Hearings (436B-24)

Whenever the licensing authority refuses to issue, renew, restore, or reinstate a license or proposes to take disciplinary action or other licensing sanctions against a licensee, the proceeding before the licensing authority shall follow the procedures outlined in Chapter 91 (the administrative procedure laws).

In all proceedings, the licensing board and each of its members shall have the same powers as circuit courts to administer oaths, compel the attendance of witnesses, require the production of documents, and examine witnesses. If any person disobeys an order or subpoena from the board/member, or if a witness refuses to testify on a lawful matter, any circuit court judge can compel obedience upon application by the board/member, just as for disobedience of a circuit court's subpoena or refusal to testify there.

Judicial Review by Circuit Court (436B-25)

Any person aggrieved by a final decision and order of the licensing board in a "contested case" as defined by Chapter 91, is entitled to judicial review of that decision by the circuit court of the circuit where the licensing board that issued the final order has jurisdiction.

In summary, licensing disciplinary proceedings follow administrative procedures, the board has circuit court powers to compel evidence/testimony, and final board orders can be appealed to the appropriate circuit court

Section 461J-12.5 and 436B-13.3 Inactive Status

As a licensee in Hawaii, you can request in writing to place your license on inactive status. The request can be made during the licensure period or at renewal. While on inactive status, you cannot practice physical therapy. If you violate this prohibition, you will face disciplinary action under this chapter and the laws and rules set by the licensing authority for your specific license.

The board retains authority to initiate or continue any disciplinary or enforcement action against a licensee, regardless of their inactive status

An inactive license must be renewed during the same period as an active license. Licensees on inactive status are not required to fulfill the continuing competence requirements. However, it is your responsibility to stay informed about the current licensing and renewal requirements while inactive.  

To reactivate an inactive license, the licensee must:

1. Pay the renewal and any applicable fees.
2. Have obtained continuing competence units equivalent to those required for a single renewal period of an active license within the last two years before applying to restore the license to active status. The licensing authority may ask you to provide information to ensure you are fit to practice the profession, such as reporting any license sanctions, pending disciplinary actions, or criminal convictions that have not been annulled or expunged.

Your reactivation application can be denied if you do not meet all the requirements or for the reasons outlined in section 436B-19. If your application is denied, you will receive a written notice explaining the reason for the denial and informing you of your right to a hearing. If your reactivation application is denied, you will need to reapply for licensure and meet all the licensing requirements in effect at the time of your new application.

Section 461J-13 Penalty

If you violate or fail to comply with any part of this chapter, you may be fined up to $1,000 for each violation.

Section 436B-16 Licensee Reporting Requirements: Notice of Judgments, Penalties

You must provide written notice to the licensing authority within 30 days if there is any judgment, award, disciplinary sanction, order, or other determination that finds you civilly, criminally, or otherwise liable for any personal injury, property damage, or loss caused by your conduct in practicing your profession or vocation. This includes such determinations made in other jurisdictions.

Failure to comply with providing this written notice is a violation punishable by:

• A fine of at least $100 for the first violation
• A fine of $250 to $500 for the second violation
• A fine of $500 to $1,000 for any subsequent violations

Any action taken to impose or collect these fines is not considered a criminal action.

Section 436B-17 Filing of Current Address

You must file your current mailing, business, and residence addresses with the licensing authority. If any of these addresses change, it is your duty to provide written notice to the licensing authority within 30 days of the change.

If you fail to notify the licensing authority of an address change, the licensing authority, executive secretary, or any designee is absolved from the duty to provide you with any legally required notices. In other words, they will not be responsible for providing you with notices if they do not have your current address on file due to your failure to update it.

Section 436B-26 No Compensation for Unlicensed Activity; Civil Action

If a person engages in any activity that requires a license but does not have a valid, current license, then that person cannot recover compensation through a civil lawsuit.

Specifically, they cannot sue to try to get paid for:

• Work or services they performed
• Materials or supplies they provided
• Or the reasonable value of the work, services, materials, etc.

This applies whether they try to sue based on a contract or any other legal basis for recovering payment. The failure to maintain a proper license before engaging in the licensed activity prevents them from recovering any compensation through a civil action.

In essence, it bars an unlicensed person from using the civil court system to get paid for doing licensed work without a valid license. Their only recourse would be to get properly licensed first.

Section 436B-26.5 Citation for Unlicensed Activity; Civil Penalties

This section allows investigators to issue citations and civil penalties to individuals operating physical therapy businesses or practicing physical therapy in the state without proper licensing.

Each citation must be in writing, describing the alleged violation(s) of specific laws/rules. It may include an order to stop the unlawful activity (abatement order) and assess civil penalties based on this schedule:

• First violation: Up to $500 or 40% of the total value of goods/services provided, whichever is greater.
• Second violation: Up to $1,000 or 40% of the total value, whichever is greater.
• Subsequent violations: Up to $5,000 or 40% of the total value, whichever is greater.

Citations must be served personally or by certified restricted mail. The cited party can request a hearing within 20 days to contest the allegations, abatement order, or penalty amount.

If a hearing is requested, the director or a designated hearings officer will conduct it per administrative procedures, with the power to subpoena, take testimony, make findings, and issue a final order.

The citation becomes the final director's order if no hearing is requested within 20 days. The director can ask the court to ensure that any ultimate decision, such as reducing or stopping something, and any fines are carried out. 

Any appeals from the final order go through normal administrative appeals procedures to the circuit court.

These civil citation penalties are separate from any other civil or criminal remedies provided by law

Section 436B-27 Civil and Criminal Sanctions for Unlicensed Activity; Fines; Injunctive Relief; Damages; Forfeiture

If you, as a licensee, aid or abet an unlicensed person in evading this chapter or the applicable licensing laws, or if you combine or conspire with, permit your license to be used by, or act as an agent/partner/associate of an unlicensed person with the intent to evade the laws, you may be fined:

• Up to $1,000 for the first offense
• Up to $2,000 or 40% of the total contract price (whichever is greater) for the second offense
• Up to $5,000 or 40% of the total contract price (whichever is greater) for any subsequent offenses

For this section, "contract price" means the total money offered by the consumer for the provision of goods and services.

Any person who engages in an activity requiring a license from the licensing authority and fails to obtain it or uses any word/title/representation to falsely imply they are licensed (except licensees who inadvertently let requirements lapse but correct it promptly) is guilty of a misdemeanor. Each day of unlicensed activity is considered a separate offense.

The department, licensing authority, or any person can file a suit to enjoin (prohibit) the performance or continuance of unlicensed acts where a license is legally required. If injured, they can also sue for damages. Reasonable attorney fees/costs will be awarded to the prevailing plaintiff/petitioner. Proof of actual damages is not required to get an injunction.

Any tools, materials, or property used by someone to provide professional services without a required license shall be forfeited to the State as determined by the court.

Rules

Duties of a Supervising Physical Therapist

A licensed physical therapist must supervise all physical therapy care provided by physical therapist assistants and any support/auxiliary staff.

The supervising physical therapist is responsible for managing all aspects of each patient's physical therapy care. They can only utilize assistance from physical therapist assistants or support staff. The supervising PT's duties include:

1. Interpreting referrals when available
2. Conducting the initial patient examination, evaluation, diagnosis, and prognosis
3. Developing and implementing the plan of care based on the evaluation, including goals and anticipated outcomes
4. Determining which components of care the PT will provide directly and which can be delegated to assistants/aides
5. Directly reexamining the patient one-on-one and revising the care plan as needed
6. Establishing the discharge plan and documenting the patient's discharge status
7. Overseeing all services provided to the patient, including proper documentation per guidelines
8. Being accessible by telecommunications when not onsite and able to be physically present within 2 hours if needed

The supervising PT must ensure any assistants or aides under their supervision are competent and can safely complete delegated activities.

A supervising PT can supervise up to 3 individuals total, which can be any combination of:

1. A temporary PT licensee
2. A student
3. A physical therapist assistant

Duties of Physical Therapists Assistants and Support or Auxillary Personnel

Physical therapist assistants and support personnel are authorized to carry out specific treatment tasks under the direction of a supervising physical therapist. These tasks include:

1. Physical therapist assistants, temporary physical therapist licensees, and physical therapy students are allowed to: 

• Assist with coordination, communication, and documentation.
• Provide patient-related instructions.
• Engage in procedural tasks like therapeutic exercise, functional training for self-care and home management (including activities of daily living (ADLs) and instrumental activities of daily living (IADLs)), work-related functional training including work hardening and work conditioning, prescription and application of devices and equipment, fabrication of devices and assistive, adaptive, orthotic, protective, supportive and prosthetic equipment. Also included are airway clearance techniques, integumentary repair and protection, electrotherapeutic and physical agent modalities, and mechanical modalities.

2. Physical therapist assistants may conduct manual therapy except for specific joint mobilization and manipulation.

3. Temporary physical therapist licensees or physical therapy students may perform manual therapy techniques, including mobilization or manipulation.

Identification of Personnel 

Any licensed physical therapist must wear a name tag prominently displaying their name and the title "physical therapist" or "PT"

The supervising physical therapist must make sure that all physical therapist assistants and support staff wear a name tag showing their name and professional title while providing care.

Requirements for Temporary Physical Therapist and Physical Therapist Assistant Licenses

If an applicant is seeking a temporary license while applying for a permanent one, they must provide the board with:

• Required documents and evidence of qualifications
• Proof that they've applied for the licensure examination within six months or evidence of having taken the exam and awaiting results.

Additionally, they must submit a completed Statement of Supervising Licensed Physical Therapist, provided by the board, from each proposed supervising physical therapist. This statement confirms that the supervisor agrees to oversee the applicant, including names, license numbers, and start dates. The applicant must be supervised by a physical therapist with a permanent active license throughout their temporary licensure period.

Applicants can request a change in their supervising physical therapist by submitting a written request to the board. This request should include reasons for the change, the date of the change, and a Statement of Supervising Physical Therapist from the new proposed supervisor. It must be signed by the applicant, the new supervisor, and the immediate prior supervisor. If the previous supervisor cannot be reached, the applicant must provide adequate documentation of their attempts to contact them.

Temporary licenses typically expire within six months or earlier under certain circumstances: 

• Termination of the supervisory relationship between the applicant and the supervising physical therapist.
• Failure to pass the required physical therapy licensure examination.
• Applicant's qualifications for licensure are misrepresented as determined by the Board.
• Cause for termination due to specified acts committed by the temporary licensee.
• Issuance of a permanent license. The board may extend the six-month period to one year for valid reasons. Only one temporary license is issued per applicant.

Temporary licenses are not granted to individuals unauthorized to work in the United States.

