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PROMOTING QUALITY PRACTICE
Discontinuation of Service
College of Occupational Therapists of Ontario
November 1998
Practice Scenarios:
1. I have had a contractual employment relationship with a rehab company, in which I am the only OT employed by the agency. My contract has been terminated abruptly and many of my clients continue to require OT intervention. Is it my responsibility to arrange for alternative services?
2. I have completed an assessment with my client and proposed a treatment plan. My client has indicated he is not in agreement with the plan and will not give consent for me to continue. As he is not wanting to proceed any further, I am planning to discharge him. Is that appropriate?
3. I have been working with a client for over a year on the same treatment goal to establish increased independence. I have made many recommendations which my client has not followed through with, despite my efforts to identify the potential risks and benefits of doing so. She is not progressing and therefore I have informed her that I plan to discharge unless she follows through with the treatment plan. Is that okay?
4. I was asked to "assess and treat" a client for one specific problem. In the course of completing this request, I have become aware of several other problems which could be resolved through OT intervention. The funding agency does not feel it is necessary for me to continue but I have indicated that I cannot discharge knowing that my client is in need of further service. Am I right?
Probing Questions
1. How do Sections 6. and 7. of the Professional Misconduct Regulation apply in these situations?
2. Is a client's refusal to proceed with treatment considered a request for discontinuation?
3. What are considered 'reasonable expectations' for clients to achieve set goals?
4. Who is responsible for arranging alternative services for clients when an employment contract is terminated?
Response
Discontinuation of service is an inevitable conclusion of all client-therapist relationships and therefore must be considered at the outset of the service agreement. A complete intervention process includes determining when the task will be complete. The decision to discontinue service is directly linked to a clear and complete understanding of the initial request for service, the expected outcomes and the plan to achieve these goals. Preparing for discharge therefore begins with the referral and is an ongoing consideration throughout the intervention process.
The Professional Misconduct Regulation identifies the parameters required for appropriate discontinuation of professional services under section 6. and 7. The Regulation states:
1. The following are acts of professional
misconduct for the purposes of clause 51(1) (c) of the Health Professions Procedural Code:
6. Discontinuing professional services that are needed unless,
i. the client requests the discontinuation,
ii. alternative services are arranged,
iii. the client is given a reasonable opportunity to arrange alternative services,
iv. services to the client have been discontinued without consultation with the member,
v. the client can no longer meet agreed-upon terms of payment, and all reasonable attempts on the part of the member to facilitate such payment have been unsuccessful,
vi. the client has been given reasonable opportunity to achieve set client goals, or
vii. the facility providing services has exhausted the resources allocated to those services.
7. Discontinuing professional services contrary to the terms of an agreement between the member and
a contracting agency or a hospital within the meaning of the Public Hospitals Act without reasonable cause.
As with most regulations, the criteria above leaves room for interpretation, and in the actual practice setting it is not always clear how these rules apply. There are some general practices which the therapist will find helpful to keep in mind when considering their responsibilities with regard to discontinuation of service.
* It is recommended that the therapist thoroughly negotiate with all involved clients, the terms of the request for service; being mindful of the implications for discharge. The therapist should clarify the scope of the referral, the expected outcomes, the process for assessment and if indicated, treatment. These factors should be discussed with the primary clinical client, the referral source and any other secondary clients involved (e.g., client's legal representative, family member) to ensure everyone's expectations are clear and agreed upon, before the process begins.
* Within the Standards of Practice there is a requirement for managing professional practice, applying a systematic approach and utilizing a communication process (Standard 2, 3 and 4). Application of each of these standards will help to ensure the above process is followed.
* It is important to recognize that conflicts, unexpected barriers or a change in events may interfere with the original intervention plan. It is recommended that when these situations do arise the therapist must carefully consider the issues and choose a course of action based on a process of evaluation. Further discussion, negotiation or clarification with the appropriate stakeholders is advisable before action is taken.
* It is not uncommon to be in a situation where discontinuation of service occurs before all of the client's needs are fully met, or the therapist's recommendations are completely carried out. This may be appropriate in certain circumstances, however, it is recommended in all cases that the status of goals and recommendations at the time of discharge be documented and include any available options for follow-up.
