ETHICAL NEPHROLOGY SOCIAL WORK

PRACTICEAnita L. Dottes, LCSW

Dottes’ Seminars & Communications, LLC

Disclaimers• ‘Practice friendly’ vs. conceptual• Interactional vs. lecture format• Case examples – not intended to represent

actual persons/events

OBJECTIVES• Complete self-awareness inventory.• Differentiate between ethics & morals.• Review social work code of ethics & biomedical

ethical principles.• Discuss examples of ethical issues/dilemmas.• Provide a framework for decision making.

SELF-AWARENESS INVENTORY

Individualized assessment of ethical standards, behaviors & attitudes.

1. Why did you decide to become a helping professional? _____ desire to help others _____ role model _____ situational influence _____ other

2. What skills, character traits, etc. make you an effective social worker? 3. Think of 1 person you know and admire professionally. What traits do you respect & model?4. Can you be an ethical professional without being a moral person?

5. Do you have personal biases or feelings that have ever interfered with your ability to work with a client? If yes, how did you handle the situation?6. Do bias & prejudice negate one’s effectiveness as a professional? Why or why not?

7. What are the most frequent ethical dilemmas encountered in your practice? _____ client/patient centered _____ facility/employment centered _____ colleague centered _____ profession centered

8. If you observed a colleague behaving in an unethical manner, what would you do? _____ address the matter with your colleague _____ report the matter to a supervisor _____ talk to your colleague & report to a supervisor _____ do nothing ... you don’t want to become involved

9. If you became aware of unethical practices within your organization, what would you do? _____ discuss it with your immediate supervisor _____ follow organizational guidelines for reporting issues _____ do nothing, you are not willing to put your job at risk _____ report the matter anonymously to the news media

10. When was the last time you independently reviewed the swk code of ethics?_____ within the last year _____ within past 2-5 years

_____ > 5 years11. Reason for review?_____ school/research _____ guidance for issue/problem

12. In your opinion, does the availability of a life-sustaining treatment mandate it’s use?_____ yes/always _____ no/never _____ yes/in some casesDescribe your personal and/or professional life philosophy that supports your position. Is there a conflict between the two?13. In the case of life and death treatment decisions, who should should have the last word? _____ patient/family/surrogate decision maker _____ the courts/legal system _____ government _____ economic entities (insurance companies, based on cost/benefit)

14. If your colleagues and/or clients were to honor you with a special tribute, how would you like to be described?

MORALS, ETHICS & LAWpersonal group legal

WHY SOCIAL WORK ETHICS?• GUIDE CONDUCT• REDUCE MALPRACTICE & LIABILITY RISKS• BASIS FOR ADJUDICATION OF ETHICS COMPLAINTS• MECHANISM FOR PROFESSIONAL ACCOUNTABILITY

TYPES OF COMPLAINTS• MISTAKES WITH ETHICAL IMPLICATIONS

• ETHICAL DECISIONS WITH ARGUMENTS FOR & AGAINST

• MISCONDUCT

WHAT IS ETHICAL SOCIAL WORK PRACTICE?

• CONCEPTUAL DEFINITIONAdherence to ethical & professional guidelines• OPERATIONAL DEFINITION3 C’s: commitment to do the right thing consciousness/awareness of actions competence/ability

SOCIAL WORK CODE OF ETHICS, VALUES, PRINCIPLES, & ETHICAL RESPONSIBILITIES*

• VALUE: Service to othersPrinciple – help people in need & address social problems

• VALUE: Social justicePrinciple – challenge social injustice

• VALUE: Dignity of worth of the individualPrinciple – respect inherent dignity & worth of individuals; promote socially responsible self-determination

Approved by 1996 NASW Delegate Assembly * & revised by 2008 Delegate Assembly.**

• VALUE: Importance of human relationships Principle – recognize central importance of relationships