Ethics and Physical Therapy

Professional Ethics, Conduct

Professional ethics incorporates the values, principles, and morals into professional decision-making within our respective professions. Without this guidance, we risk falling into pitfalls that can cause harm to ourselves, others, and society at large.

An insightful perspective shared by a friend emphasizes the importance of intuition, that gut feeling, as a guide for ethical decisions. However, it's crucial to recognize that not everyone possesses the same intuition or gut instincts. Therefore, relying solely on individual feelings may not always lead to universally ethical decisions.

We often witness the consequences of ethical lapses within our professional circles—colleagues facing sanctions or making headlines in the newspaper or online social networks for the wrong reasons. It makes you cringe.  How did that person allow that to happen? Why did they do that? These instances remind us of the critical need for a strong ethical foundation. Professional ethics safeguard against such missteps, aiming to prevent these issues from occurring in the first place.

In our professional roles, we must tap into our training, knowledge, and ethical obligations. These resources guide our actions and behaviors, helping us make informed and morally sound decisions in our respective fields.

HAR 16-100-50, titled "Professional Misconduct, Gross Carelessness, or Manifest Incapacity in the Practice of Physical Therapy", describes, under law, at a minimum, what a licensee in Hawaii shall not engage in.  Unprofessional conduct, extreme carelessness, or clear inability to practice physical therapy includes but is not limited to: 

1. Administering negligent treatments or evaluations
2. Falsifying or improperly altering patient records
3. Misappropriating/misusing drugs, money, supplies, or equipment
4. Aiding or allowing unlicensed practice of physical therapy
5. Accepting fees for services not actually provided
6. Improperly delegating to or supervising physical therapist assistants or aides
7. Practicing physical therapy beyond the legal scope of practice defined in the chapter
8. Failure to follow APTA guidelines for documentation, code of ethics, or professional conduct
9. Not immediately referring a patient to an appropriate provider if there is reasonable belief the patient's condition is beyond the PT's scope or is a condition in which physical therapy is contraindicated. 

In summary, it covers negligent care, record falsification, mishandling resources, enabling unlicensed practice, fee issues, supervision failings, exceeding scope, ethics violations, and failure to refer appropriately.

Principles of Ethics

Ethics are crucial in guiding our decisions about what is morally right and wrong, extending seamlessly from our personal lives into our professional conduct as physical therapists. Our choices in the professional realm are intricately tied to the unique context in which we practice. In this discussion, we will delve into fundamental principles of ethics. As we progress, we hope you will find alignment with these principles, affirming that your practices align seamlessly. However, you may also encounter ethical gray areas that prompt further consideration and reflection within your clinic or practice area.

Autonomy

Let's start with the basic ethical principles, beginning with autonomy. Autonomy refers to the moral right to make choices about one's own actions. In other words, it's the right to self-determination. For practitioners, respecting autonomy means refraining from interfering with patients' choices. We allow and enable patients to make their own choices. That said, we can still educate patients about the risks, benefits, and consequences of choices without diminishing autonomy. 

In our approach to patient education, we prioritize providing information to empower individuals to make informed decisions regarding their therapy. However, it's essential to acknowledge that within the health and rehabilitation sector, our dedication to helping others can inadvertently overshadow the principle of respecting autonomy.

For instance, when a patient declines therapy, it's crucial to communicate their decision's potential risks and benefits. However, persistent attempts to convince or pressure them could undermine their autonomy and demonstrate a lack of respect for their choices and preferences.

Maintaining a delicate balance between offering guidance and honoring an individual's autonomy is paramount. By providing comprehensive information and fostering open communication, we create an environment where patients can confidently exercise their autonomy in making choices about their care.

Nonmaleficence

This principle embraces the timeless guidance from the Hippocratic Oath - "do not harm." As healthcare practitioners, it reminds us that if we cannot provide direct assistance to our patients, we must, at the very least, ensure we do not cause harm or exacerbate their condition. When we examine harm, we must recognize its diverse manifestations, encompassing physical, psychological, social, mental, reputational, or even harm to one's liberty, property, and more.

The nuanced nature of harm leads us to question both the recipient and the nature of the harm, especially when working with patients who may lack decision-making capacity, such as those with advanced dementia. Understanding harm in this context requires a delicate approach, considering differing interpretations and perspectives on what constitutes harm.

Furthermore, it's vital to acknowledge that our perception of harm may diverge from the patient's own assessment. For instance, we may believe that non-participation in physical therapy could harm the patient, while the patient may not perceive it as detrimental. Hence, we must carefully consider whose perspective of harm we are referencing.

Beneficence

In alignment with nonmaleficence, we delve into the principle of beneficence, representing our duty to prevent harm and promote the greater good. This duty involves the act of removing harm and actively fostering positive outcomes. However, it's essential to recognize that this moral obligation has limits, especially when our actions, aimed at benefitting the patient, may inadvertently cause harm to ourselves as healthcare providers. Balancing the pursuit of benefit with preserving our well-being is a critical aspect of this ethical consideration.

Beneficence in healthcare centers on promoting the patient's overall well-being. However, a crucial and complex aspect is navigating the potential disparity in perspectives regarding what constitutes the patient's "good" or best interest. As healthcare providers, we often have a professional understanding of what interventions may optimize a patient's health and quality of life.

Yet, it's paramount to acknowledge and respect the individualized perspectives of each patient. What we might perceive as a beneficial treatment or intervention may be viewed differently by the patient based on their unique experiences, pain thresholds, fears, and personal circumstances. For instance, encouraging a patient to walk for their health may conflict with their personal experiences of pain and fear of falling, causing them to consider it against their best interest.

The essential approach lies in effective patient education, open dialogue, and collaborative decision-making. Providing comprehensive information about risks, benefits, and potential outcomes empowers patients to make informed choices aligned with their values and concerns. It's about finding a balance where we promote the patient's well-being while respecting their autonomy and individual perceptions of what benefits them.

Justice

The principle of justice in healthcare is becoming increasingly significant as the demand for limited healthcare resources continues to rise. Justice emphasizes the fair distribution of both burdens and benefits in society, aiming to give individuals their rightful due. In healthcare decision-making, this principle is pivotal in determining who should receive essential resources, examining if some individuals deserve these resources more than others, and identifying the stakeholders responsible for these allocation decisions.

However, achieving justice in healthcare is a complex challenge, as it involves addressing various contextual factors, including religious beliefs, professional ethics, legal frameworks, institutional policies, and more. It's crucial for healthcare professionals to uphold the principles of justice by advocating for all patients, particularly those without strong advocates. By doing so, we contribute to a system where healthcare decisions are made fairly and ethically, guided by the best interests of the patients and the community.

Informed consent

Informed consent is a fundamental ethical and legal principle in healthcare. It requires healthcare professionals to provide patients with comprehensive and easily understandable information about their proposed intervention strategies. This includes outlining the potential benefits, risks, potential risks, side effects, alternatives, and any other relevant details associated with the proposed course of action.

Informed consent is more than just a checkbox to complete a procedure or evaluation. It embodies a vital opportunity for genuine communication and understanding between healthcare providers and their patients. It's about engaging in a meaningful conversation, ensuring that patients fully comprehend the proposed evaluation or treatment, its potential benefits, risks, alternatives, and what is expected from them throughout the process.

This process of obtaining informed consent should be conducted with care, empathy, and a genuine concern for the well-being and understanding of the patient. By explaining and addressing any concerns, questions, or uncertainties, we establish a foundation of trust and collaboration with the patient. This, in turn, enhances patient satisfaction, compliance, and overall outcomes.

Moreover, by approaching informed consent in this way, we uphold ethical principles, such as autonomy and beneficence, by respecting the patient's right to make informed decisions about their own healthcare. It's an opportunity to empower patients with knowledge and involve them in the decision-making process regarding their own health, promoting a sense of ownership and engagement in their care.

Veracity

Informed consent, an ethical cornerstone, hinges on the principle of veracity. Veracity dictates our duty to convey truth and integrity in all our patient communications. Let me pause momentarily to clarify that I will use patient, resident, and individual client interchangeably. Now, diving deeper into veracity, its significance becomes apparent as we delve into case examples later.

Confidentiality

Confidentiality, deeply rooted in the Hippocratic Oath, is paramount. The oath asserts, "Anything I see or hear of the life of men, whether in a professional capacity or otherwise, which should not be passed on to others, I will hold as professional secrets and not divulge them." Hence, we possess a duty to restrict access to treatment-related information, maintaining a strict confidentiality boundary between us and our patients.

Yet, stepping back and acknowledging exceptions grounded in justice and beneficence is crucial. Certain laws mandate breaching confidentiality to protect citizens, such as reporting child abuse or elder abuse in specific states. We function as mandated reporters, adhering to distinct timeframes, notably in cases of child and elder abuse. Nevertheless, upholding confidentiality remains vital.

Fidelity

Fidelity, closely intertwined with confidentiality, embodies our moral duty to uphold promises and fulfill commitments made to individuals.

Patients rightly expect us to honor both explicit and implicit promises. The explicit promises, such as scheduled appointments like, "We'll meet you at 9:30 for your physical therapy session," are clear commitments. Simultaneously, implicit promises, rooted in regulations like HIPAA and confidentiality, assure patients that we will preserve the privacy of shared information and provide the services prescribed by the physician.

Continuing to explore fidelity, we recognize five crucial expectations patients reasonably hold regarding healthcare contexts. These expectations encompass:

1. Treating them with fundamental respect and dignity,
2. Demonstrating competence and capability in performing our professional duties (a topic we'll delve into shortly),
3. Adhering to a professional code of ethics,
4. Following organizational policies, procedures, applicable laws, and licensure regulations,
5. Honoring any agreements made with the patient or client.

Duty

This underscores the obligations we hold toward others within society. Often, these duties stem from the nature of relationships between parties. In the context of therapy, initiating a patient-therapist relationship entails specific duties toward the patient. These encompass obligations to deliver a defined standard of care and maintain confidentiality, among other responsibilities. Establishing and upholding these obligations forms the foundation of ethical practice and professional conduct within the healthcare domain.

Rights

We will now discuss rights to a certain extent. Rights pertain to the ability to exercise a moral entitlement to either perform an action or refrain from doing so. In the realm of healthcare, a variety of rights come into play. The Patient's Bill of Rights, introduced some time ago, is a fundamental document. Additionally, healthcare facilities or communities may adopt their own Bill of Rights, outlining specific rights within their organizational context.

These rights encompass various aspects, including the right to health insurance irrespective of preexisting conditions—an evolving right. Federal statutes also delineate specific patient rights concerning privacy, such as the Health Insurance Portability and Accountability Act (HIPAA). Moreover, different states may have their unique Bill of Rights. Hence, it is crucial for us to understand and adhere to these rights as mandated by our respective organizations and regions of practice.

