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Terminated for declining Chemo Patient
Hello all,
I'm new to this forum but thought that I could get some unbiased points of view on the situation I am currently going through.
I was recently terminated from my job (a chain massage "clinic") because I refused to work on a client who is currently undergoing chemo therapy. This client did have a very generic doctor's note in is file stating "may recieve massage therapy", I do not know if it was from his oncologist or his general practitioner. I AM NOT TRAINED IN ANY SORT OF ONCOLOGY MASSAGE, having said that, I declined to work on the client. At the end of my shift that day I was suspended because I refused to work on this client and subsequently fired.
I am not sure that oncology certification is a requirement the way prenatal massage certification is required to work on a client that is pregnant. I'm appalled, I really feel that I made the ethically correct decision not just for me but for the well being of the client.
Any advice, opinions, points of view are greatly appreciated!
Thanks.
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Replies to This Discussion
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Permalink Reply by Susan G. Salvo on
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During student clinic, an instructor is always available to assist students in situations in which they are unfamiliar/uncomfortable.
Is it possible that therapists working in massage chains have the same type of support?
And how can students/therapists learn to work on clients with tennis elbow, who are paraplegics, or who are hearing impaired (just fill any condition here, they are just examples) if they refuse to treat?
George, I agree with you concerning the right of refusal issue (and thanks for the clarification – but the teacher in me often treats these discussions like case studies, so I frequently pull different elements into the equations to encourage high level thinking rather than state my opinion).
George Lee, LMBT said:Unfortunately, you are missing something. Vanessa's refusal was a focus on the client by not proceeding into an area with which she was unfamiliar and potentially creating harm. It wasn't because she was afraid of touching a cancer patient. She refused not to protect herself, but the client. Harming the client is not to the client's best interest, no matter how well intended.
We at the Society for Oncology Massage have written into our standards of practice the right of refusal. It is common for a cancer client to request some technique or application of massage that may not be good for them. It is our responsibility as professionals to recognize these conditions and keep the client's best interest at heart. It is also our responsibility to educate ourselves to be able to understand what these conditions are and if we are not certain that what we may do is safe, then to error on the side of caution and not do them. First do no harm. The client trust in you as a professional not to harm them. This does not mean we cannot benefit the client in other ways and still provide a positive and rewarding massage experience.
When a physician writes a referral vs. a prescription, he is depending on the professional referree to use their skilled judgement on determining the proper course of treatment for the patient including the right to decline treatment if it is potentially harmful to the patient. If an oncologist refers a patient to a surgeon for a procedure and the surgeon says it would be unsafe or cause harm, the oncologist accepts that.
d. Right of Refusal. The practitioner shall decline to use any massage
technique that the practitioner judges may be detrimental to either client or
practitioner.
In another response you mentioned that the intake form, history and physical, etc. should reveal any problems. That is correct. But, does the average therapist know how to deal with the special information that a cancer patient may reveal? I believe the answer is no. Consider the disparate standards for massage across the nation, as your own work with MTBOK is trying to address. In many schools students are taught to completely stay away from cancer patients and if this was Vanessa's case, having her work on a cancer patient was going against her training.
Though I have some personal feelings on the matter, the legal issues of her situation will be completely dependent on Vanessa's location, training, etc.
George Lee, VP Society for Oncology Massage
Susan G. Salvo said:If we continue to address Vanessa’s topic, there needs to be some mention or focus on the client.
It was also her (the client’s) massage, her desire to feel better, and her time too.
Has anyone put themselves into the client’s shoes?
Jenifer moved into that direction, but it got lost in our “therapist rights” agenda.
My understanding is that the therapeutic relationship serves the client.
Am I missing something??? -
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Permalink Reply by George Lee, LMBT on
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Susan, I think that would be ideal. As a matter of fact the next point in our standard of practice is...
e. Consultation. If the practitioner encounters an unfamiliar condition that cannot
be adequately evaluated through research, the practitioner shall consult with a
knowledgeable professional to determine the best course of action.
