SKILLS & LEARNING
FREELANCE PRACTICE: MANAGING CANCER CARE CLIENTS Anne Wright Registered Dietitian, AM Dietetics
Anne has extensive experience in many areas of Dietetics including clinical roles in Australia and with the NHS, in Higher Education and now is a freelance practitioner with AM Dietetics.
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There is no doubt in my mind that freelance practice is a wonderful place to be for a dietitian. It comes with a long list of benefits such as variety, being able to manage your own appointment books, flexible working hours, strong and supportive freelance networks and being able to utilise a range of different practice models. Freelance does, however, come with special concerns and particular issues around which the registered dietitian needs to be mindful. Opening my daily emails brings a raft of different requests: weight management, women’s ‘issues’, IBS, allergies and intolerances, inflammatory conditions and more. Then, there it is: the cancer question arises. In my practice, I receive at least three emails a month from prospective clients or their relatives asking for help with a cancer diagnosis. The emails are usually asking for help ‘fighting the cancer’. My emails this month have included: “Hi, my Dad has been diagnosed with multiple myeloma; looking for a diet not to feed the cancer.” “I have stage 3 breast cancer and am going through my third chemo course. I would like some help with some meal plans, getting my energy back and fighting the cancer. I eat a raw diet.” “You are my last hope; my husband has a rare brain cancer and needs a ketogenic diet. Are you familiar with using cannabis oil therapy?” My heart sinks when I read emails like this. As a dietitian, I want to help. That’s what we do. There is nothing more rewarding that being able to help someone feel better, or to manage their condition with dietary changes. There is nothing better than seeing that your clients have gained from your support and guidance. Then there is the fact that, when it comes down to it, freelance practice is a business.
The temptation in freelance is to ‘take everything’. The temptation is to assume that your knowledge base is so broad that you can advise on any condition that comes your way. When dealing with freelance clients, paying clients, there is an emphasis on client choice. The issue of payment potentially adds to dilemma in practice. Questions arise for freelance dietitians such as, “Do I give them what they want?” and “If I say no, then where will the client end up getting their advice? Will it be safe?” So, what is the problem? The issue with taking on and assisting cancer care clients in freelance practice is around professional ethics and the very real issue of protecting yourself legally. In freelance practice, ethics are more important than ever. You are still bound by the HCPC standards of proficiency and, potentially, are at greater risk of exposure to unsafe practice allegations due to the single practitioner care model. Managing cancer care clients can put a practitioner at a risk due to the issues arising from the emotions and fears that may come with cancer care clients and their families. These include hope and desperation, unproven diet therapies being touted as miracle cures and the phases that come with the grieving process. To demonstrate context, many years ago, whilst working for the NHS, I witnessed a series of complaints against a well-meaning dietitian who offered to remove the enteral feeding equipment from the home of a gentleman who had recently passed away. The relatives saw
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SKILLS & LEARNING this as ‘too soon’ and as somewhat mercenary, so complaints ensued. The dietitian in question had just thought it to be a gesture of kindness. It is difficult to determine how families will react. The complaints were dealt with sensitively, aided by the support of a team. In freelance practice, there is generally no such team. So how do freelance dietitians combine accepting referrals to maintain an income, managing to practice within ethical and evidence based guidelines, keeping the client happy and working to the dietetics care model, whilst protecting themselves and the profession? TIPS FOR ACCEPTING CLIENTS
Communication and consent Self- referrals are acceptable in freelance practice. This is fine for many situations but is not advised for cancer care clients. In cases of a cancer diagnosis, before even accepting the client, it is necessary to contact the potential client’s GP and/or oncology team in order to confirm the diagnosis and treatment plan. This should be done with the consent of the client. It is also important to include contacting the local NHS service Dietetic team, if there has been some involvement, for a handover of care. During the course of the client’s care, he or she may be likely to spend some time as an inpatient. If this is the case, it is important to maintain communication with the dietitians in the NHS service and to work with mutual respect and goals of care. There may be miscommunications from the client or family, regarding treatment goals, which may lead to questions about your care. It is sensible, therefore, to ensure that your peers are in no doubt that you are practicing to standard. If, after establishing the diagnosis and details of care, a freelance dietitian does decide to accept a client for cancer care, then there must be written consent for treatment and for information sharing/confidentiality. Know your unproven diet theories for cancer care There are so many unproven dietary therapies for managing and ‘curing’ cancer. ‘Starving the cancer’ by ridding sugar from the diet, alkaline diets, Gerson therapy and ‘raw’ food diets, juicing, ketogenic diets, paleo and vegan diets are just a few. It is important to have a good knowledge of 50