Paternalism

While not a distinct ethical principle, paternalism is a significant concept. Paternalism occurs when an individual, often a healthcare provider, disregards a person's autonomy and substitutes their own beliefs, opinions, or judgments for the judgment of the individual involved, typically a patient. They may act without obtaining informed consent or going against the patient's wishes under the pretext of seeking to benefit the patient.

In cases of paternalism, individuals rationalize their actions by asserting that they acted in the person's best interest. This often happens when someone believes they know better or what's best for the person in question without adequately considering the desires and wishes of the patient. Paternalism is sometimes observed in healthcare, particularly when dealing with families, such as in end-of-life care, where family members may have differing opinions on the care plan compared to the patient. In long-term care settings, involving the family in decision-making instead of the patient can also be a form of paternalism, especially in cases of dementia where the patient's capacity to make decisions may be intact.

Recognizing and addressing paternalism is crucial in promoting patient-centered care and upholding the principle of autonomy. Respecting and honoring patients' wishes and involving them in decision-making processes is essential to providing care that aligns with their values, preferences, and autonomy. 

Physical Therapy Code of Ethics

Our code of ethics incorporates rules or principles intended to express the profession's values.

Licensing boards/credentialing agencies incorporate professional codes of ethics into licensure regulations or credentialing rules. This ethical framework isn't confined to association membership; it universally applies to all practitioners within the field. Whether at the state or national level, adherence to the strictest code of ethics should be a priority, ensuring you maintain a strong ethical foundation in your practice.  It may mean, for example, using evidence-based practice, a certain quality measure, or maybe incorporating something very specific into our rules. 

The code of ethics plays a pivotal role in promoting the basic tenets of the profession. It codifies our fundamental beliefs of the professions and the common moral values the profession chooses to protect patients and clients from harm. It gives meaning to the distinctiveness of your role as a physical therapist or physical therapist assistant. It serves as a unifying bond between professionals, fostering a common standard and shaping the very essence of being a practitioner in this field. These values become integral to your moral and behavioral repertoire, akin to how you integrate social, cultural, and other personal values.

Furthermore, courts reference the code of ethics to gauge appropriate professional behavior and as a component of the standard of care expected from practitioners. In legal scenarios, the code of ethics can significantly impact the outcome, acting as a measuring stick for proper conduct.

It's important to acknowledge that the code of ethics isn't a comprehensive guide dictating behavior or decision-making with absolute certainty. Rather, it's a foundational starting point, a point of reference, and an aspiration to steer professional practice. While it offers invaluable guidance, gray areas may still necessitate careful consideration and ethical discernment.

Unethical Practice

Unethical practice within healthcare refers to actions that deviate from established professional standards. This deviation spans from unreasonable, unjustified, or ineffective practices to outright immoral, harmful, or knowingly wrong. Evaluating ethicality often involves a litmus test, a gut check, where practitioners assess their discomfort or unease with a certain practice.

Ethical analysis is multifaceted and influenced by various social, religious, and cultural perspectives. Acknowledging that not everyone will share the same ethical analysis, and disagreements are part of the ethical discourse is important.  As practitioners, we often arrive at our ethical analysis from many different views, and not everybody will agree, but that's okay.

We have to recognize what we will or won't do. Sometimes, it's a matter of discussing with your supervisor or somebody in your compliance team. Unethical practice has a profound impact, primarily on the patient, but it also extends to the practitioner, the employing organization, insurers, society, and more.  Instances of unethical behavior can lead to loss of professional license and credibility, highlighting the substantial risk unethical practices pose to one's professional investment and the credibility of the healthcare system at large.

Considering the investment of time, effort, and resources put into acquiring professional qualifications, it becomes imperative to safeguard one's ethical standing and uphold the profession's integrity. Maintaining ethical practice is a moral duty and a strategic decision safeguarding the individual practitioner and the healthcare system. Somebody said to me one day, and it just resonated with me: Gosh, I spent so much money and time to get through school; why would I place that at risk to do anything that I would consider unethical? So, I think of it in that regard as well.

APTA Code of Ethics for Physical Therapy Personnel

This delineates the obligations of all physical therapists and physical therapist assistants, as determined by the APTA.

Purpose

If you will, there are a few purposes for the code of ethics. They include:

1. Define the ethical principles that form the foundation of physical therapy practice in patient management, consultation, education, research, and administration.
2. Provide the standards of behavior and performance that form the basis of professional accountability to the public, to your patients, again, to insurance providers, et cetera.
3. Guide you as a physical therapy practitioner who may face ethical challenges regardless of your professional role, responsibilities, or workplace setting.
4. Educate physical therapists, students, physical therapist assistants, other healthcare professionals, regulators, and the public regarding the core values, ethical principles, and standards that guide your professional conduct.
5. Establish standards for judging unethical conduct. 

Code of Ethics

When examining the code of ethics in-depth, it's structured around the five fundamental roles of a physical therapist: patient management, consultation, education, research, and administration. This ethical framework revolves around the core values that underpin the profession, navigating the intricate landscape of ethical action across multiple realms. 

In the realm of physical therapy, practice is fundamentally shaped by seven core values, each playing a significant role in guiding the actions and decisions of practitioners. These core values form the ethical compass of the profession, anchoring the practice within a strong ethical foundation and ensuring the delivery of patient-centric, responsible, and morally sound care.

Those core values are:

1. Accountability
2. Altruism
3. Compassion or caring
4. Excellence
5. Integrity
6. Professional duty
7. Social responsibility

The Physical Therapy Code of Ethics because it seamlessly intertwines each principle with its corresponding core values. This integration makes the code particularly effective in conveying ethical guidelines and principles to diverse audiences. Fundamental to this code is that it emphasizes a significant responsibility to empower, educate, and facilitate greater independence, health, and quality of life for individuals facing impairments, limitations, disabilities, and more.

As I said earlier, while a code of ethics serves as a robust guiding framework, it's important to acknowledge its limitations. No code can comprehensively cover every situation or circumstance encountered in practice. In straightforward situations, aligning actions with the code is relatively clear-cut. However, the true challenge lies in navigating the gray areas, where careful consideration of the principles and core values becomes crucial in making ethically sound decisions.

Principle #1

Physical therapists shall respect the inherent dignity and rights of all individuals.

This principle relates back to the core values of compassion and integrity. This means that physical therapy practitioners must act in a respectful manner toward each person, regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability. 

Acknowledging and addressing personal biases is a critical principle reiterated in numerous codes of ethics across various professions. Recognizing biases is foundational to providing all individuals fair, just, and equitable care. In the contemporary landscape, extensive training and emphasis on implicit bias, diversity, equity, and inclusion aim to bring these biases to light and ensure they do not influence treatment, consultation, education, research, or administrative decisions.

Principle #2

Physical therapists shall be trustworthy and compassionate in addressing the needs of our patients.

This principle relates back to the core values of altruism, compassion, and professional duty.

You shall adhere to the profession's core values and act in the best interests of patients and clients over the interests of the physical therapist. It emphasizes the need to provide physical therapy services with a compassionate and culturally sensitive approach, valuing individual differences and backgrounds. Furthermore, it is crucial to ensure that patients and their surrogates have access to necessary information for informed decision-making. Collaborative decision-making with patients and clients empowers them in matters concerning their healthcare. Additionally, safeguarding confidentiality and respecting patient privacy are integral components of ethical practice, with disclosures made to appropriate authorities in line with legal and ethical guidelines.

Principle #3

Physical therapists should be accountable for making sound professional judgments.

This principle relates back to the core values of excellence and integrity.

Physical therapy practitioners should demonstrate independent and objective professional judgment in the patient's best interests and professional judgment informed by professional standards, evidence, experience, and patient values. Physical therapists should make judgments within their scope of practice and their level of expertise. Communicate, collaborate with, or refer to peers or other healthcare professionals when necessary, and do not engage in conflict of interest. Provide appropriate direction and communication with physical therapist assistants and other support personnel. 

Principle #4

Physical therapists shall demonstrate integrity in their relationships with patients, families, colleagues, students, research participants, other healthcare providers, employers, payers, and the public. 

This principle relates back to the core value of integrity and brings us back to veracity.

It emphasizes the importance of providing accurate and truthful information, avoiding any misleading representations, and refraining from exploiting individuals under a supervisory relationship, be it students, patients, or employees. Moreover, it underscores the responsibility to discourage and report misconduct and illegal or unethical acts among healthcare professionals, highlighting the imperative to protect vulnerable individuals from abuse.

This principle has an unequivocal stance against engaging in any form of sexual relationship with patients, supervisees, or students, reinforcing the critical importance of maintaining professional boundaries and ensuring a safe and ethical environment. Additionally, the strong stance against harassment, whether verbal, physical, emotional, or sexual, reinforces the commitment to a respectful and inclusive professional atmosphere. Altogether, this principle underscores a profound dedication to upholding the highest standards of ethical conduct and fostering a culture of accountability and integrity within the healthcare community.

Principle #5

Physical therapists shall fulfill their legal and professional obligations.

This principle relates back to the core values of professional duty and accountability.

This principle includes complying with applicable local, state, and federal laws and regulations. Physical therapists must have primary responsibility for supervising assistance and support personnel. They should encourage colleagues struggling with physical, psychological, or substance-related impairments that could negatively impact professional responsibilities to seek assistance or counseling. Furthermore, if aware that a colleague is unable to perform duties with reasonable skill and safety, physical therapists should report this to the appropriate authority, whether that is a licensing board, organizational leadership, or other governing body. In the event that a physical therapist terminates a provider relationship while the patient still needs services, the physical therapist ought to notify the patient and provide information about alternative care options.

Principle #6

Physical therapists shall enhance their expertise through lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors.

This principle relates back to the core value of excellence.

This principle encompasses maintaining and improving professional competence through continued professional development based on critical self-assessment and reflection. Physical therapists should evaluate the strength of evidence and applicability of content presented in professional development activities before integrating that knowledge into practice. They ought to cultivate practice environments supportive of professional growth, lifelong learning, and excellence. Lifelong learning is crucial—physical therapists must move beyond checking boxes to satisfy continuing education requirements. Instead, they should actively broaden their skills and knowledge throughout their careers.

Principle #7

Physical therapists shall promote organizational behaviors and business practices that benefit patients, clients, and society.

This principle relates back to the core values of integrity and accountability.

