Ethical concerns may arise about discharging clients from audiology and/or speech-language pathology services. Sometimes the audiologist or SLP believes that discharge is appropriate but the client or family disagrees. Similarly, the client or family may wish to terminate services when the audiologist or SLP believes that additional treatment would be beneficial. In other instances, organizational policy, funding limitations, or some other constraint may complicate the decision although all involved parties wish to continue services.
Discharge decisions are more easily reached and understood when the purpose and expected outcome for admission to treatment is agreed upon when a client is admitted for service. Typically, the audiologist or SLP and the client or family discuss together the goals of intervention and how they will be achieved. The discussion also would include how and when progress toward the goals will be assessed and evaluated, the possibility for changing the plan during the treatment process, and what follow-up will be provided. All of this information is documented in a written plan that is shared with the client or family.
Audiologists and SLPs also find it helpful to establish criteria for discharge within their own work settings. Specific criteria are more easily tailored to the role served by the program in the community. For example, a practice setting that focuses on evaluation may establish criteria for discharge that includes description of the communication disorder, development of suggested objectives for initial treatment, and the availability of a treatment provider in the client's community. For another work setting, the discharge criteria could focus on items such as achievement of established treatment goals; a change in the client's or family's priority needs for service; and a documented leveling off in change relative to the established objectives. In all cases, the discharge should consider functional communication competence as well as treatment data or test scores. The client's welfare and needs always provide guidance for decisions.
Among the more difficult decisions about discharge are those in which funding no longer is available and the audiologist or SLP believes that additional services are necessary. Some of these dilemmas may be avoided by understanding funding limitations prior to admission and establishing goals that realistically may be achieved in the time available. In other instances, the professional and family will need to work to find other funding sources or other service settings where qualified audiologists or SLPs may have greater flexibility in providing services.
Understanding any limitations ahead of time, financial or otherwise, also may assist the audiologist or SLP to plan a different type, intensity or frequency of intervention that could maximize client change within the funding available. Examples include a different schedule (e.g., two weeks of service, two weeks of home programming), different frequency and intensity (e.g., 30-minute sessions three times per week vs. twice weekly one-hour sessions), or type of treatment (group vs. individual).
Another particularly difficult decision about discharge occurs when the client or family discontinues treatment against the recommendation of the audiologist or SLP. Although the audiologist or SLP will recognize the importance of documenting the decision in the client's files, it is important that, where allowed by the employment setting, written communication about the decision is provided to the client or family. This should include any recommendations and, usually, an open invitation to discuss resumption of services in the future.
ASHA's Preferred Practice Patterns (rev., 1997) include information that is helpful in planning appropriate discharge. They outline expected outcomes for most assessment and treatment diagnostic categories. A review of outcome data for diagnostic categories by age ranges, severity, and treatment parameters also can assist the audiologist or SLP in establishing realistic timelines and goals for discharge. These data currently are being collected by SLPs in both health care and school settings through ASHA's National Outcomes Measurement System. Some employment settings also collect data of this nature.
Code of Ethics Provisions
The ASHA Code of Ethics (rev., 2003) provides guidance for decision-making about discharge. Principle of Ethics I states that it is our "responsibility to hold paramount the welfare of persons served." The Rules of Ethics for this Principle require that we "use every resource, including referral when appropriate, to ensure that high quality service is provided" (Principle of Ethics I, Rule B); that we "fully inform" the persons served about "the nature and possible effects of services rendered and products dispensed" (Principle of Ethics I, Rule F); and that we "evaluate the effectiveness of services rendered and products dispensed," and "provide services or dispense products only when benefit can reasonably be expected" (Principle of Ethics I, Rule G).
Principle of Ethics II also applies to decisions in discharge by requiring that individuals "engage in only those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience" (Principle of Ethics II, Rule B). This implies, among other things, that referrals to others are necessary when a client's needs can no longer be met by the managing audiologist or SLP.
In addition to referral, the Code also suggests some alternatives to discharge. Principle of Ethics I, Rules I and J, suggest that there may be times when judicious use of correspondence or telecommunication can be considered. Principle of Ethics II, Rules D and E address the appropriate delegation of services to others.
Although the decisions relative to client discharge may raise serious ethical questions for the audiologist or SLP, resources are available to help them resolve those dilemmas. Current Association position statements, guidelines, and practice documents should be consulted. For example, see the ASHA Technical Report on Admission Discharge Criteria in Speech-Language Pathology (2004) (members only).