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The Moral Dimensions of Functional Assessment

Over 20 years ago Gary Kielhofner DrPH wrote in "Functional Assessment: Toward a Dialectical View of Person – Environment Relations" (The American Journal of Occupational Therapy, March 1993, Volume 47, Number 3):

"Functional Assessment or the determination of what a person is capable of, sits at the politically loaded juncture between the individual and surrounding institutions. Along with a range of other evaluative procedures such as certification exams, driver tests, literacy evaluations, and court judgements, functional assessment is often used to determine what freedoms a person will and will not have, what roles he or she may take on, what activities he or she may do, and what benefits or resources he or she will receive. Moreover, functional capacity increasingly has legal and moral connotations"...

Link to functional competence

Gary Kielhofner goes on to say "That functional competence is intimately linked to moral worth. Judgments of functional capacity rank alongside evaluations of moral integrity in forming social opinion about the worth of particular persons."

Ability to function tied to society

"The ability to function in one’s daily occupations carries this tremendous social, moral, and legal weight because it is tied in essential ways to society. Functional ability in occupations is linked to success and perpetuation of social and cultural ways of life."

"In this context, the problem of functional assessment is not merely a problem of accuracy or efficiency. The issue is embedded in the distribution of power and shaped by the visions with which we identify problems experienced by our clients, which are of concern to the human collective."

So what about the Case of Work Assessment?

"Conventional wisdom and professional ideology suggest that to work is positive both for the individual, who gains economic, psychological, and social resources by working, and for society, which prefers taxpayers to consumers of tax-supported social assistance. In an ideal world, the good of the individual and the good of the social group converge. Decisions may be made in the best interest of both. However, the convergence of individual and social needs is often unclear, and outright antagonism sometimes exists."

So what about the instances when there are problems in the workplace?

"If these problems are indeed present in the workplace is it not reasonable that some persons would wish to escape a particular workplace or work altogether? Moreover, when a person is disabled or injured, the functional assessment problem is to determine whether he or she should return to work. Embedded in this question is a deep moral issue that must center on several complex problems. Can the person do the work? Does the person want to work? Is the work environment a place in which any reasonable person would have incentive to work? Is the work good for this person?"

Are issues present?

"Issues of environment, workplace conditions and incentives (or disincentives) are largely ignored. Rather we commonly assume that the problem resides in the individual. In fact, the worker who does not wish to work, or whose behavior suggests disincentive to work, is socially identified as malingering."

Thoughts on the words by Dr. Kielhofner

As I ponder these words by Dr. Kielhofner, how are we as clinicians determining work ability or functional capacity? I bring up the case example of John Doe. What about John's fears and worries about recovery from his injury and his ability to return to his job?

Do we focus on the physical injury and ignore the rest after all it is a back injury! Or do we identify the underlying fears and worries that are impacting his rehabilitation?

Whose job is it to determine the barriers and move John forward in rehabilitation... John, or the clinician who is the "expert in enabling occupation"?

Friday, March 13, 2015
Posted by Lorraine Mischuk at 11:18 AM 0 | Comments

Heath: Defining Health, Well-Being and Functional Capacity

It is understood that we need to be healthy to be able to work. So what does being healthy mean?

I first look to the trusty dictionaries as to how health is defined.

Dorland's Illustrated Medical Dictionary defines health as "a state of optimal physical, mental, and social well-being, and not merely the absence of disease and infirmity".

Next I turn to Wikipedia, which speaks to health as the general condition of a person's mind and body, usually meaning to be free from illness, injury or pain (as in "good health" or "healthy").[1] The World Health Organization (WHO) defined health in its broader sense in 1946 as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity."[2][3] Although this definition has been subject to controversy, in particular as lacking operational value and because of the problem created by use of the word "complete," it remains the most enduring.[4][5] Other definitions have been proposed, among which a recent definition that correlates health and personal satisfaction.[6][7] Classification systems such as the WHO Family of International Classifications, including the International Classification of Funding, Disability and Health (ICF) and the International Classification of Diseases (ICD), are commonly used to define and measure the components of health.

Patient / case scenario

So what happens in the case of John Doe? He is 45 years old and the primarily bread winner for his family of 3 young children, and his wife Sally is currently not working as their youngest child is 3 months of age. John was in a motor vehicle accident where he injured his back. He is not back at work where he works at the pork processing plant. He sees his family physician regularly, attends physiotherapy 3 times per week and does his daily home exercises. However he still has problems with standing and walking for any length of time, and lifting any significant amount of weight. The physiotherapist and physician try to reassure John that "it just takes time", however the case manager of the insurance company keeps asking him when he is going to be back at work.

Worry is introduced

John is getting worried because the case manager tells him that he should have been healed by now. He saw what happened to his neighbour Sam when he had a work injury last year. The insurance company "cut him off" when they thought he should have been better, yet Sam is still off work and seems to be doing worse.

John has not been sleeping well lately and finds it harder and harder to motivate himself to help out around the house. He keeps thinking that he will end up like Sam, unemployed with no hope of finding a job because "who is going to hire someone with a bad back who can't do their job?"

John also kept thinking about the CT scan and the specialist appointment, that this would be the answer. But the doctor told John that they could not find anything wrong with his back. John now worries even more "people don't believe him that he really has an injury, the doctors just can't find it".

Functional Capacity Evaluation

John Doe is referred by the case manager for a Functional Capacity Evaluation (FCE), where the question is can John go back to work at the pork processing plant. The medical documents that accompany the referral record his slow progress with physiotherapy, and reports of ongoing pain.

So now the Occupational Therapist (OT), who is the Expert in enabling occupation, is going to determine John's functional capacity and return to work ability.

I would think that these are pretty big shoes to fill! Yes, all of the typical testing will be completed, range of motion, strength testing, lifting, carrying, pushing/pulling, standing, walking, pain questionnaires. John keeps telling the OT during the FCE that his pain is getting worse, and that he does not want to overdo it, as he will then suffer for a few days. The OT says "yes I understand but you need to try as hard as you can, it is very important that the insurance company sees that you gave your full effort".

Fear is introduced

John also keeps thinking about the case manager who keeps telling him that it is his responsibility to fully participate in rehabilitation. His neighbour Sam was told by his case manager that he was not trying hard enough and now he has no money coming in.  But are John's perceptions accurate?  Or are his perceptions skewed and now they are effecting his ability to fully participate in rehabilitation?

So when I look at John Doe's scenario who sustained a physical injury and regarding the question of his functional capacity and return to work ability, what about that definition of health, where does this fit into the scenario? What about the "optimal physical, mental, and social well-being, and not merely the absence of disease and infirmity"? As the expert in enabling occupation do we address John's worries and concerns so that he can participate fully in the FCE or do we ignore them?

Continued... Functional Capacity Evaluation – a moral dimension

Thursday, May 01, 2014
Posted by Lorraine Mischuk at 3:17 PM 0 | Comments

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