Counseling Today, Ethics Update

End-of-life care for terminally ill clients

David Kaplan June 2, 2008

Editor’s note: American Counseling Association members received the 2005 ACA Code of Ethics bundled with the December 2005 issue of Counseling Today. Completed over a three-year period, this revision of the ethical code is the first in a decade and includes major updates in areas such as confidentiality, dual relationships, the use of technology in counseling, selecting interventions, record keeping, end-of-life issues and cultural sensitivity.

All ACA members are required to abide by the ACA Code of Ethics, and 21 state licensing boards use it as the basis for adjudicating complaints of ethical violations. As a service to members, Counseling Today is publishing a monthly column focusing on new aspects of the ACA Code of Ethics (the ethics code is also available online at www.counseling.org/ethics). ACA Chief Professional Officer David Kaplan conducted the following interview with Vilia Tarvydas and Christine Moll, two members of the ACA Ethical Code Revision Task Force.

David Kaplan: The 2005 revision of the ACA Code of Ethics breaks new ground in addressing the needs of the terminally ill and end-of-life care (see Standard A.9.).

Christine Moll: Palliative end-of-life care is a growing area for all human service practitioners, whether they are counselors, social workers or psychologists. Through the new standard on end-of-life care, ACA has become a pioneer in addressing the immediate needs of the terminally ill in our society. In addition, Standard A.9 was written to assist counselors for the next 10 years, and I think that this is truly visionary.

DK: Why did the Ethical Code Revision Task Force feel that it was important to address end-of-life care?

Vilia Tarvydas: The ACA Ethics Committee had been periodically receiving inquiries about end-of-life care. The number of inquiries grew with the implementation of the Oregon assisted suicide law and some prominent cases, such as the Terri Schiavo right-to-die case in Florida. It became obvious to us that our code was not giving sufficient guidance to counselors.

CM: We are affirming the right of a person to determine their level of care, and if that means talking with their doctor about hastening their death, then that’s where that person’s right of determination is. We recognize that this is as controversial for many counselors with particular religious values and morality stances as the issue of abortion. We are not taking a moral stance on this, and we are not promoting physician-assisted suicide. What we are promoting is an individual’s right to determine their own choice.

DK: Isn’t the new end-of-life care standard about more than physician-assisted suicide?

VT: Absolutely! It is really all about helping a client maximize their quality of life. The section is focused on helping terminally ill clients live with a decent quality of life until they die. It recognizes the terminal illness but focuses on the need to be alive until the moment of death, to make choices, get emotional support and meet holistic needs while the client is still alive.

CM: The new standard focuses on the end-of-life developmental stage that affects the client, their family, their legacy and their community of friends. It is about developing and implementing plans that will increase and enhance a client’s ability to make decisions and remain as independent and/or self-determining as possible.

VT: And the new ethical code standard makes it clear that professional counselors can play an important role in providing end-of-life care for terminally ill clients.

DK: The recent revision of the ACA Code of Ethics calls for confidentiality to be broken to protect a client from “serious and foreseeable harm” (see Standard B.2.a). Does the new standard speak to confidentiality with a terminally ill client who wishes to consider hastening his or her death?

CM: Standard A.9.c. states, “Counselors who provide services to terminally ill clients who are considering hastening their own deaths have the option of breaking or not breaking confidentiality, depending on applicable laws and the specific circumstances of the situation and after seeking consultation or supervision from appropriate professional and legal parties.”

So in and of itself, a statement from a terminally ill client that they want your help in thinking through the issue of hastening their death does not constitute serious and foreseeable harm and thus would not automatically call for the breaking of confidentiality.

DK: Can an ethical complaint be filed with ACA against the counselor for violating the edict to “do no harm” if the counselor agrees to assist a terminally ill client to explore the hastening of his or her own death?

VT: Standard A.9.b. states that “Recognizing the personal, moral and competence issues related to end-of-life decisions, counselors may choose to work or not work with terminally ill clients who wish to explore their end-of-life options. Counselors provide appropriate referral information to ensure that clients receive the necessary help.”

Because of this statement, counselors cannot be brought up on charges to the ACA Ethics Committee of doing harm by helping a terminally ill client explore end-of-life decisions. The other side is that counselors who feel that their own morality and personal views will not allow them to assist terminally ill clients who wish to explore end-of-life options cannot be brought up on charges for refusing to assist the client, as long as they provide appropriate referral information. (Editor’s note: Note that state laws that conflict with this response take precedence.)

DK: Does competence play into the decision about whether to provide end-of-life care to terminally ill clients?

VT: Yes. The provision of end-of-life care is a very specialized and complicated matter. It requires knowledge of holistic approaches — not just counseling interventions but also knowledge of medicine and the exploration of spirituality. There are very particular types of skills involved, and counselors who are in a general practice at times will need to consult with or refer to a variety of professionals.

CM: Competence in working with terminally ill clients means having the ability to integrate the clients’ physical, emotional, social, spiritual, cultural and family needs into a plan that helps them effectively work through this last developmental life stage.

DK: Let’s get back to the important aspirational aspect of Standard A.9., “End-of-Life Care for Terminally Ill Clients.” While we have been focusing on mandates, this standard actually has a preponderance of aspirational statements.

CM: This was not just written as a “nuts and bolts” standard. As I stated before, it is important to remember that we are working with clients on a developmental moment in their life that will affect how peacefully they die, what their legacy will be and the impact they have on their family and community of friends.

VT: Counselors are different than such professionals as clinical psychologists because, in addition to assisting the client with solving problems they may experience, we focus on assets and the growth and development that one can experience during the dying process. So the “Quality of Care” section of A.9. was written to make sure that we don’t get lost in the stampede to focus on the actual moment of death or the method of death, so we do not get bogged down purely in legal details.

The “Quality of Care” section focuses on making sure that we are attuned to helping clients obtain high-quality end-of-life care for their physical, emotional, social and spiritual needs, exercising the highest degree of self-determination possible, giving them every possible opportunity to engage in informed decision-making regarding their end-of-life care and receiving complete and adequate assessment regarding their ability to make competent, rational decisions on their own behalf from a mental health professional who is experienced in end-of-life care practice.

DK: Both of you, as well as the entire Ethical Code Revision Task Force, are to be congratulated for writing a very sensitive and helpful new standard that focuses on the best interests of a client with a terminal illness.

Next month: A new focus on cultural sensitivity

Letters to the editor: ct@counseling.org

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