This principle involves fostering practice settings that enable autonomous, accountable professional judgment. Physical therapists should seek fair and reasonable service remuneration, refrain from accepting gifts influencing professional decisions, and disclose any financial stakes in products or services recommended to patients. For instance, they should reveal ownership interests in durable medical equipment companies or other healthcare businesses. Physical therapists must ensure documentation and coding accurately conveys the nature and extent of services furnished. They should avoid employment arrangements that prevent the fulfillment of professional obligations to patients. Billing, coding, HIPAA, and social media merit particular attention, as lapses in these areas frequently lead to disciplinary action.

Principle #8

Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, and globally.

This principle connects to physical therapy's core values of social responsibility. Practitioners can actualize this by providing pro bono services to the economically disadvantaged, uninsured, and underinsured, if feasible in their setting. They should advocate reducing health disparities, improving healthcare access, and addressing wellness and preventive services. Though physical therapists often treat existing disabilities and impairments, focusing on health promotion and disease prevention remains crucial.

Physical therapists ought to steward healthcare resources responsibly, avoiding over- and under-utilization. Another key facet is educating the public about physical therapy's benefits and the profession's unique role. Getting involved with advocacy organizations and meeting with legislators to promote the field allows practitioners to embody this principle fully. Sitting at the policymaking table helps ensure the profession's perspectives are heard.

Common Ethical Issues

Ethical Challenges vs. Ethical Dilemma 

In my readings within the nursing literature, I encountered a distinction that resonated with me: ethical challenges versus ethical dilemmas. Ethical challenges encompass a broad spectrum of ethical issues, ranging from the ordinary to the significant. These challenges permeate our everyday professional experiences.

On the other hand, ethical dilemmas represent a unique subset wherein we grapple with choosing between distinct options, both of which may have ethical merit. The complexity lies in the realization that in an ethical dilemma, no choice is unequivocally ideal. When faced with such a dilemma, we find ourselves navigating the delicate balance of competing values. Regardless of the path we choose, we must come to terms with the fact that each option will bear its own set of consequences. 

Everyday Ethical Issues vs. Big Ethical Issues

When delving into the literature, it becomes evident that ethical issues can be broadly categorized into two major groups: everyday ethical issues and significant ethical dilemmas.

1. Everyday Ethical Issues:

   • These encompass a wide array of common ethical challenges encountered in daily practice. Examples include issues related to informed consent, respect for autonomy, refusal of services by patients, addressing offensive behavior, and maintaining confidentiality. These issues are part of routine practice and require consistent attention and ethical decision-making.

2. Significant Ethical Dilemmas:

   • On the other hand, significant ethical dilemmas represent a more profound and intricate set of challenges. These encompass issues such as end-of-life care decisions, the delicate choices regarding withholding or withdrawing life-sustaining treatments, and the ethical considerations surrounding hospitalization. These dilemmas often involve critical and profound decisions, forcing healthcare professionals to weigh conflicting values and principles.

Reasons for Ethical Dilemmas

• Patients or their loved ones must make life-or-death decisions
• The patient refuses treatment
• Staffing assignments may contradict cultural or religious beliefs
• Peers demonstrate incompetence
• Inadequate staffing or resources

Patients are making possibly life or death decisions. Patients are making choices in general. The patient refuses some level of treatment, whether, again, that's physical therapy, medication, or food, for example. 

Moreover, healthcare professionals often encounter ethical challenges tied to cultural or religious beliefs, especially when these beliefs conflict with the assigned staffing arrangements. Such conflicts can raise dilemmas regarding balancing one's professional responsibilities with personal convictions.

Equally concerning are instances where healthcare professionals witness peers engaging in incompetent practices, potentially compromising patient safety and care quality. These situations force ethical deliberation on whether and how to address these concerns.

Inadequate staffing and resources, a pervasive issue and is a reality for most of us right now in today's healthcare landscape, present a critical ethical dilemma. Healthcare professionals often grapple with delivering optimal care under strained conditions, where there's an ethical tension between providing the best care possible and dealing with resource limitations.

Common Ethical Issues in Healthcare Setting

In the healthcare profession, we commonly encounter several ethical issues that deserve our careful attention. These encompass both the need for thorough and accurate documentation as well as navigating complex workplace demands:

• Documentation Lapses
  • Ensuring timely and accurate documentation of patient encounters is critical. We should document every encounter as soon as it occurs or shortly thereafter, at least at a bare minimum, every day. Lapses in documentation, such as shortcuts, using Xs or dots, or cloning/copy-pasting records, can compromise patient care and credibility in legal situations.  Documentation needs to reflect what we did accurately.
• Employer Demands and Productivity Quotas
  • Balancing productivity demands with ethical practice is essential. While efficiency and productivity are not inherently unethical, falsifying billing or misrepresenting services to meet quotas is unethical.
• Use and Supervision of Support Personnel
  • Utilizing support personnel within the boundaries of state practice acts is crucial. Clearly defining the roles and responsibilities of support staff to ensure they adhere to legal and ethical guidelines is vital.
• Impaired Practitioners
  • Recognizing and addressing impaired practitioners due to mental health issues or substance abuse is essential for patient safety and maintaining professional ethics. Prompt intervention and support are imperative in such cases.
• Student Supervision
  • Adequate supervision and mentorship for students during clinical placements are ethical responsibilities. Neglecting to provide proper guidance and supervision can compromise the learning experience and ethical conduct of students. I have heard students complain that their mentors didn't supervise them.  

Addressing these ethical challenges involves upholding professional standards, prioritizing patient care and safety, and ensuring compliance with legal regulations. It's incumbent upon healthcare professionals to maintain ethical conduct while navigating the demands and responsibilities inherent in their roles. I remember going on my clinical a long time ago and was just left to my own. I saw my supervisor the day that I walked on the job and at the end of my time there. That is reasonably unethical.

Common Ethical Issues in Student Supervision

• Patient welfare must come first
• Cannot delegate clinical decision-making
• Must inform client of qualifications/credentials
• Increase supervision based on knowledge, experience, competence
• Document the amount of supervision
• Protect client confidentiality
• Unethical for therapists to sign for clinical hours they did not supervise

Patient welfare should always remain the top priority in healthcare settings. When supervising a student, the responsibility for clinical decision-making lies with the experienced practitioner, not the student. The supervisor's role is to facilitate, guide, and collaborate with the student, but the ultimate responsibility for patient care and decisions rests with the supervisor.

Medicare and the setting can determine the level of supervision in the facilities I work in. It is also crucial to determine the appropriate level of supervision based on the student's competence. This supervision level may vary from direct onsite supervision to less direct supervision based on the student's abilities, experience, and current regulations. Clear documentation of the level of supervision provided is essential, ensuring transparency and compliance with guidelines.

Additionally, it's vital to inform the client about the presence of a student and share the credentials and qualifications of the supervisor. This transparency fosters trust and allows for informed consent, maintaining the integrity of the patient-provider relationship. The supervising practitioner remains accountable for the entirety of the patient encounter, overseeing and ensuring the quality and safety of care provided.

Common Ethical Issues in Confidentiality

• Records management, storage, ownership, retention
• Information exchanged
• Disclosure/release of information
• Access to records
• Exchange of records between professionals

Common Ethical Issues in Client Abandonment

Examples of misconduct

• Failing to give sufficient notice
• Failing to provide an interim plan
• Failing to complete the paperwork
• Withholding paperwork
• Removing materials or records
• Maligning the facility or organization
• Recruiting clients

There is nothing unethical about leaving a place of employment.  You may be leaving for a family reason or find a better job or a position advancement; however, you still need to focus on the ethics and the welfare of your client.

Key ethical considerations during a change of employment include:

Handling transitions in healthcare employment with ethics and patient welfare in mind is critical. Here are key ethical considerations during such transitions:

• Giving Adequate Notice
  •    Before leaving, provide sufficient notice to your employer to prevent treatment disruptions for your clients. Be mindful of the impact on patient care and work with the employer on a transition plan.
• Completing Paperwork and Orders
  • Ensure all necessary paperwork, including treatment orders, is completed before leaving. Do not withhold essential documentation, as it may adversely affect patient care during the transition.
• Maintaining Professionalism and Integrity
  • Refrain from maligning your previous employer or facility when leaving. Maintain professionalism and ethical conduct during your departure, and consider assisting in recruiting efforts if requested.
• Avoiding Client Recruitment
  • Avoid soliciting clients to follow you to a new practice, as this can be seen as unprofessional and may compromise patient trust and continuity of care.
• Addressing Patient Abandonment
  • Take responsibility for patient care to prevent abandonment during transitions, especially in critical settings like nursing homes. Collaborate with appropriate authorities and healthcare professionals to ensure patient safety and continuity of care.
• Reporting Ethical Violations
  • if faced with severe ethical violations, such as client abandonment, consider reporting to the relevant boards or authorities to ensure accountability and protect patient well-being.

These ethical guidelines underscore the importance of maintaining patient welfare, professionalism, and integrity throughout career transitions within the healthcare field. Balancing personal or professional changes with ethical obligations is essential to uphold the standards of care and trust patients place in healthcare professionals.

Examples

Reflecting on past experiences, I vividly recall an incident when transitioning into a new contract. The preceding provider chose to discharge every therapy order before departing, potentially as a means to inconvenience the incoming provider. However, the true consequence of this action was a disservice to the patients, who were left without the necessary therapy services. It reinforced the importance of considering patient welfare above all else.

As you leave prior employment, it's essential not to remove essential services or contribute to a negative environment. Maintaining professionalism and a sense of responsibility toward both the facility and the patients is paramount. Additionally, refraining from recruiting clients away from the previous facility showcases good professional practice and helps in building positive relationships within the healthcare community.

Common Ethical Issues in Reimbursement for Services

• Misrepresenting information to obtain reimbursement
  • Accurate documentation is required
  • Must remain current with payer policies
• Providing service when there is no reasonable expectation of significant benefit
  • Cannot provide services when the prognosis is too poor to justify therapy
  • Cannot exaggerate the extent of improvement in obtaining reimbursement

Accurate and honest documentation is fundamental in healthcare. When delivering therapeutic activities, it's crucial to document correctly what was performed and billed accordingly. Misrepresenting services to obtain higher reimbursement is unethical and undermines the healthcare system's integrity. If you did therapeutic activities, that's what you document; that's what you bill. It's just as easy as that.

Ethical practice necessitates ensuring that the services provided hold a reasonable expectation of benefiting the individual receiving care. It's essential to continuously evaluate the interventions' efficacy and modify the care plan if necessary. If a person reaches a plateau or the chosen interventions no longer yield benefits, adjustments must be made to the plan of care ethically and professionally. 

Exaggerating improvement or progress to increase payment is unethical and compromises the trust and accuracy required in healthcare practice. Upholding transparency and providing care based on genuine needs and benefits to the patient should always be the guiding principle in healthcare documentation and billing.