Response to Scenarios
1. It is not necessarily the OT's responsibility
to arrange for alternative services in this situation. Ideally,
the termination process and responsibilities of the employee
and employer were determined when the employment contract was
first negotiated. Regardless of when the discussion occurs, however,
the primary concern in this scenario is that all of the therapist's
clients need to be informed of the change in service provision,
and provided with information about opportunities for alternative
service (i.e. plan for a replacement or alternative resources).
Although it may be the employer who does this, the therapist
has an obligation to ensure that the employer is aware of the
client's right to information. In some situations, where the
relationship is not amenable to open discussion, the therapist
may need to communicate these expectations in writing to the
employer. It is expected that the therapist will take all reasonable
steps to ensure that the clients are advised of the options available
to them.
In addition to providing notice to the clients, it is important
that the client records be maintained appropriately (e.g. securely
and for the required time) and that access to these records be
granted to the appropriate individuals. The therapist has an
obligation to ensure the employer is aware of and will meet these
requirements. The therapist may need to take further action if
he/she does not have the confidence that the employer will follow
through with this responsibilty.
In some cases there may be clients who want to continue to receive service from the original therapist. The therapist may be in a position to accommodate this request, providing it is not contrary to a previous contractual agreement and is done in an open and transparent manner. The therapist may not solicit business from any of these individuals and, if they request service, the therapist should ensure these clients are also aware of any alternative options.
2. It is not appropriate for the OT to assume that refusal to proceed with an intervention is grounds for discharge. The client's refusal to proceed is actually a withdrawal of consent and should be dealt with accordingly. It is apparent in this scenario that the client remains in need of services as identified in the assessment. Rather than moving into discharge planning, the therapist may need to ensure the client is capable of making an informed decision to withdraw consent. If it is clear that the client has the capacity to withdraw consent then the therapist must explore other factors. The refusal to proceed may be due to any one of a number of reasons (e.g., personal conflict, discomfort with the type of intervention, disagreement with the goals). It is necessary for the OT to gain some further understanding of the problem and manage the situation accordingly. The client must be provided with information about other options or alternatives prior to a decision to discontinue. If the client is not deemed capable of withdrawing consent, then the therapist should be discussing the treatment plan and gaining consent from a substitute decision maker.
3. As stated in the Professional Misconduct Regulation, discontinuation of professional services is acceptable when the client has been given reasonable opportunity to achieve set goals. The issue is, what is considered 'reasonable'? The term reasonable would suggest that the therapist has discussed the issue with the client and has provided clear options, expectations and sufficient time to complete the goals. This scenario provides a good example of why it is important to discuss and agree upon the treatment goals and the plan prior to engaging in the process. Each client-therapist relationship should be treated as a contractual agreement from the beginning.
4. This scenario also highlights the importance of clarifying the scope of the request and proposed intervention initially. Consideration of issues related to scope should occur at the point of screening the referral and may need to continue throughout the assessment and intervention phase. As part of the contractual agreement to proceed with a referral, all the players need to be clear about the service to be provided. Clients should understand the limits of the request and referral sources need to be aware of the extent of the intervention. It is not uncommon for a therapist to become aware of additional problems or intervention needs through the course of assessing and treating a client for a specific request. This situation is more easily handled if it has been anticipated and discussed ahead of time. Should the therapist be in the position of identifying further needs, the therapist must communicate these observations to the client, document them in the record and, with consent, share them with the referral source or any other appropriate person. The therapist may also choose to identify options for the client or others to follow up on. It is not expected that the therapist will address anything which is beyond the previously agreed upon scope of the original request.
Your response to this practice scenario
is appreciated. Please contact Susan James, Director of Professional
Practice, with your comments or questions:
Susan James
(416) 214-1177 or 1-800-890-6570
ext. 233
sjames@coto.org
Resources:
- College - Guiding Principles of Practice - Section 6 Transparency, 1998
- College Standards of Practice, 1996
- College Code of Ethics, 1996
- College - A Guide to the Health Care Consent and Substitute Decisions Legislation for Occupational Therapists, 1996
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