Ethical Dilemmas for Nutrition and Dietetic Practitioners

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1 Ethical Dilemmas for Nutrition and Dietetic Practitioners Kathryn K Hamilton MA RDN CSO CDN FAND Catherine Gruenfelder MS RDN Patricia Gibbons, BS NDTR

2 Disclosures Kathryn Hamilton MA RDN CSO CDN FAND Board Member/Advisory Panel/Consultant Cancer Support Community American Cancer Society CDR and Academy Volunteer positions Commission on Dietetic Registration, Past Chair Quality Management Committee, member (CDR liaison) Employee Morristown Medical Center, Morristown, NJ Research Support No outside support

Goals and Objectives Discuss the Academy s Code of Ethics and Scope of Practice documents and their relationship to responsible dietetics practice.

3 Goals and Objectives Discuss the Academy s Code of Ethics and Scope of Practice documents and their relationship to responsible dietetics practice. Describe risks assumed by practitioners knowingly or unknowingly preforming an act or service outside the scope of practice. Describe strategies to reduce risk of liability, especially as RDNs and NDTRs assume increased responsibilities and enter new areas of practice.

4 Code of Ethics The Academy Code of Ethics Applies to the Following Practitioners: All members of the Academy who are credentialed (RDN or NDTR) All members of the Academy who are not credentialed All RDNs and NDTRs who are not members of the Academy. The fundamental principles of the Code of Ethics are: Dietetics practitioners conduct themselves with honesty, integrity and fairness. Dietetics practitioners support and promote high standards of professional practice (for the benefit of clients, the public, and the profession) by reporting perceived violations of the Code of Ethics. r/code-of-ethics

5 Scope of Practice for individual RDNs and NDTRs Scope of Practice document not on file in the state of New Jersey. Scope of practice document available through the Academy of Nutrition and Dietetics Quality Management department. Scope of practice in nutrition and dietetics encompasses the range of roles, activities and regulations within which nutrition and dietetics practitioners perform. For credentialed practitioners, scope of practice is typically established within the practice act and interpreted and controlled by the agency or board that regulates the practice of the profession in a given state. Quality Management statement

6 Statutory versus Individual Scopes of Practice Statutory Scope of Practice. Legal scopes of practice for the health care professions establish which professionals may provide which health care services, in which settings, and under which guidelines or parameters. With few exceptions, determining scopes of practice is a state-based activity. Individual Scope of Practice. Each nutrition and dietetics practitioner has an individual scope of practice that is determined by education, training, credentialing, and demonstrated and documented competence in practice. An individual's scope of practice in nutrition and dietetics has flexible boundaries to capture the breadth of the individual's professional practice. Individuals and organizations must ethically take responsibility for determining the competence of each individual to provide a specific service.

7 Professionally risky behaviors may include working beyond the scope of your training and credentialing. a significant change in practice area shortened or inadequate training; allowing your skills and knowledge to stagnate. taking a risky job (one that you are not qualified to preform or you do not have enough time or resources to do well). a lack of self-reflection by the practicing RDN or NDTR regarding competence in a new and different practice area inadequate assessment of competence by the RDN and NDTR s supervisor

Over- the-counter medications Outpatient setting

8 Scenarios in which ethical and legal dilemmas arise Inpatient setting Issue: Dietary Supplements and Over- the-counter medications Outpatient setting Issue: Weight Management Polling questions after a short skit

9 Dietary Supplement usage statistics Council for responsible Nutrition Consumer Survey on Dietary Supplements

10 Guidelines for recommendations Guidelines regarding the Recommendation and Sale of Dietary Supplements available to all practitioners. All patients/clients should receive a complete assessment of diet and dietary supplement use as a routine component of their nutrition status assessment

12 Polling Question Should the dietitian advise on the use and dosing of dietary supplements and over-thecounter medication? YES or NO

13 Key Practice Considerations Individual State (and Organizational) Scopes of Practice supersede the Academy s Scope of Practice. It is within the Academy Scope of Practice for RDNs and NDTRs to discuss and recommend use and dosage of dietary supplements. It is not within the Academy Scope of Practice for RDNs and NDTRs to recommend use and dosage of over-the-counter (OTC) and prescription medications. Recommendations for OTC medications should be discussed with the medical and nursing staff providing the patient s care. It is within the Academy s Scope of Practice for RDNs and NDTRs (under the supervision of an RDN)to identify and discuss interactions between dietary supplements and medications.

14 Ethical Issues Academy Code of Ethics RDNS are required to demonstrate competency in their areas of clinical practice. Recommendations for dietary supplements should be based on a thorough review of current scientific evidence and literature. All recommendations should be made in the patient/client s best interest and should be safe to use, including there being reasonable assurance of freedom from product toxicity as well as not causing harm with respect to ongoing disease states. The dietetics practitioner demonstrates respect for the values, rights, knowledge, and skills of colleagues and other professionals.

15 CDR Practice Competencies Sphere 10: Clinical Care Applies knowledge of the interrelationship and impact of pharmacotherapy, dietary supplements, functional and nutrients on health and disease in accordance with Scope of Practice and Standards of Professional Performance for RDNs Collects information related to the patient s use of pharmacotherapy and dietary supplements Applies knowledge of pharmacotherapy and its effect on nutrient absorption, utilization and metabolism when developing and/or revising the plan of care Evaluates, educates and counsels on the interrelationship and impact of pharmacotherapy on nutrient absorption Makes recommendations for the appropriate use of vitamin and mineral supplementation in the management of health and disease Adheres to legislation, regulations, standards and organization policies related to recommending, prescribing and dispensing vitamins and minerals, dietary supplements, functional foods and medical nutrition foods/products.