If there were a trained therapist available to advise, guide, direct, etc. it would be a great educational moment. There's nothing like OJT (On the Job Training). Perhaps a "master therapist" as it were for each organization? But, are spas going to do that? As you alluded to, this is a multifacted issue. Where does "spa work" end and theraputic work begin? Of course we all know it overlaps. How to we get "spas" or massage centers to recognize conditions outside "normal", and I use that word very loosely, and address it safely and adequately rather than focus on maximizing the numbers of clients? I feel the "spa" industry needs to address this and sooner or later they will, because they are dancing on the edge and eventually someone is going to get hurt. Then, they will be spoken to in the language they know best, money.
As far as refusing or declining, it doesn't always have to be total. It can be restricted to a specific area or method. For example not working an area deeply, but applying less invasive techniques that can still provide comfort and relief. I also belive in finding your own way, but we must respect when that experimentation may be detrimental to your client. Know your abilities, know yourself.
George
Susan G. Salvo said:During student clinic, an instructor is always available to assist students in situations in which they are unfamiliar/uncomfortable.
Is it possible that therapists working in massage chains have the same type of support?
But how can students/therapists learn to work on clients with tennis elbow, who are paraplegics, or who are hearing impaired (just fill any condition here, they are just examples) if they refuse to treat?
George, I agree with you concerning the right of refusal issue (and thanks for the clarification – but the teacher in me often treats these discussions like case studies, so I frequently pull different elements into the equations to encourage high level thinking rather than state my opinion).
George Lee, LMBT said:Unfortunately, you are missing something. Vanessa's refusal was a focus on the client by not proceeding into an area with which she was unfamiliar and potentially creating harm. It wasn't because she was afraid of touching a cancer patient. She refused not to protect herself, but the client. Harming the client is not to the client's best interest, no matter how well intended.
We at the Society for Oncology Massage have written into our standards of practice the right of refusal. It is common for a cancer client to request some technique or application of massage that may not be good for them. It is our responsibility as professionals to recognize these conditions and keep the client's best interest at heart. It is also our responsibility to educate ourselves to be able to understand what these conditions are and if we are not certain that what we may do is safe, then to error on the side of caution and not do them. First do no harm. The client trust in you as a professional not to harm them. This does not mean we cannot benefit the client in other ways and still provide a positive and rewarding massage experience.
When a physician writes a referral vs. a prescription, he is depending on the professional referree to use their skilled judgement on determining the proper course of treatment for the patient including the right to decline treatment if it is potentially harmful to the patient. If an oncologist refers a patient to a surgeon for a procedure and the surgeon says it would be unsafe or cause harm, the oncologist accepts that.
d. Right of Refusal. The practitioner shall decline to use any massage
technique that the practitioner judges may be detrimental to either client or
practitioner.
In another response you mentioned that the intake form, history and physical, etc. should reveal any problems. That is correct. But, does the average therapist know how to deal with the special information that a cancer patient may reveal? I believe the answer is no. Consider the disparate standards for massage across the nation, as your own work with MTBOK is trying to address. In many schools students are taught to completely stay away from cancer patients and if this was Vanessa's case, having her work on a cancer patient was going against her training.
Though I have some personal feelings on the matter, the legal issues of her situation will be completely dependent on Vanessa's location, training, etc.
George Lee, VP Society for Oncology Massage
Susan G. Salvo said:If we continue to address Vanessa’s topic, there needs to be some mention or focus on the client.
It was also her (the client’s) massage, her desire to feel better, and her time too.
Has anyone put themselves into the client’s shoes?
Jenifer moved into that direction, but it got lost in our “therapist rights” agenda.
My understanding is that the therapeutic relationship serves the client.
Am I missing something??? -
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Permalink Reply by Paul Lewis, RMT, NCBTMB,MFHT on
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Hello Vanessa, and thanks for sharing your story. I have read a few of the responses, not all and many good points have been brought up. I would like to comment on a few things if I may.
First of all I must say good on you for knowing your limitations and not pretending, or trying to get on the job practical experience and putting at risk your client and yourself. I don't know if you spoke to the client, viewed their health history form or if you just refused to work on the client because you are not familiar with treating cancer patients. In this case one suggestion would have been to talk to the client to understand the scope of treatment they seek and mention to them that you are not comfortable and refer them to another therapist.