• Scheduling services not reasonably necessary
  • Must be based on clinical need
• Providing more hours of care than can be justified
  • Must be based on clinical need
• Providing complimentary care or discounted care
  • Fee alterations are not provided based on referral sources or personal relationships.

Scheduling and providing services that are not clinically necessary or justified is an ethical concern in healthcare. It's essential to base the scheduling and provision of services on a genuine clinical need and avoid unnecessary or excessive care that doesn't benefit the patient. Similarly, offering more hours of care than what is required can lead to overutilization of resources and may not align with the patient's best interests. It's important to ensure that the care provided is appropriate and in line with the patient's needs and treatment plan. 

Providing complimentary or discounted care that is typically billable can be ethically complex. Considering the overall impact on the healthcare system, patient expectations, and professional standards is essential when determining the appropriateness of offering care without reimbursement. This is a little different from pro bono services that might apply to your setting. This is more like, "Hey, if you follow me to this practice, I'll discount your bill by 25%.

I'll make it worth your while." That's what we don't do. Or, "I wanna continue services. Do you mind doing those for free even though they can't be reimbursed?" Those are the things that we shy away from.

Common Ethical Issues in Therapy with Children

When working with children, it's essential to prioritize the child's best interests. However, common ethical considerations often revolve around follow-up care for the child. These issues may include families failing to adhere to appointments, following your instructions, or sharing confidential information with non-family members. Sometimes, there can be ambiguity in the relationships and responsibilities involved in managing the therapeutic alliance with parents and caregivers.

Distrust or frustration regarding reimbursement limitations, concerns about parenting techniques, or potential neglectful behavior can also arise. In some cases, parents may misuse resources, not follow the care plan, or even threaten to withdraw the child from services. Privacy and confidentiality issues persist, particularly when conducting telephone follow-ups, where the caller's identity may not be clear or non-legal guardians seek information they're not entitled to. Parents might request confidential information they shouldn't have access to, further complicating these situations.

Common Ethical Issues

• Documentation lapses
• Employer demands/lack of resources
• Impaired practitioners
• Coercion

These are some of the common issues. To reiterate, ethical concerns among staff members are prevalent, with approximately 90% of clinicians acknowledging that they encounter ethical challenges in their daily work. These issues typically revolve around everyday matters, not necessarily major ethical dilemmas. A significant concern, reported by 79% of clinicians, is the lack of resources. This shortage can encompass various aspects, from the unavailability of durable medical equipment (DME) to the absence of leg rests for wheelchairs, among other things.

Coercion is another significant ethical concern. It's not limited to therapy but can extend to various situations. For example, you might have observed people secretly mixing medications into applesauce for someone without their knowledge. This act could easily be avoided by simply informing the person about the medication. Additionally, lapses in documentation, as previously discussed, are common ethical issues in healthcare.

In physical therapy, competence is not merely a goal but an expectation. We trust that our colleagues are competent, and our responsibility is to uphold and contribute to this competence.

Ethical Dilemma Examples

I will share a few examples of ethical dilemmas, some of which may involve therapy, while others have arisen recently.

Inadequate Staffing Example -A senior PT who manages the weekend therapy at the hospital had two physical therapists called in the night before a weekend shift, which left the therapy team short-staffed that weekend.  There are patients that have to be seen per hospital policy.  

Resource limitations and staffing shortages are common challenges in healthcare. Dealing with these issues may require creative solutions and proactive communication. Consider strategies such as:

1. Calling in PRN Staff: If available, part-time or PRN (as needed) staff can help cover shortages.

2. Overtime: In some cases, asking existing staff to work overtime may temporarily alleviate staffing issues.

3. Supervisor Involvement: Reporting your concerns to your supervisor is essential. They may have insights, and their involvement can help address resource challenges.

4. Prioritizing Care: While not ideal, prioritizing patients based on their needs may be necessary during staffing shortages.

5. Flexible Scheduling: Adjusting treatment schedules, including evening sessions if possible, can help manage patient loads more effectively.

6. Team Collaboration: Work closely with your team to share responsibilities and help each other during resource shortages.

It's crucial to address these challenges promptly to ensure patient care remains a top priority and ethical standards are upheld.

Inadequate Resources Example-Nurse Jan is the wound care nurse for a home health agency. She stopped by the office to pick up additional wound care supplies for her weekend visits. However, the charge nurse told her the wound care supplies delivery did not arrive. As a result, there are not enough supplies on hand for the visits Nurse Judy has scheduled.

Nurse Judy is facing a challenging situation with a shortage of wound care supplies for her scheduled weekend visits. To handle this issue ethically, she can consider several approaches:

1. Purchase Supplies: As suggested, Nurse Judy could explore local pharmacies or medical supply stores to purchase essential wound care supplies. While this may be an added cost, it ensures that patient care remains uninterrupted.

2. Physician Consultation: Nurse Judy can contact the physicians for patients with wound care needs. She can discuss the supply shortage issue with them and request adjustments in orders based on the current supplies available.

3. Supply Allocation: Prioritize the most critical cases based on the remaining supplies. Ensure that patients with more severe conditions receive the limited available resources.

4. Notify Patients: If it's unavoidable that some visits will need to be postponed due to supply shortages, Nurse Judy should contact the affected patients as soon as possible. She should explain the situation honestly and reschedule their visits.

5. Resource Management: Collaborate with her team and the agency's management to develop strategies for better resource management and supply monitoring in the future.

In all these actions, open and honest communication is crucial. Nurse Judy's primary ethical responsibility is to maintain patient safety and ensure that their care is not compromised.

Keep in Mind

Ethical issues in healthcare, including those related to resource shortages, patient care, and professional conduct, remain consistent regardless of the payer or healthcare setting. The fundamental ethical principles and values that guide healthcare professionals apply universally. Whether one works in a private practice, a public hospital, a home health agency, or any other healthcare context, the obligation to prioritize patient well-being, maintain confidentiality, and adhere to professional standards remains constant. Understanding and addressing these ethical challenges is a critical part of delivering quality healthcare services.

In ethics, it is essential to emphasize the role of evidence-based practices. Specifically, we must rely on empirical evidence when considering treatment protocols for various diagnoses or clinical considerations. Questions that demand our attention include the frequency of treatment for a given patient, the duration of treatment (in weeks), the number of visits, time allocation, and the selection of appropriate modalities.

Within my practice, which primarily focuses on long-term care and involves Medicare, it's worth noting that Medicare administrative contractors often incorporate evidence into their guidance. This evidence-based approach determines which treatments are eligible for reimbursement and which are not. In cases where the evidence does not support a specific treatment, they clarify that reimbursement is not feasible.

Ideally, they define the recommended number of treatments, the appropriate timeframe for treatment delivery, and the associated guidelines. However, exceptions are acknowledged and justified through thorough documentation. It is imperative to highlight that quantifiable, measurable changes resulting from treatment interventions play a pivotal role in justifying the continuation of care. It's important to remember that our compensation typically hinges on the treatments we provide in each session. Exceptions arise only when a treatment session faces a challenge, such as a denial. In such cases, the accurate presentation of information is of utmost importance.

Education

• Ethical duty to educate the public and ourselves
  • Are you as educated as you should be about long-term care?
  • Do you listen for and correct misperceptions?
• Staying current in one’s profession is an ethical duty to the constituency the profession serves
  • Formal education, clinical competence, personal growth

It is essential to continuously educate the public while also maintaining our own knowledge base. A fundamental question we should ask ourselves is whether we are as well-informed as we need to be in our specific clinical setting. This involves being aware of the rules and regulations governing our practice, staying updated on legislative developments in Congress relevant to our field, and understanding the dynamics with our payers.

How often have we heard someone say, "I simply don't grasp the complexities of insurance," or witnessed a divide between those in acute care and long-term care, each harboring misconceptions about the other's domain? As professionals, we have a duty to address such misperceptions. Whether it's debunking the idea that a particular care setting is only for end-of-life care or correcting misunderstandings between colleagues, it falls upon us to ensure clinical competence and foster personal growth.

In the realm of physical therapy, competence is not merely a goal; it is an expectation. We trust that our colleagues are competent, and it is our responsibility to uphold and contribute to this competence as well.

Ethical Dilemma Examples

• Incompetence among peers
• Asked to perform a treatment for which you are not trained or competent
• Questioning MD orders (e.g., order written for medication to which patient is allergic)

Nobody wants to entertain the thought of someone being incompetent to provide care. However, the reality is that issues of incompetence do exist and can present significant ethical dilemmas in therapy. What should we do when confronted with a situation where we are asked to perform a treatment for which we lack training or competence? Ideally, we should respond by acknowledging our limitations and readily admit that we are not qualified for the task while suggesting a more suitable colleague who can address it effectively. For example, if it involves a specialized treatment like lymphedema therapy, we should refrain from attempting it ourselves, assuming we can manage it or misrepresenting our capabilities.

Another vital aspect of our professional duty is to question physician orders when we have concerns. If we encounter a treatment plan or modality that raises doubts or poses a risk to the patient's well-being, it's our ethical responsibility to express these reservations. For instance, if a physician orders a specific modality, but we suspect that the patient's skin integrity in that area is compromised and unlikely to tolerate it, we should seek clarification from the physician or suggest an alternative approach.

In all cases, the guiding principle must be the unwavering commitment to putting the patient's best interests first. Our paramount duty is to ensure the highest level of care and safety for our patients, even if it means challenging or seeking clarification on medical decisions.

Involving Patients in Medical Decisions

Frequently, healthcare providers encounter situations where there is a conflict between the preferences of the patient and the desires of their family, significant other, adult child, or parents. These conflicts can manifest in various ways, such as a patient refusing medication when their family insists they should take it or family members wanting to withhold information from the patient, thereby excluding them from their care plan. Other examples include patients refusing nutrition, treatment, and blood sugar control.  

Ethical Dilemma Example

Mr. Morris is in end-stage renal failure. Despite efforts to help manage the disease, including dialysis three times weekly, his condition has worsened. Mr. Morris's physician has noted the decline in his status and has informed the family that Mr. Morris may have only a few weeks to live. Mrs. Morris and their children are skeptical about telling Mr. Morris how bad his condition is, and the physician has made no effort to talk to the patient about it. After his family left for the evening, Mr. Morris called for the nurse and asked her to tell him what the doctor said, stating he felt like he was not getting the whole story.

This is a real ethical dilemma. It is not uncommon for family members or significant others to withhold information, often with the intention of protecting their loved ones. Nevertheless, from an ethical perspective, this raises concerns related to paternalism, where someone else is presumed to know better than the patient. Ethical principles such as veracity, informed consent, and autonomy are paramount here.