• VALUE: IntegrityPrinciple – behave in a trustworthy manner

• VALUE: CompetencePrinciple – practice in areas of competence develop & enhance skills

BIO-MEDICAL ETHICSPRINCIPLISM*

• AUTONOMY – individual’s right to self determination

• BENEFICENCE – to do good

• NON-MALEFICENCE – to do no harm

• JUSTICE - equitable distribution of resources *Tom Beauchamp & James Childress: Principles of Bio-Medical Ethics, 3rd Edition, NY: Oxford University Press, 1989

SOCIAL WORK VALUES & BIO-MEDICAL ETHICS

SERVICE TO OTHERS Bio-medical – BeneficenceSOCIAL JUSTICE Bio-medical - JusticeDIGNITY & WORTH OF INDIVIDUAL Bio-medical: AutonomyINTEGRITY & COMPETENCE Bio-medical: Non-maleficence

STANDARDS OF PRACTICE

NASW Code delineates standards which address ethical responsibilities to:• Clients • Colleagues• Practice Setting• Social Work profession• Society

CLIENT CENTERED ETHICAL RESPONSIBILITIES

• Commitment

• Self-determination

• Informed consent

• Cultural competence & social diversity**

COLLEAGUE CENTERED• RESPECT• Cultural competence & social diversity**• IMPAIRMENT OF COLLEAGUES

• UNETHICAL CONDUCT

PRACTICE SETTING CENTERED• COMMITMENT TO EMPLOYERS• COMPETENCE• ETHICAL CONDUCT

PROFESSION CENTERED POLICIES/PRACTICES

INDIVIDUAL CENTERED Personal & Professional Value Conflicts

CASE ILLUSTRATIONS

CASE A: client & colleague centered

• JOE SMITH a new family care coordinator with the organ recovery agency, approaches an AA family re: organ donation (their relative has been declared brain dead). He enters the room, and there are 5 people present: an elderly woman & man; 2 middle aged women & a man who appears to be in his 20’s. JOE introduces himself, alternately making contact with everyone, but directing his comments to the elderly woman.

The family seems reserved & some even appear hostile and angry. Joe is confused ...What factors/information might be the basis for Joe’s interactions with this family?Which client related ethical value/principle is Joe breaching? Explain.

cultural diversity self-determination informed consent

CASE B: multi-focus centered(patient, facility, colleague)

Linda Smith is a 24 y/o female with ESRD 2/2 HTN & DM. She initiated HD in an acute care hospital. In planning for out-pt. dialysis, staff advises Ms. Smith that PD is the best treatment option for her. She is scheduled for a peritoneal dialysis catheter, and not given the option of facility dialysis.The pt. tells you (swker) that she doesn’t want PD, doesn’t want “that catheter sticking out of me”. Rather, she wants to go to a dialysis unit near her home. However, she doesn’t feel comfortable going against the doctor’s recommendation”.

In your team meeting, you advise staff of the patient’s wishes. Additionally, because of her age & social issues, you don’t believe she is a good home candidate. However, you are advised by the medical director that “more young people are needed in the p.d. program; reimbursement is better for home treatment than for facility dialysis; the facility’s bottom line and your job, are dependent on maximizing reimbursement.”One member of your team remarks . . . “Where does she get off talking about what type of treatment she’d rather have? She’s never worked a day in her life. She should be thankful Medicaid is paying to keep her alive. These people want everything their way.”

What are the ethical issues here ...a. Client perspectiveb. Organization/facility perspectivec. Colleague perspectived. Personal/professional perspective

What would be your role as an ethical social worker? How would you help resolve the conflicts?

CASE C: client, facility, society

Mrs. S – 45 y/o female admitted with ESRD 2/2 HIV nephropathy. She was infected by her 2nd husband of 4 yrs. They have no children together, though Mrs. S has 2 children, ages 14 & 19 from a previous marriage.Pt. is critically ill . . . @ d/c she requires chronic dialysis & wound care for a stage 3 sacral decubitus. She & spouse refuse HH f/u @ d/c, citing confidentiality concerns re: AIDs dx. Pt’s children who live in the home are unaware of their mother’s dx.

