Discontinuing Occupational Therapy Services

BACKGROUND

Kendra, an occupational therapist (OT), receives a referral from an employer to assess Rafael’s ability to return to work. While at work, Rafael suffered a slip and fall accident. Rafael is a worksite manager whose duties include: sitting at a desk to complete administrative tasks, walking to the warehouse for quality control checks, and lifting light equipment.

After working with Rafael on activity modification and upper extremity strengthening for approximately three months, Kendra confirms Rafael has achieved his occupational therapy goals. She recommends he start returning to work on a gradual basis with modified hours and adaptive equipment. Rafael disagrees with Kendra’s professional opinion. He says it’s too soon to return to work, raises his voice during occupational therapy sessions and accuses Kendra of siding with his employer.

Over the next few weeks, Rafael misses several sessions with Kendra, which were intended to support his return to work and finalize discharge arrangements. She attempts to contact him by phone on multiple occasions and is not successful. Kendra wonders if she should discharge Rafael based on his poor attendance and the deterioration of the client-therapist relationship. Kendra also knows Rafael’s employer is expecting a progress report. Kendra does not want to abandon Rafael, however, when he misses his sessions without any notification, other clients on the waitlist are negatively impacted. Kendra wonders if she should discontinue her occupational therapy services.

CONSIDERATIONS

  • Kendra considers arranging a meeting with Rafael to identify concerns and offer solutions
  • Kendra wonders if Rafael understands the implications of not attending his occupational therapy sessions and if she has an obligation to continue to treat him.
  • Kendra examines her organization’s policies and procedures that relate to discharging clients. She attempts to contact Rafael again by phone, leaves a voice mail, and sends him a letter outlining a timeframe for him to contact the clinic, beyond which his file will be closed and he will be discharged.
  • Kendra reviewed the applicable College documents:
    • Guide to Discontinuation of Service
    • Ontario Regulation 95/07: Professional Misconduct
    • Standards for Record Keeping.
  • After reviewing section 7 of the Professional Misconduct Regulation, Kendra understands it can be considered professional misconduct to discontinue services “…that are needed unless the discontinuation would reasonably be regarded by members as appropriate having regard to:
    • the member’s reasons for discontinuing the services,
    • the condition of the client,
    • the availability of alternate services, and
    • the opportunity given to the client to arrange alternate services before the discontinuation.”

OUTCOME 

  • Kendra reflects on her reasons for discontinuing occupational therapy services based on the Professional Misconduct Regulation:
    • Rafael is no longer participating in the occupational therapy sessions. Kendra knows the refusal to proceed with the remaining occupational therapy sessions is not grounds alone for discontinuation and she must make reasonable attempts to understand or clarify the client’s reasons for declining to proceed.
    • Rafael has met his occupational therapy goals. The final sessions are to support gradual return to work.
    • Kendra is planning to discuss the implications of not proceeding with the remaining sessions and discuss options. 
  • Rafael receives the letter and contacts the clinic to inform Kendra he is not ready to return to work and is seeking legal advice to explore his options. He asks Kendra for a copy of his clinical record. 
  • Kendra asks Rafael if he would like to proceed with the remaining sessions to support his return to work and if he does not wish to continue, he will be discharged from occupational therapy services. She discusses the risks and implications associated with discontinuing service including her need to report his lack of participation to the employer. She explains that he can resume his occupational therapy sessions once he is ready, however there is a possibility he will be placed on a waitlist. 
  • Rafael states that he prefers to close his file and be discharged from occupational therapy services. He tells Kendra he will contact her if he decides to return to the clinic.
  • Kendra carefully documents all communications with Rafael including her discharge note, which includes: client status, reason for discharge, when the occupational therapy service was initiated, summary of outcomes, discharge recommendations, and date of discharge.

DISCUSSION

Unexpected discontinuation of services can be complex and sometimes challenging. OTs should use their clinical judgement to consider the level of risk for the occupational therapy service that is provided and the potential implications of discontinuing service. OTs should attempt to contact clients verbally and/or in writing to discuss any concerns relating to the provision of service. If services must be discontinued, the client should be given as much notice as possible. OTs should use the client record to document all conversations and decisions related to discontinuing services. If a client chooses to end occupational services abruptly, OTs, if given the opportunity, should discuss the risks involved with that decision and provide suggestions for alternative or follow-up care.   

REFERENCES

CONTACT

If you have any questions about this case, or have any ideas or requests for future cases, contact the Practice Resource Service: 1.800.890.6570/416.214.1177x240 or practice@coto.org

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