Healthcare practitioners must uphold their duty to provide information in situations like this. Patients have the inherent right to be informed about their condition and prognosis. While it may not always fall on the physical therapy practitioner to deliver such information, knowing where to direct the patient to ensure they receive the information they are entitled to is crucial. Resolving such situations requires a collaborative approach, ensuring that the patient's rights and autonomy are respected while addressing the concerns of their family. This case highlights how various ethical principles intersect and must be carefully navigated to provide the best care.

End of Life Wishes

This issue frequently arises in acute care, hospitals, long-term care, and even home care. A survey of ethical challenges in end-of-life care often reveals two prevalent issues: a lack of resources and a breach of the patient's autonomy. In these circumstances, family members, healthcare staff, or others may exert pressure on the healthcare team to undertake actions that run counter to the wishes of the dying individual.

What becomes paramount in such cases is the necessity to be aware of the dying person's wishes. Is there an advanced directive or some form of documented guidance in place? Waiting until the last moment to address these critical matters is far from ideal. Ideally, well in advance, someone should have worked with the patient to articulate their true desires and what they wish to avoid in their end-of-life care.

The complex aspect emerges when family members express differing opinions from the patient. Some may assert, "We can't just let mom die," while others may believe, "Mom wouldn't have wanted to live like this." There is no conflict of interest when family members concur with the patient's wishes. However, it's common for conflicting statements to arise, complicating the situation. Healthcare providers, including therapists, can sometimes feel caught in the middle as they hear both the patient's and the family's perspectives.

In such situations, it can be beneficial to involve an ethics committee. The central principle to uphold is that of autonomy and self-determination. The patient's voice and choices should be respected and preserved whenever possible.

This underscores the fact that our primary duty and commitment always lie with the patients we treat. Patient advocacy remains paramount, but there may be scenarios where family interests come into play, as our second duty is to the family. 

Ethical Dilemma Example

Mrs. Douglas has metastatic lung cancer. Her physician has advised about treatment options that may prolong her life by six months to a year. However, to the dismay of her family, Mrs. Douglas has chosen comfort measures only. Mrs. Douglas has prepared an Advanced Directive, including signing a DNR. 

In cases like these, where the patient's wishes diverge from those of the family, it is crucial to prioritize the patient's autonomy and their documented preferences. The patient's wishes, as outlined in their Advanced Directive, should be respected and followed. This is a fundamental principle of medical ethics and legal practice.

Conversely, if a patient lacks an Advanced Directive and the healthcare facility is unsure of their preferences, it is imperative to initiate the appropriate discussions. While it may not fall upon us directly, someone within the care team should engage with the patient and their family, if possible, to understand their preferences and document them. These critical conversations should explore the patient's values, goals, and treatment preferences, ensuring that their decisions are at the forefront.

Entering a Skilled Nursing Facility (SNF)

• Disparity between views (taking a medication or getting a specific type of treatment)
• Paternalism contradicts autonomy
• Must discuss decisions with the client in detail and make the decision best for the client and the family

Entering a skilled nursing facility highlights the common disparity between the views of healthcare professionals and patients or clients regarding certain treatment options or medications. This discrepancy often underscores the ethical conflict between paternalism and autonomy.

Paternalism suggests that healthcare providers may act in what they believe to be the patient's best interests, even if it means overriding the patient's autonomous decision. However, this approach contradicts the principle of autonomy, which grants patients the right to make informed decisions about their care.

Engaging in detailed discussions with the client or patient is imperative, providing comprehensive information to ensure informed consent. Open and honest communication, or veracity, is critical to ensure that the patient truly comprehends the options and is actively involved in decision-making. Ultimately, the decision should best serve the well-being and preferences of the client and their family.

The scenario becomes even more complex when a person's legal competence is in question, particularly in the context of seniors. 

Legal Incompetence

There has to be legal incompetence. We look to the family when the person is cognitively unable to decide. The actual decision rests with the legal guardian, who must weigh the implications of the family’s standpoint in relation to the patient’s interests. Consideration is to be given to the patient's needs, physical condition, personality, and whether continued home care is possible.

If the individual has not been deemed incompetent, they must be part of that decision. When considering placement, ethics plays a significant role. It's crucial to assess whether the individual can genuinely be adequately cared for at home.

Analyze Ethical Dilemmas-RIPS Model

The RIPS Model is a way of analyzing ethical dilemmas.

Step 1: Recognize and Define the Ethical Issue 

• Realm
• Individual process
• Implications for action
• Type of ethical situation
• Barriers

Step one involves recognizing and defining the ethical issues at hand. This process is quite similar to our previous discussion. In this step, you need to determine the realm, the process, the implications for action, the nature of the ethical situation, and any barriers you might encounter. Let's delve into these aspects in greater detail:

Realm. Begin by identifying the ethical realm to which the issue belongs. There are three primary realms to consider:

• Individual Realm pertains to matters related to the patient's or client's well-being. It focuses on rights, duties, interpersonal relationships, and individual behaviors.

• Institutional or Organizational Realm: The emphasis is on the organization's well-being. You should consider the structures and systems that contribute to achieving its goals.

• Societal Realm: This realm is concerned with the common good of society as a whole. It involves ethical considerations that transcend individual or organizational interests and aim to benefit the broader community.

Individual Process. The second aspect of recognizing ethical issues involves assessing individual processes. These processes help you understand how the problem manifests in terms of moral decision-making. Consider whether the issue aligns with any of the following aspects:

• Moral Sensitivity: Recognizing, interpreting, and framing ethical situations. It involves being aware of the ethical dimensions of a situation and understanding the potential implications for all involved parties.
• Moral Judgment: In this step, you are tasked with deciding what is morally right or wrong. You evaluate the ethical principles and values at play and decide on the most appropriate course of action.
• Moral Motivation: Moral motivation concerns your ability to prioritize ethical values, principles, and considerations over personal financial gain or self-interest. It involves a willingness to act in accordance with one's ethical beliefs even when there may be external pressures to do otherwise.
• Moral Courage: This aspect is about implementing the chosen ethical action, even when doing so may lead to adversity or challenges. It requires the determination to follow through with the right course of action despite potential consequences or resistance.

Situation. How do you classify the ethical situation? To effectively analyze the ethical situation, you should classify it into one of the following categories:

• Problem or Issue: Determine whether the situation qualifies as a problem or issue, meaning whether important moral values are being challenged.
• Temptation: If the situation involves a choice between a right action and a wrong action, where the wrong action may offer personal benefits, it falls under the category of temptation. This often tests your moral integrity.
• Silence: When key parties recognize the existence of ethical issues but remain passive, not discussing or taking any action to address them, the situation can be classified as one of silence. This is a scenario where there is an unspoken agreement not to confront ethical challenges.
• Distress: If a structural barrier hinders you from doing what you believe to be right, it falls under the distress category. There are two subcategories:
  • Type A Distress: In this case, the barrier is apparent but prevents you from doing what you know is right.
  • Type B Distress: Here, there is a barrier, but you are uncertain about the specific nature of the problem. Something feels ethically wrong, but you may be unable to pinpoint it.

Dilemma. There are two or more correct courses of action that cannot both be followed. You're doing something right and also doing something wrong, and most often, this involves ethical conduct. Ethical dilemmas typically involve the need to balance and make decisions between conflicting principles. Some common examples include:

• Honoring Autonomy vs. Preventing Harm: On one hand, you may be required to respect an individual's autonomy and their right to make decisions about their own life, even if it might lead to harm. On the other hand, there's an obligation to prevent harm, which may require intervention that infringes upon their autonomy.
• Conflicting Traits of Character: Ethical dilemmas can also involve conflicting character traits, such as honesty vs. compassion. For instance, you might need to decide between being completely honest and potentially hurting someone's feelings or showing compassion by withholding some information to protect them.

Step 2 Reflect

• Background
• Major stakeholders
• Consequences of action or inaction
• Laws broken?
• Professional guidance
• Right-versus wrong tests

When faced with an ethical dilemma, it's crucial to consider the following factors carefully:

• Relevant Facts and Contextual Information: Begin by gathering all the pertinent facts and contextual information about the situation. This provides the foundation for making an informed ethical decision.

• Major Stakeholders: Identify and understand the key parties involved in the situation, as their interests and perspectives can significantly influence the ethical implications.

• Consequences: Analyze both intended and unintended consequences of potential courses of action. This includes considering the impact on individuals, organizations, and the broader community.

• Relevant Laws, Duties, and Ethical Principles: Examine any applicable laws, regulations, professional duties, and ethical principles that are relevant to the situation. These provide a framework for ethical decision-making.

• Professional Guidance: Seek guidance from your profession's ethical guidelines or code of conduct. This guidance can help you align your decision with industry standards and values. Examine whether the situation aligns with the code of ethics, the guide to professional conduct, or any core values of your profession.

• Right vs. Wrong Tests: Evaluate the situation by asking if a course of action is morally right or wrong, considering your own values and principles. You may include: 

  • Legal Test: Determine if any actions the involved parties take are illegal, as this can impact the ethical assessment.

  • Stench Test: Assess whether the situation feels wrong or unethical, even if it may not be clearly defined as such by laws or regulations.

  • Publicity or Front Page Test: Consider how the situation would be perceived by the public or if it were to become widely known. This can shed light on potential reputational and ethical concerns.

  • Universality or Mom Test: Reflect on whether the decision is right, regardless of who is involved. Consider what your moral compass or what your "mom" would advise. 

Step 3 Decide the Right Thing to Do

You can do this in three different ways. It's rule-based. You follow only the principle that you want everyone else to follow, so that's deontological. It's end-based. You do whatever produces the greatest good for the greatest number of people, so that's teleological. Or it's care-based. Do unto others as you would have them do unto you, so that is the golden rule.

Step 4 Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

We're considering implementation here. Did it meet our expectations? What were the challenges? How does it compare to other situations? Did it enhance our professionalism? Do we need to establish policies or procedures to prevent such occurrences in the future?

Example Using RIPS Model (Kate)

Kate graduated from State University last year and is working at County Hospital. Her PT school best friend, Sandy, works in a small rehab hospital across the state. They often compare experiences and ideas for interventions. The young colleagues, typical of their generation, primarily communicate via text messaging and Facebook. They rarely talk on the phone.  

On a Monday morning, Kate starts her workday by reviewing scheduled patient charts. Looking through the new admissions, she notices a familiar last name. She checks the face sheet and confirms that the patient is Ms. Edwards, one of her former professors at the state university. Kate is surprised to see that Ms. Edwards was admitted to rule out a brain tumor.

Kate walks down the hall to visit her former professor but doesn't find her in the room. Assuming she's undergoing tests, Kate plans to check back later. However, she doesn't get the chance to meet Ms. Edwards that day. Later in the evening, while on Facebook, Kate writes a message on her friend Sandy's wall about their former professor's hospital admission. The message quickly spreads through the Facebook news feed, and Kate discusses Ms. Edwards' condition with several former classmates and others.