This actions would not only convey to the client that you are willing to to see them, but current treatment procedures is out of your scope and comfort level. I think the client would have been accepting of this. Communication is a very important component of the client-therapist relationship. It sounds like you just refused to see them from your comments.
Food for thought..
I treat and have treated a variety of client from Hip replacements, Spinal chord injury, GBS, Implants, TRAM(Transverse Rectus Abdominal Muscle flap), High risk pregnancy, adhesive Capsulitis, Compartment syndrome etc.. and each client will experience and respond to their surgery differently.
Although, I may see 7 cancer patients over the month, there is not a set formula as to how to treat the "Oncology" client. Each of their presenting symptoms and request for treatment will differ. For example the treatment request of a person that had a malignant tumor removed from their back compared to a single mastectomy with 40 nodes removed or double mastectomy with only one node removed will be different although each may undergo chemotherapy. I have had client that weeks earlier had a hip replacement but what they are looking for is treatment for TMJ or TOS. You never know what the person is looking for unless you or the receptionist talks to the client first. Another point I am making here is that even though I have had training in one area or another, I don't automatically, and never assume that I can treat the person just because what the client is presenting with may be under the umbrella of what I have learned. Don't be afraid to refer if it is not in your scope of practice. I have a health history form that I use in conjunction with other specific forms when gathering health information. If you would like a copy let me know.
I also think going forward you should convey to your employer your skill level and scope of practice so that the person making the appointments and the client can make an informed decision prior to making an appointment. Communication is vital in our profession.
Paul
George Lee, LMBT said:Susan, I think that would be ideal. As a matter of fact the next point in our standard of practice is...
e. Consultation. If the practitioner encounters an unfamiliar condition that cannot
be adequately evaluated through research, the practitioner shall consult with a
knowledgeable professional to determine the best course of action.
If there were a trained therapist available to advise, guide, direct, etc. it would be a great educational moment. There's nothing like OJT (On the Job Training). Perhaps a "master therapist" as it were for each organization? But, are spas going to do that? As you alluded to, this is a multifacted issue. Where does "spa work" end and theraputic work begin? Of course we all know it overlaps. How to we get "spas" or massage centers to recognize conditions outside "normal", and I use that word very loosely, and address it safely and adequately rather than focus on maximizing the numbers of clients? I feel the "spa" industry needs to address this and sooner or later they will, because they are dancing on the edge and eventually someone is going to get hurt. Then, they will be spoken to in the language they know best, money.
As far as refusing or declining, it doesn't always have to be total. It can be restricted to a specific area or method. For example not working an area deeply, but applying less invasive techniques that can still provide comfort and relief. I also belive in finding your own way, but we must respect when that experimentation may be detrimental to your client. Know your abilities, know yourself.
George
Susan G. Salvo said:During student clinic, an instructor is always available to assist students in situations in which they are unfamiliar/uncomfortable.
Is it possible that therapists working in massage chains have the same type of support?
But how can students/therapists learn to work on clients with tennis elbow, who are paraplegics, or who are hearing impaired (just fill any condition here, they are just examples) if they refuse to treat?
George, I agree with you concerning the right of refusal issue (and thanks for the clarification – but the teacher in me often treats these discussions like case studies, so I frequently pull different elements into the equations to encourage high level thinking rather than state my opinion).
George Lee, LMBT said:Unfortunately, you are missing something. Vanessa's refusal was a focus on the client by not proceeding into an area with which she was unfamiliar and potentially creating harm. It wasn't because she was afraid of touching a cancer patient. She refused not to protect herself, but the client. Harming the client is not to the client's best interest, no matter how well intended.
We at the Society for Oncology Massage have written into our standards of practice the right of refusal. It is common for a cancer client to request some technique or application of massage that may not be good for them. It is our responsibility as professionals to recognize these conditions and keep the client's best interest at heart. It is also our responsibility to educate ourselves to be able to understand what these conditions are and if we are not certain that what we may do is safe, then to error on the side of caution and not do them. First do no harm. The client trust in you as a professional not to harm them. This does not mean we cannot benefit the client in other ways and still provide a positive and rewarding massage experience.
