A couple of months ago, I received a series of phone calls from a woman out East whose mother had suffered a stroke and was in a care center near here (Iowa).
When we discussed the fee during a subsequent call, the daughter complained that it was too high, and that it would not be financially feasible for her mother to have the frequent treatments she would need. I offered the senior discount, but she still thought it was too high. I explained the time it takes to do a treatment, plus the travel time I would need to go to the care center, which is 10 miles away. The daughter disagreed with my estimate of how long it would take me to drive there. She did agree that it might be better for her to seek the services of a more affordable practitioner who was just starting out and would probably like to help. I recommended a colleague who lives a few blocks away from the care center, and gave the woman her number. I then called the other acupuncturist and told her about the referral.
I heard from the daughter about three weeks later. She had not called the other acupuncturist and had forgotten about the referral. She requested that I see her mother but began objecting to my fee. I offered that the other practitioner would be more affordable. She then said that she would prefer to have her mother see me, as I was the more experienced practitioner. I agreed to go out on a Saturday morning, and we negotiated that the fee would be $60, rather than my usual $80. I estimated two-and-a-half hours from door to door for the first session, and let her know that this visit would take me the time that I would normally see two or three patients in the clinic.
When I got to the center, the mother was sitting in her wheelchair outside the room. I greeted her, pushed her in to the room and immediately noticed that she was completely unable to say anything other than "deebadeebadeeba." I was not surprised to see that she was hemiplegic on the right side. She was also wearing a wig. She had braces on her right wrist and her right ankle. Her pulses were large and slippery, her tongue covered with a thick yellow coating. She was unable to use her right arm at all, and the tissue was flaccid. The rehab assistant was unable to tell me anything about the woman's condition. The charge nurse was a fill-in and was also not familiar with the patient's history. The patient seemed to be oriented and alert, and seemed to understand what I was saying. At one time, she verbally said "yes." Another time, she said, "deebadeebadeeba" while nodding "no." It seemed to me that she was frustrated by not being able to communicate verbally. I was not able to make much more of a cognitive assessment.
I decided to explain the acupuncture procedure. I went through my usual explanation of what we would do and the sensations she would experience. She seemed uncomfortable with the idea of the needles, so I demonstrated, as I often do, by placing a needle in my own LI 11. I told her that it was painless. She agreed to let me demonstrate to her how painless it was by placing a needle in her LI 11. She agreed that it did not hurt. When I proposed that we go on with the treatment, she appeared frightened and uncomfortable. I asked if she felt that way, and she nodded as if to say yes. I decided at that point not to continue the treatment and returned to the office. I called the daughter and left a message about what had happened.
In this case, there were several complex situations and dynamics that I think put me in an ethically complicated position, not only with respect to this patient, but also in terms of myself and my practice:
- Speaking on the phone with the daughter several times, including long-distance phone calls, totaling about one hour of my time. It seemed that I was spending too much time for which I was not compensated, and had not even yet seen the patient.
- Accepting a patient for care who would need me to go to the care center at least weekly for a few months. I knew that being out of the office for that period of time meant that I would see fewer patients per week, and I would not earn enough from that client to make up for the loss of clinic income.
- Agreeing to significantly reduce my fee for the first visit, while also knowing that I would be spending more time than usual with the patient. Here, I put myself in a position of feeling I had not been fairly remunerated, and if the care continued, feeling resentful of the situation over the long haul.
- Agreeing to see the patient when the daughter was not present. Since the patient could not really answer questions, I was unable to do an intake beyond observation, pulse and tongue. When I first made the appointment, the daughter had planned to be there, but circumstances changed. With this patient, I was operating with limited diagnostic information, so I could not make a complete assessment or treatment plan.
- Agreeing to see a patient who would have to remove her wig, be undressed and transferred out of the wheelchair into the bed, all of which I felt uncomfortable doing. She obviously would need assistance with every step of the process. I was unsure about the liability regarding the care center and whether I would legally be put in jeopardy by assisting and transferring a patient in the care center. If she had fallen, I am not sure how the liability would have worked. I had not anticipated this when I agreed to see the woman.
- Attempting to treat a patient who could not give consent without the appropriate consenting person present. When I got back to the clinic, I was relieved that I had not tried to give a treatment. The client could not really give consent and appeared frightened, and I terminated the process. It would have been preferable to have the written and verbal consent of the person who could give it, as well as the clear agreement of the patient, in whatever form that it could be given. In the mental health field, I have heard this discussed, but I have never seen it mentioned in the Oriental medicine field so far. This situation is similar to one in which a child is treated, and consent is obtained from the parent. I felt, at the time, that I did not have the agreement of the patient to undergo treatment with acupuncture. I am not sure if this patient legally has consent over her affairs. I know that there is a power of attorney paying her bills. It seems that we should use the same ethical standard as would be used in the field of medicine for this type of case.
- Reporting to the daughter about the events that occurred at the visit. I did not have consent from the mother or the appropriate consenting person to discuss her situation with the daughter. However, I thought I had to let the daughter know what had ensued after I returned from the visit.
I was amazed to see how fast things went from my wanting to be helpful to finding myself in a tricky ethical position in so many ways. I might have even gotten myself into a dangerous liability situation. I remember the "old days," when I was younger and starting out in practice, wanting everyone to have an opportunity to experience acupuncture at an affordable rate. I charged very little, saw patients in my living room and adjoining study. At that time, I would never have thought twice about going out to see a patient outside the clinic, no matter how inconvenient it was for me.
The times have changed, and my awareness of ethics has changed. I realize that we do not really do people a favor by compromising our own standards. People for whom we go out on a limb seem to be less likely to improve from our ministrations, and we put ourselves in risky situations by doing these things.
If I had a practice that was based on going out to see people in their homes or other locations, it would be different for me. If I had a practice that was completely based on the "pay what you can" principle, it also would be different. If I were eager to build my practice and not very busy in the office; it would be different. I have no argument with practitioners who may choose to do practice in those kinds of ways.
But for me, with a busy office practice, it is against my own standards and outside my comfort range to do the things I was being asked to do. Therefore, if for no other reason, it would have been inappropriate for me to engage that patient in care on those terms.
It is interesting that despite all of the ethical arguments that could be brought to bear on this case, staying true to what I feel comfortable with is the best guideline for me. It is nice to see that the inner voice is still working and can be trusted so well. Now, if only I can remember that the next time a desperate person calls and asks me to go out of my way to help them.
Click here for previous articles by Laura Christensen, MA, LAc, MAc.