That evening, Ms. Edwards' daughter discovers the news of her mother's hospitalization on the social networking site, which surprises her. She immediately calls her mother, who is upset by the news, and contacts Joanne, the County Hospital's Director of Physical Therapy. Joanne summons Kate to her office the following day, expressing irritation and asking for an explanation.

Kate is confused by the issue and attributes it to a generation gap between herself, Ms. Edwards, and Joanne, all of whom are baby boomers. She defends her actions, stating that sharing and communicating information in this manner is common among people her age. However, Joanne emphasizes that the problem isn't about technology or etiquette but about confidentiality. Kate is puzzled by Joanne's frustration.

This situation resembles the one I mentioned earlier, where someone who wasn't directly involved with the patient's treatment shared information about the location of an estranged mother with family and others.

Let's go through the RIPS model now. 

Step 1: Recognize and Define the Ethical Issue  

• Realm: While Kate is sure it is individual, Joanne considers it institutional.  
• Individual process: Kate doesn't have the moral sensitivity to even recognize that her messages were a breach of confidentiality, as too was her decision to read the chart of a patient to whom she had no professional connection or obligation.
• Implications for action: Joanne must address Kate's obvious lack of understanding of confidentiality issues.
• Type of ethical situation: A problem: It's a problem in that the inappropriateness of Kate's actions is really not even clear to her.
• Barriers: Yes, there are barriers. Joanne has the authority to take action, but it's unclear if she fully understands the generational challenge she is confronted with.

Step 2: Reflect

• Background: We don't really know anything more than this. We know that Kate is not treating Ms. Edwards; she's just curious about her.
• Major stakeholders: Kate, Joanne, Ms. Edwards, and Kate's friend, Sandy, who is dragged into this because Kate was chatting with her.
• Consequences of action or inaction: Yes. Joanne is obligated to take action. As a new professional, Kate must understand that her professional responsibilities affect her personal life and values.
• Laws are broken: There is a HIPAA violation at a bare minimum.
• Professional guidance: Kate would do very well to reflect on the principles of the code of ethics regarding respectively the rights and dignity of all individuals and the exercise of sound professional judgment. She needs to look at integrity and social responsibility.
• Right versus wrong tests. Is it illegal? The situation feels wrong for sure, if not to Kate. Is there discomfort if this information becomes public? Probably. Would your parents take action in a similar situation? The answer is probably yes. Finally, is there a violation of the professional code of ethics? Again, the answer is yes.

Step 3: Decide the Right Thing to Do

So what do you do? For Kate, the barrier to behavior change is getting her to understand that her actions, while perhaps socially acceptable and expected among her peers, are inconsistent with the expectations of her profession and her patients.

Step 4: Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

So what do you do? This situation may result in a change in institutional behavior as Joanne looks at her orientation program and recognizes she has young staff with social norms that differ from hers. 

This whole situation looks at confidentiality and how we, as therapists, manage protected health information that we have at our disposal. Confidentiality, again is one of our biggest obligations. Changes in technology and communication are challenging how we view confidentiality. We need to look at it in light of the technology. There should be some level of policy and procedures in place that are reviewed regularly and are part of orientation as well.

Second Example Using RIPS model (Mike and James)

James is working in home care. He enjoys the independence and variety of work. One of his current patients, Mike, an active 72-year-old retiree and widower who recently had a left total knee replacement, spent a week at a rehab center before he came home.

Mike has a great attitude, eager to get back in the swing of things. Payment for his physical therapy is unaffected by outpatient guidelines as long as he remains at home. This makes James very happy because Mike is a hard worker and he is an ideal patient. He can't afford to pay for physical therapy beyond what Medicare and supplemental insurance will allow. James aims to ensure Mike's safety in the home environment and his ability to manage independently. His discharge goal is to be self-sufficient while possibly experiencing some residual pain and capable of transporting himself to physical therapy on an outpatient basis. The plan of care is estimated at three times a week for three weeks.

When the PT arrives for his third appointment in the first week, he notices that his patient's car is in the driveway rather than in the garage. Mike answers the door and goes into the kitchen, where he's putting away groceries. James knows that there's no family in the area, and he asks Mike who did the driving and the shopping. Mike says, "Well, I did." James is surprised because Mike should be technically homebound to recieve physical therapy in the home. There are physical and clinical issues, but Mike's like, "Yeah, I get it, but there's gotta be a little wiggle room. What harm is there in me trying to do a little bit for myself?"

Mike's car is gone when James arrives for the next follow-up appointment. About five minutes later, Mike returns to his house in his car. Mike stated that went to the hardware store for plumbing supplies to fix the leaky sink.  Jamies notices Mike is getting up the stairs and he's getting back into the home safely, but obviously with some level of effort. 

James feels conflicted. Mike needs more physical therapy, but based on the fact that he's shown obvious progression, he's technically no longer homebound; what does he do? Does he continue home care, or does he discharge and send him to outpatient?

Step 1: Recognize and define the ethical issue

• Realm: Individual and societal
• Individual process: Moral sensitivity on James's part
• Implications for action: Mike will stop receiving PT that can benefit him
• Type of ethical situation: A dilemma
• Barriers: Concern for Mike's safety 

The realm is individual between James and Mike, but I think there's also a societal element here because of reimbursement. There's that moral sensitivity in the individual process, particularly for James.

Implications for action. So if James exercises moral courage, Mike will stop receiving home care that could benefit him, and we don't know if he could or could not go to outpatient at this point.

This is a dilemma. Mike is exercising his autonomy, but James is concerned for his safety. James is exhibiting non-maleficence in wanting to keep Mike on home care. James is also concerned about veracity. He believes in being truthful. He doesn't wanna lie about the homebound status.

Are there barriers? Yes, one barrier is for Mike's safety if home health is discontinued.

Step 2: Reflect

• Major stakeholders: James and Mike
• Consequences of action or inaction: Mike will lose the additional PT he needs if James takes action.  Inaction means that he receives PT while not technically homebound.
• Laws broken? Medicare laws are very specific regarding homecare
• Professional guidance: Principle 7 of the Code of Ethics
• Right vs. Wrong: Illegal? Yes. The situation feels wrong. Discomfort if information becomes public? Yes. Are your parents likely to take action in similar circumstances? Yes. Violations of APTA's professional codes and documents? Yes. 

But inaction means that he has a patient who is not home-bound. Are there laws broken? Yeah, Medicare has very specific laws regarding home care, obviously. What is the professional guidance? Regarding the state and the code of ethics, a physical therapist shall seek only such remuneration as is deserved and reasonable. There's a core integrity here as well. Right versus wrong tests. I think all of these, we could say it feels wrong. Your mom would take action in a similar situation. It doesn't pass the stench test.

Step 3: Decide the Right Thing to Do

• So what does James do? While James must consider discharge, he must also do all he can to ensure Mike's safety by ensuring his continued access to the outpatient services he needs.  

Step 4: Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

• It's unclear whether any institutional policy or culture change is warranted, but that possibility should be fully explored. I think what we're looking at here is, to some degree, there's pressure to provide patients with optimal care within the guidelines. There's pressure always to do the right thing in light of reimbursement. You can't let reimbursement drive practice. We must ensure that proper sequence is followed and that we do the right thing for our patients and practice.

Example-Jenna

Jenna has been working at Pond View for about six years. She is known for her wound care expertise. She's been the CI for the past four years and recently completed the CI credentialing course. She supervises at least three students yearly as they rotate through their clinical experience. She enjoys the interactions, particularly those related to wound care. This is the next to last clinical rotation for Brendon, a third year DPT student at the local university who made a career change from the corporate world and thus is a little older than the students who generally rotate through. He is working with another PT, Mary, for the first part of his rotation, and then he will move on to Jenna's supervision about midway through.

One day, three weeks into the affiliation, Brendon stays late to finish up some paperwork. He ends up leaving the building at the same time as Jenna, who also worked late. They get into a long conversation while standing in the parking lot. Brendon's very interested in wound care and asks Jenna many questions about what he'll see when working with her in the next few weeks. They also exchange a little small talk during which Jenna mentions that her birthday is the next week. With the conversation winding down after 20 minutes, Brendon asks Jenna if she would let him buy her a birthday drink at a nearby bar (within walking distance). She responds that she appreciates the offer, but it strikes her as inappropriate given that she'll be his supervisor in just a few weeks.

He responds that, having worked in the corporate environment, he's sensitive to these types of issues. "It's just one birthday drink, and anyway, you can think of it as a penny for your thoughts because I want to pick your brain about some cases that I've seen." She sees this as reasonable. Would having a single drink with Brendon while engaged in a professional dialogue be so wrong?

I would like you to take this one back with you and go through the steps I have laid out.  

Step 1: Recognize and define the ethical issue

• Realm: Into which realm or realms does this situation fall: individual, organizational/institutional, or societal? 
• Individual process: What does the situation require of Jenna? Of Brendon? Which individual process is most appropriate: moral sensitivity, moral judgment, moral motivation, or moral courage?
• Implications for action: Are there implications for action on the parts of anyone besides Jenna and Brendon?
• What type of ethical situation is this: a problem, dilemma, distress, or temptation?
• Are there barriers to Jenna taking action?

Step 2: Reflect

• What do you know about the legal obligations Jenna may face?  
• Who are the major stakeholders?
• What are the potential consequences of action or inaction on Jenna's part?
• What ethical principle(s) may be involved?
• How does this scenario stack up against the “tests?”

Step 3: Decide the Right Thing to Do

• If it fails all of the “tests,” this step is superfluous
• If it passes the tests, then determine the right thing to do
  • Rule-based: Follow only the principle you want everyone else to follow
  • Ends-based: Do whatever produces the greatest good for the greatest number of people
  • Care-based: Do unto others as you would have them do unto you

Step 4: Implement, Evaluate, and Assess Needed Changes to Prevent Recurrence

• Having determined in your own mind the right thing to do and the best way to implement the decision, reflect on the course of action chosen and think about whether a change in the clinic's organizational policy or culture might prevent this scenario from recurring

Consequences Of Ethical Dilemmas

Ethical dilemmas can affect individuals, potentially leading to burnout and stress. It's essential to address these dilemmas promptly and effectively for several reasons. Unaddressed ethical dilemmas can fester and grow, making them more challenging to resolve later. Addressing them early can prevent escalation. Swift resolution of ethical dilemmas can help reduce the stress and emotional burden that staff may experience. This, in turn, supports their well-being and mental health.