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the current dietary therapies and those present on the internet and in the media and to be aware of the evidence around each of the same. When being asked to assist with an unproven dietary therapy, the freelance dietitian should be in a position to discuss the evidence, possible benefits and dangers of proceeding with such therapies. Be able to stand your ground and be involved in frank and honest discussions about what you can offer. Unproven therapies should not be commenced on recommendation by the dietitian. Maintain your knowledge base and work within the dietetic care process When accepting a client in the case of cancer care, the following points are important: • A current knowledge of the evidence base and up-to-date guidelines for cancer management is essential: NICE guidelines, oncology SIG documents, PEN evidence based practice points. • Maintain a robust CPD record. • Always use the dietetic care process. • Keep within the scope of practice. Take care in discussions around supplements and herbal therapies as these can be taken as tacit approval by clients. • Outcome measures - keep them realistic, manageable and measurable. Establish these with the client to ensure that there is a mutual understanding of the goals of care. • Use approved and evidence-based resources and give goals of care in writing. It is advisable to use permitted resources produced by other reputable organisations which are known to have accepted and evidence-based materials. Document, document, document The key to documentation is to leave absolutely no doubt that the client was continually assessed, monitored and treated by a competent dietitian. Documentation helps prove that the dietetic care process has been followed correctly, that the dietitian has justified their clinical decisions based on the evidence base, has worked within their scope of practice and has provided the expected standard of care to the client. Accurate and comprehensive documentation honours the ethical concepts on which best
practice is based and demonstrates the basis for professional and clinical decisions. This includes records or care and letters to the client’s GP and/or oncologist, outlining a summary of each consultation. It may even be useful to use a client/practitioner contract, which outlines care expectations, goals and treatments. Professional/peer supervision The most mentioned concern for freelance dietitians in clinical practice is usually the isolation that can come with the choice to ‘go it alone’. Professional supervision and establishing a mentoring relationship with another dietitian is advised. This is particularly important when faced with accepting cancer care clients. Clinical supervision allows the freelance dietitian to discuss currency, cases and ethical dilemmas and, when documented correctly, also works to provide further evidence of good practice if unsafe practice allegations are raised. On reading the HCPC disciplinary hearing summaries, I was alarmed to see that there had been discussions, in one case, around ‘the dietitian’s word’ vs ‘the client’s word’, despite documentation being maintained. Clinical and peer supervision is one way that a freelance dietitian can have the backing of the ‘team’ with additional and ‘cross-check’ documentation and, therefore, to not be left unsupported should cases be brought against them. Maintain your insurance and memberships Professional indemnity insurance provides cover for claims brought against the policyholder due to their professional negligence. By the end of this year, the government will introduce legislation which requires registrants to have professional indemnity insurance as a condition of their registration with the HCPC. Ensuring current membership with the BDA is crucial for dietitians in freelance practice, as this, along with other benefits, ensures that professional indemnity arrangements are in place. If a dietitian chooses not to maintain membership with the BDA, they must arrange their insurance independently and be able to declare currency of policy when renewing HCPC registration. It is important to note that, in the event of a claim, the onus is on the dietitian to demonstrate
that they have worked within the bounds of safe practice. Know your limits/know when to say no Even if a freelance dietitian has a reasonable amount of experience working in oncology and has all of the safe practice structures in place, it is important to consider whether or not accepting a cancer care client falls within their abilities, or, indeed, if accepting the client poses a professional risk. Of course, not all cancer care clients will come with the danger of unsafe practice allegations and ethical challenges, but, often, freelance Dietitians are seen as a ‘last port of call’ for clients after being through the public health services. Very often, therefore, these clients do come with potential agendas which cannot be met by the dietitian. Freelance dietitians, often generalist practitioners, can be in danger of using the ‘take everything’ approach. The freelance dietitian needs to know their limits and to know when to refer onto more specialist practitioners. Consideration needs to be made too, as to whether the client can best be supported within a team, rather than working with a dietitian in a single practitioner model. CONCLUSION
Managing a client who has cancer can be challenging, but also incredibly rewarding. There is no reason why dietitians in freelance practice should ‘shy away’ from accepting these clients, but they should be aware of the potential ethical issues that can come alongside. In most cases, following the dietetic care process and evidence-based guidelines can help these clients with their diagnosis and disease progression, as well as complications, side effects of treatment and the disease and changing physical capacity and quality of life. In some instances, the dietitian may accept a cancer care client who has chosen to go down the path of an unproven dietary therapy. This can be done with special care and support and, without endorsing the therapy, with an effort to protect the client by ensuring that an adequate diet is maintained and no harm is done. The most important thing is that both the client and the freelance dietitian should be protected. www.NHDmag.com August / September 2016 - Issue 117
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