16 Operating within your Scope of Practice RDN is competent in making the recommendation regarding dietary supplements. Competency is documented and demonstrated. The Dietary Supplement recommendation is evidence-based. compliant with federal and state regulations. allowed by your employer or organization. performed within the Code of Ethics.

18 Polling Questions Should NDTRs or RDNs be allowed to recommend dietary supplements and medical nutrition supplements sold out of their office? Yes No

19 Polling Question Is it in the NDTRs scope of practice to be providing weight management Medical Nutrition Therapy? Yes No

20 Scope of Practice: Nutrition Care Process (2013 Scope of Practice document) RDN Role Nutrition Assessment Preform Nutrition Diagnosis Preform Nutrition Intervention Determine/recommend or initiate interventions (as per established or approved protocols); may assign to appropriate support staff (NDTR and others). Nutrition Monitoring and evaluation Monitoring: determine /approve; may assign to support staff. Evaluate: document outcomes of intervention reflecting input from all sources to recognize contribution from the nutrition care team. NDTR Role Nutrition Assessment Assist with or initiate data collection as directed by RDN and begin documenting elements for finalization by RDN. Nutrition Diagnosis Per RDN assigned task, communicate and provide input. Nutrition Intervention Implement/oversee standard operating procedures; assist with implementation of patient interventions and education as assigned by RDN. Nutrition Monitoring and evaluation Implement/oversee standard operating procedures, complete, document and report to the RDN and others the results and observations of assigned monitoring.

21 Key Considerations Practice within your Scope of Practice. Conduct the visit with honesty, integrity and fairness. Adhere to evidence-based practice; defensible in a court of law. Address true or perceived conflict of interest in dietary supplement recommendations and sales.

22 Ethical Consideration The dietetics practitioner, in dealing with and providing services to clients and others, complies with the same principles set forth in the Code of Ethics Responsibilities to the Public. Practice must be supported by evidence-based principles and current information. Practitioner must present reliable substantiated information.

23 Legal Considerations Professionally risky: false and misleading practices deceptive advertising of services not promoting specific goods not providing accurate and truthful information

24 Practice Applications Assume responsibility and accountability for professional competence in practice involving dietary supplements; identify current and applicable regulation or guidelines. Avoid directly recommending use or dosing of over the counter medications or prescription medications to clients; do not distribute samples of OTC or prescription medications. Document recommendations of all dietary supplements and suggestions to medical staff in the health records in hospital, clinic or private practice settings.

25 Practice Applications: sale of supplements Understand the legal issues related to sale of dietary supplements Provide full disclosure of any financial relationships with suppliers and manufacturers when recommending and selling supplements to clients When suggesting a brand or retail outlet for purchase of dietary supplements, be sure to offer several options to avoid the perception of conflict of interest

Scope of Practice information for RDNs and NDTRs in New Jersey http://www.

26 Scope of Practice information for RDNs and NDTRs in New Jersey /advocacy/quality-healthcare/consumer-protection-andlicensure/state-licensure-agencycontact-list Scope of Practice Decision Tool Small one time fee Can be used multiple times Available to members and non-members

27 Standards of Practice and Standards of Professional Performance SOP and SOPP are tools for credentialed nutrition and dietetics practitioners and describe competent levels of practice related to direct patient care. They serve as guides for self-evaluation and to determine the education and skills needed to advance an individual's level of practice. Although not regulations, the standards may be used by regulatory agencies to determine competency for credentialed nutrition and dietetics practitioners.

28 Case Studies and Practice Tips Case Studies Recommendations by RDN for Physical Activity Guidance Screening for Swallowing Difficulty by RDNs Initiating Orders for Nutrition-Related Laboratory Tests for RDNs Practicing in Hospital, Ambulatory and Private Practice Settings RDN to Write Independent Parenteral Nutrition (PN) /Enteral Nutrition (EN) Orders Practice Tips Practice Tips: Legal Implications of Scope of Practice Practice Tips: When to Cosign Practice Tips: NDTRs and Autonomy Practice Tips: What is Meant by "Under the Supervision of the RDN?" Practice Tips: RDN-NDTR Team Steps to Preserve Practice Tips: SOP-SOPP Highlights Practice Tips: DTR Scope of Practice Nutrition Care Process Practice Tips: Considerations for the 'Non-Registered' Status Individual Practicing in the Nutrition and Dietetics Field

Decision Process 1. Are you competent to make the nutrition recommendation? Competency is documented and demonstrated 2. Is the recommendation evidence-based? 3.

29 Decision Process 1. Are you competent to make the nutrition recommendation? Competency is documented and demonstrated 2. Is the recommendation evidence-based? 3. Are you operating within your scope of practice? Compliant with Federal and State regulations Allowed by Employer/Organization 4. Are you performing within the Code of Ethics? Acting without bias or conflict of interest Conducting oneself with honesty and integrity

30 Practice with confidence Find a mentor. Ask questions. Be confident and competent in your area of expertise. Be a responsible, honest practitioner. Stay current in your knowledge. Consider additional training or credentialing in your area of expertise.

31 Thank you to all of our wonderful actors!

32 QUESTIONS

Scenario RDN or RD with approximately 12 years of practice experience in clinical and community nutrition who is not presently practicing.

RDN or RD Not Presently Employed Learning Plan Scenario RDN or RD with approximately 12 years of practice experience in clinical and community nutrition who is not presently practicing. KH was employed