Some ethical dilemmas may have legal consequences, potentially resulting in actions such as loss of licensure, termination of employment, reprimand, or implementing an action plan to respond to the issue.

Ethics Committee

Hopefully, you have an ethics committee that you can go to with some of these issues. If you don't, it might be something that you consider in your place of employment, suggesting or at a bare minimum, having a team there.

Avoiding Ethical Dilemmas

How do you avoid ethical dilemmas? You do it by Protecting Thy Patients and Thyself. It's a mnemonic.

• P: Put a copy of your licensure law on your desk and read it!
• R: Report ethical and legal violations
• O: Open your eyes
• T: Tell them you want it in writing or in an email. If it doesn't seem right, it probably isn't right. Tell them you want it in writing or an email. If somebody asks you something that doesn't make sense or you're questioning it (it doesn't pass your stench test), ask for it in writing. They won't typically put it in writing if it's illegal or unethical.
• E: Encourage ethical behavior
• C: Complete, thorough documentation
• T: Think!! Don't fall into the trap of panicking first and thinking later.

• T: Take the patient’s interest above all
• H: Handle situations as they arise
• Y: Yearn to learn

• P: Plug into your professional associations
• A: Ask a lot of questions
• T: Train and supervise all subordinates properly
• I : Internet sources (but be cautious too; clarify and make sure you have the correct information)  
• E: Establish a relationship with a mentor or peer
• N: Never fall behind
• T: Take a good look at the professional literature
• S: Surf the internet for regulatory changes   

• &

• T: Take the time to read your code of ethics
• H: Hand over patients to those with expertise
• Y: Yield to the dictates of payers  
• S: Save a copy of the correspondence
• E: Explore all alternatives
• L: Look at professional association/licensure homepages
• F: Fill out all forms accurately and truthfully

Resources to Help

• Core documents from APTA -- APTA Code of Ethics, APTA Guide for Professional Conduct, Standards of Ethical Conduct for the Physical Therapist Assistant
• Consensus Statement on Clinical Judgement in Health Care Settings
• Other resources from APTA
  • Coding and Billing
  • Compliance
  • Managed care contracting tool kit  
  • PT in Motion

Situational Examples

I'm gonna go through these examples a little bit on the quick side. I would like you to bring these back to your clinics and maybe talk about them as a group as they relate to ethics.

When compiling documents for an additional development request, you discover that the restorative nursing assistant documented that services were rendered when the resident was clearly out of the facility and in the hospital. 

I've seen this in physical therapy and occupational therapy, where we continue to document, and the patient was discharged. It's clear the person was never seen or actually treated because we probably would not have that documentation. That is truly an ethical violation and you can kind of brainstorm what you would do.

You, the therapist, have delegated the treatment of a client to the physical therapy assistant under your supervision.  The client complains of pain during the treatment session.  The PTA applies ultrasound to the patient during the session without consulting you and without a physician's script/order to do so.

We see this sometimes when the PTA has applied a modality that was not part of the plan of care, and they have changed the plan of care without consulting the physical therapist - of course, that is a huge "NO."

When reading the daily notes of the assistant you are supervising, you discover that he is adding and changing goals for the client without consulting you. 

This is very similar to the prior example. It is also a no-no, as it is not in the PTA's scope of practice, and the therapist must be consulted on any change to the plan of care (treatments and goals).

You work in an outpatient clinic, primarily dealing with Medicare Part B as a payer. Your clinic has an aide. You ask the aide to complete the therapeutic exercise program with the client, and you bill for these services.

This example goes back to fraud and abuse. We cannot bill for services provided by individuals who are not legally allowed to provide that service in that setting.

As a PT, you have been told to continue treating your patient—just three more sessions—so the facility can continue to obtain skilled reimbursement and because the family is not quite ready at home for discharge.

Could you work on something? I suspect yes, but that might be wrong if it's just for that facility to get reimbursed. So I think you'd have to look at that one cautiously—if there truly is something clinically skilled that you could be doing, then by all means, but if there isn't, then we would probably want to continue with discharge.

A 56-year-old man is referred to physical therapy for sciatica, degenerative disc disease, and degenerative joint disease. He is the sole caretaker for his disabled wife. Over the last month, he has lost his capacity to bend, lift, and carry during activities of daily living and work. Medicaid will only provide for a PT evaluation.  No follow-up services are covered.  The PT recommends follow-up twice a week for four weeks.

I mean, this is a tough one. How do you proceed? Should the patient be asked to pay out of pocket? Should the patient be offered free or discounted services? No, because we don't do that. We need to look at alternatives to traditional duration and frequency, models of care. Maybe there are some other options there. Maybe we need to advocate for the patient to the insurance provider to seek additional services. 

As a therapist, you suspect that a patient is concealing information that may impact his health, but you want to respect his privacy.

This situation is a tough one. If your patient doesn't share, they don't share. We develop that trust relationship and hope they share with us. We have to obviously always keep their confidentiality.

As the supervisor of your department, you see that Marie, one of the PTs, has been regularly receiving expensive gifts from the elderly woman's family. The woman was scheduled to be discharged from the program weeks ago, but Marie continues to delay the discharge, citing many reasons.

This is a problem. I think most of us work in a situation where we are not allowed to accept gifts, and it looks like we're getting some gift or kickback from this patient. That is a no-no. 

You are friends with Paula on Facebook, and you happen to notice that she is also friends with several of your patients and their family members. 

Is that terribly wrong? Not necessarily, but I think at a bare minimum, we would want a policy that addresses whether we can be friends with these individuals or not. Maybe we could be friends after treatment ceases, and maybe not during treatment. Again, that would be up to a policy and procedure there.

Lauren, a PT, is the only witness to a patient fall in the clinic gym. The patient has balance problems, and the PTA, Hal, working with her, was not guarding her. Lauren observed Hal placing a gait belt on the patient after the fall and before calling for assistance. Lauren is unsure what to do about this situation. 

That's another ethical situation. This person was not maintaining appropriate patient safety, which must be addressed.

Jim, a PT, works at a private practice with several regional clinics. It has a centralized management structure. One of the top managers calls Jim and asks him to call a previously scheduled new patient to reschedule an initial evaluation since a VIP/shareholder has been referred to the clinic and wants to be seen as soon as possible. Jim is uncomfortable with this request.

This goes against justice and fairness, really. What do you do here? It's an ethical consideration. I don't know that we have an exact answer, but I think it's something we need to talk through. Maybe there's room for both people to be treated. If there's not, we must put our patients first.

Sara works in a private practice with a profit-sharing plan. Her year-end bonus is directly related to maximizing return visits as they are the most cost-effective. Her boss has been heard to say to other staff members that they should treat patients to the maximum of their benefits; after all, you can always change the goals so there is more therapy to do – it just requires being a little creative. She has also been heard to encourage therapists to discontinue treatment early for those patients with poor reimbursement. Sara is uncomfortable with this situation but is counting on her year-end bonus.

Obviously, this needs to be addressed. This is a serious "no" that would be frowned upon by any state practice act, where we deliver treatment based not on that patient's needs but on something else.

Rob, a morbidly obese disabled veteran, arrived at an outpatient clinic requesting PT services. His doctor referred him to this clinic because of their great reputation. Mary, a PT, working in the gym saw Rob walking into the clinic. She called the front desk requesting they not assign her the patient. The patient was scheduled two days later for another PT. Ellen, a PTA who works with Mary, overheard the conversation requesting that the patient not be assigned to her. Ellen knows that Mary is a fitness fanatic and has heard her make derogatory comments about people who are overweight. Ellen feels very uncomfortable about this situation and wonders if she should do anything.

If there was a real reason for that person not to be on her caseload, that's one thing, but if it's because of bias or discrimination, that's a whole other issue that would need to be addressed. 

References

American Physical Therapy Association. (2020). Code of Ethics for the Physical Therapist. Accessed at https://www.apta.org/siteassets/pdfs/policies/codeofethicshods06-20-28-25.pdf

Balak, N., Broekman, M. L., & Mathiesen, T. (2020). Ethics in contemporary health care management and medical education. Journal of Evaluation in Clinical Practice, 26(3), 699-706.

Centers for Medicare and Medicaid Services. (n.d.). What is Medicare fraud and abuse? Retrieved from http://www.medicare.gov/navigation/help-andsupport/fraud - and - abuse/fraud - overview.aspx 

CHAPTER 461J. (n.d.). Physical Therapy Practice Act. Retrieved May 9, 2024, from https://www.capitol.hawaii.gov/hrscurrent/Vol10_Ch0436-0474/HRS0461J/HRS_0461J-.htm

Hawaii Administrative Rules Title 16 Department of Commerce and Consumer Affairs Chapter 110 Physical Therapy. (2024, May 9). Retrieved from https://cca.hawaii.gov/pvl/files/2013/08/HAR_110c.pdf

Chapter 436B Uniform Professional and Vocational Licensing Act. Retrieved May 9, 2024, from https://www.capitol.hawaii.gov/hrscurrent/Vol10_Ch0436-0474/HRS0436B/HRS_0436B-.htm

Hedman, M., Häggström, E., Mamhidir, A. G., & Pöder, U. (2019). Caring in nursing homes to promote autonomy and participation. Nursing ethics, 26(1), 280-292.

Jakobsen, R., Sellevold, G. S., Egede-Nissen, V., & Sørlie, V. (2019). Ethics and quality care in nursing homes: Relatives’ experiences. Nursing ethics, 26(3), 767-777

McArthur, A. R., & Gill, C. J. (2021). Building bridges: Integrating disability ethics into occupational therapy practice. The American Journal of Occupational Therapy, 75(4).

Rafique, R. M., Siddique, M. B., & Owais, F. (2022). A Study on the Perception and Implementation of Ethics in Clinical Practice. Pakistan Journal of Ethics, 2(2), 48-53.

Nicholson, J., & Kurucz, E. (2019). Relational leadership for sustainability: Building an ethical framework from the moral theory of ‘ethics of care’. Journal of Business Ethics, 156, 25-43.

Sellevold, G. S., Egede-Nissen, V., Jakobsen, R., & Sørlie, V. (2019). Quality dementia care: Prerequisites and relational ethics among multicultural healthcare providers. Nursing ethics, 26(2), 504-514.

Sohail, M., Ashraf, H. S., Zafar, L., Zafar, A., Zaheer, M., & Anwar, N. (2021, November). Knowledge, Interest and Perception of Academic Physiotherapists with Regard to Professional Ethics. In Med. Forum (Vol. 32, No. 11, p. 150).

VanderKaay, S., Letts, L., Jung, B., & Moll, S. E. (2020). Doing what’s right: A grounded theory of ethical decision-making in occupational therapy. Scandinavian Journal of Occupational Therapy, 27(2), 98-111.