Upon return to dialysis, daughter reveals to a RN, she is doing wound care & dressing changes on pt’s decubitus. Staff is concerned as daughter in her caretaker role is being exposed to pt’s bodily fluids . . .Pt. & spouse insist on confidentiality. The RN informs you, the social worker . . .

What are the ethical issues in this case from the perspective of … pt. & spouse; family, the facility?The conflict (s)?Your role in resolving this issue?

Case D: Practice Setting

• You are an employee of he local VAH, assigned to the suicide prevention program. Recent media reports about poor qualify care & veteran deaths 2/2 long wait times for appointments have resulted in increased scrutiny on your department.

• You recently took a crisis line call from a veteran who revealed he was the “at the end of my rope . . . I’m going to end it all for myself and my family.” You sense the urgency in his voice and believe admission is required. However, your in-patient unit is full. believe

• You go to your administrator, explain the situation, and recommend that an exception be made for admission. However, you are told the department has already exceeded the month’s quota for admission. Another admit would imply that the dept’s CI counseling service is not effective.

• You are told not to document the veteran’s suicidal & homicidal ideations in your noted. Rather to indicate that his request was for counseling 2/2 a domestic situation.

Facts to consider:1. You are a new social worker (on the job for < 1 year). You

have no clout. Your supervisor has instructed you how to handle the situation.

2. You know its wrong, but . . .

YOUR ETHICAL DILEMMA IS . . .a. Client centeredb. Colleague centeredc. Practice setting centeredd. Individual/professional value centerede. All of the above

WHAT WOULD YOU DO??? How would you resolve this issue?• WHAT ARE THE RISKS IF YOU DO NOTHING?• WHAT ARE THE RISKS IF YOU DO WHAT YOU BELIEVE IS

RIGHT, AND TAKE THE MATTER TO THE NEXT LEVEL?

A pre-requisite for going to the next level . . . COURAGE

“ COURAGE IS BEING SCARED TO DEATH AND SADDLING UP ANYWAY”. John Wayne

CASE E: Colleague centered

You’re out to dinner with family, when you notice loud laughter. You look back and see your Mary, your colleague and a patient . . . They both appear to have alcoholic beverages and they are holding hands. The patient has been on dialysis for 6 months. Initially (1st 2 months) he demonstrated major coping issues . . . Missed dialysis, was hostile to staff, had excessive IWGs. Now, he comes in happy, brings the staff snacks. Maybe Mary is the reason . . .

• What is/are the ethical issue(s) here?• What should you do?

MODEL/PROTOCOL FOR DEALING WITH DILEMMAS:

1. Establish guidelines for identifying & reporting.2. Determine whether harm has occurred or will occur.3. Develop & implement a plan to resolve issues, including

maintaining a safe place for colleagues to share their concerns.

SUMMARY/CONCLUSIONS

1. ETHICAL social work practice requires knowledge of, and adherence to the social work code of ethics. Incorporate the 3 C’s into your practice – COMMITMENT, CONSISTENCY, COMPETENCE.

2. ETHICAL social work practice often requires COURAGE to do what is right. Saying no or yes can result in professional risks, depending on the situation.

3. Some of the most challenging conflicts & dilemmas are practice setting & colleague centered.

4. THEORECTICALLY, RESOLUTION OF CLIENT CENTERED CONFLICTS IS SIMPLE . . . Practice the golden rule & treat others as you would want to be treated.

IMAGINE . . .Yourself ON THE OTHER SIDE OF THE DESK

ETHICAL SOCIAL WORK PRACTICE EXPECTATIONS RESPONSIBILITIESFRUSTRATIONS

BEING A SOCIAL WORKER MEANS . . .