2017 Student Ethics Essay Award—First Place Essay

Prognostic Statements, Client Success, and Clinical Caution

by Malayna Bailey, Marshall University

2017 Malayna BaileyDocumentation of the evaluation process is central to a speech language pathologist's (SLP's) scope of practice. As SLPs, it is our duty to document findings by tying together all that we have informally observed and formally tested. The American Speech-Language and Hearing Association (ASHA) Scope of Practice says it plainly, "SLPs document assessment results, including discharge planning" as well as "formulate impressions to develop a plan of treatment and recommendations" (ASHA, 2016, p. 12). In the midst of those formulated impressions and treatment plan rests the responsibility of the SLP to determine the prognosis of each client.

From the early days of speech-language pathology, it was well-known that prognostic conclusions were difficult to reach. According to Shames, (1952), "until the changes obtained between pre-therapy and post-therapy behavior can be measured…very little can be predicted about success" (p. 386). In other words, it is impossible to definitively determine prognosis prior to treatment. Herein rest the questions: How do we as SLPs ethically provide a statement of prognosis without also being able to predict the future success of our clients? What constitutes a "reasonable" statement of prognosis which includes all three components of evidence-based practice: scientific evidence, clinical experience, and client/patient/caregiver perspectives? How can we avoid crossing the line between an ethical prognostic conclusion and an irrational guarantee?

Imagine Claire, a second-year Communication Disorders graduate clinician. Thus far in her clinical experience, Claire has worked with young children with mild to moderate, even some severe speech impairments. All of these clients have had strong support from their families, typical cognitive abilities, and compliance in therapy sessions. Claire even had the opportunity to discharge one of her clients because he reached all his goals to produce age-appropriate speech sounds. Each of these past clients had very good or excellent prognoses due to the aforementioned positive contributing factors. Claire enjoyed being able to provide good news to her client's caregivers, and felt a sense of accomplishment by being able to "fix" the problems each child had initially arrived with. Every goal her clients accomplished seemed like a "check" off her "speech to-do list", further solidifying her decision to become an SLP.

Therefore, when Claire evaluated Caleb, a preschool child with a mild articulation impairment of the "K" and "G" phonemes, she was very confident in her ability from her past clinical experiences to "fix" his speech problem. She essentially promised Caleb's mother that he would be producing all age-appropriate sounds within a few weeks. What Claire had not foreseen, though, was that Caleb would have very poor attendance and the caregiver would not follow through with any of Claire's suggestions. She had completely glazed over the "caregiver perspectives" aspect of evidence-based practice, only focusing on her own experience and the available scientific evidence. Caleb's lack of progress reflected poorly upon Claire's credibility, and Caleb never returned to therapy.

In hindsight, Claire realized that she had guaranteed the success of her client before she had seen him in a single therapy session. She had no way of knowing that the child would miss several sessions and that his mother would be non-adherent. Claire initially thought that Caleb's mother would be very easy to work with. However, Claire soon realized that by guaranteeing a successful outcome, she was ignoring the numerous unforeseen factors that contribute to a child's therapy results.

During Claire's second year, she was given the clinical assignment to evaluate and treat John, an elderly man who recently experienced a cardiovascular accident (CVA). As soon as Claire saw the medical diagnosis, she knew that the prognosis for recovery was likely very poor based on scientific evidence. Throughout the evaluation, Claire observed that John had very little awareness and a lack of motivation. His family seemed uneducated and unsupportive.

When Claire wrote the evaluation report for John, Claire found herself submitting the following prognostic statement: "The prognosis for John is poor due to a lack of awareness, poor motivation and little family support. John will not be able to make any swallowing or communication gains due to the nature of his injury." This led to a recommendation of not attempting therapy with John.

In an effort to teach Claire the importance of an evidence-based prognostic statement, her supervisor read her the ASHA Code of Ethics, focusing on Principle 1, Rules of Ethics L: "Individuals may make a reasonable statement of prognosis, but they shall not guarantee—directly or by implication—the results of any treatment or procedure." Claire was also directed to the statement in ASHA's Preferred Practice Patterns which reads, "Interventions that enhance activity and participation through modification of contextual factors may be warranted even if the prognosis for improved body structure/function is limited" (ASHA, 2004, p. 24).

Claire remembered her pediatric client from the previous year for whom she had guaranteed a full recovery. After hearing the ASHA Code of Ethics again, she concluded that the statement applied not only to positive outcomes, but also to negative ones. With several months of therapy and client/caregiver education, her CVA patient eventually gained a successful mode of communication through the use of an alternative communication system—an outcome Claire never would have imagined.

As SLPs, many of us will meet clients like Claire's. Some will have the perfect patient profile—a mild impairment, typical cognitive functioning, good motivation, and seemingly strong family support. However, all of these factors do not always come together to deliver a positive outcome. Even if all prognostic indicators are positive and present, this does not guarantee client success. Likewise, poor prognostic indicators do not guarantee the failure of a client. Reasonable statements of prognosis should be evidence-based indicators of our confidence in our clients, taking into account all three components of evidence-based practice. Although we may have great confidence in our own experiences and our client's abilities, providing a guarantee is not helpful for patients, especially if they are unable to meet those expectations. Instead, we should heed the advice of ASHA documents such as the Scope of Practice, Code of Ethics, and Preferred Practice Patterns and hold our client's success to a high, but realistic standard. We should constantly be learning from our previous experiences while also considering scientific evidence and patient perspectives. This will allow us to provide our clients with the best possible care.

References

American Speech & Hearing Association. (2016). Code of ethics. [Ethics]. Retrieved from http://www.asha.org/Code-of-Ethics/.

American Speech-Language-Hearing Association. (2004). Preferred Practice Patterns for the Profession of Speech-Language Pathology [Preferred Practice Patterns]. Available from www.asha.org/policy/.

American Speech Language Hearing Association. (2016). Scope of  Practice in Speech Language Pathology [Scope of Practice]. Available from www.asha.org/policy/.

Shames, G. (1952). An investigation of prognosis and evaluation in speech therapy. The Journal of speech and hearing disorders, 17(4), 386-392.

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