When a physician writes a referral vs. a prescription, he is depending on the professional referree to use their skilled judgement on determining the proper course of treatment for the patient including the right to decline treatment if it is potentially harmful to the patient. If an oncologist refers a patient to a surgeon for a procedure and the surgeon says it would be unsafe or cause harm, the oncologist accepts that.
d. Right of Refusal. The practitioner shall decline to use any massage
technique that the practitioner judges may be detrimental to either client or
practitioner.
In another response you mentioned that the intake form, history and physical, etc. should reveal any problems. That is correct. But, does the average therapist know how to deal with the special information that a cancer patient may reveal? I believe the answer is no. Consider the disparate standards for massage across the nation, as your own work with MTBOK is trying to address. In many schools students are taught to completely stay away from cancer patients and if this was Vanessa's case, having her work on a cancer patient was going against her training.
Though I have some personal feelings on the matter, the legal issues of her situation will be completely dependent on Vanessa's location, training, etc.
George Lee, VP Society for Oncology Massage
Susan G. Salvo said:If we continue to address Vanessa’s topic, there needs to be some mention or focus on the client.
It was also her (the client’s) massage, her desire to feel better, and her time too.
Has anyone put themselves into the client’s shoes?
Jenifer moved into that direction, but it got lost in our “therapist rights” agenda.
My understanding is that the therapeutic relationship serves the client.
Am I missing something??? -
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Permalink Reply by Cyn on
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At a Potomac Institute of Massage Therapy workshop I was cautioned NOT to provide massage services to some oncology clients ESPECIALLY if they are undergoing active chemo or radiological therapy. I inferred that it may not be safe for the practitioner, but I do not remember the specifics. I personally believe the practitioner was within her rights to refuse.
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Permalink Reply by Angela Yates on
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Vanessa,
I currently practice at a hospital and work in the Radiation and Oncology Department. In the state of Indiana states that you do not need special training specifically in Oncology to treat cancer patients. Check your state regulations and your insurance policy to see if this type of massage is covered. If your employers insurance policy states that it is covered they the "coverage" issue is taken care of.
However, there are a few contraindications for massage with a patient undergoing chemo. Chemo therapy reduces the patients immune system so the utmost care in following universal precautions is needed. Patients getting chemo may be also having radiation treatments . Radiation can burn the skin and would be a contraindication. Also, was the patients lymph system involved - this also ads to contraindications for heat and pressure. Intake is very important to ask the right questions. This may be the fear for Vanessa- if you were not trained either by your educator or your employer on what the proper intake questions that are necessary to treat a cancer patient this then leads to lack of understanding on how to treat.
If you were not trained to treat cancer patients they your employer should have been a little more companionate under the circumstances. Would your employer expect you to do a mud wrap if you were never trained? (I am in no way comparing cancer to a mud wrap)
Now to the other side - CANCER PATIENTS NEED MASSAGE. They are in pain, confused, fearful, scared and worse they spend more time worrying about others in their life and how to fight this disease. They need to know they are important and in turning a cancer patient away or refusing to work on them you are acknowledging this fear in them that they are not okay.
A basic swedish massage would have been just fine to do on this client (with a General Practitioners script). Basic (light pressure) effleurage, petrissage, friction, vibration and tapotement (in non effected areas) would be acceptable course of treatment. Following the rule "do no harm" you would be aiding in the clients healing process by circulating the blood and releasing chemicals from the brain like endorphins to aid with pain and anxiety. (The old myth that circulating the blood spreads the metastaticies is false)
The comment from Stephen Jeffrey regarding the chemo chemicals leaching through the skin and the massage therapist testing positive for these chemicals may be true for this one therapist. We can get any chemical off our clients skin this includes pain meds, cough medication and a various array of others if you think about it. If you are following the proper hand washing procedures then this decreases the exposure. I have checked with our Department Director and our Physician and they stated that the only "Medication" that would leach through the skin that would be an issue for a massage therapist would be radio active iodine. This is used for treating cancer of the thyroid and these patients are quarantined and tested prior to even going home to their families to ensure a low level of remittance. -
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Permalink Reply by Kelli Dougan on
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First and foremost, good for you for listening to that little voice inside saying "NOT" to do this massage.
Although more and more research is coming out about the safety of massage during chemo, I think there has to be a comfort level for the therapist. I personally will not work on a chemo patient (for their safety & wellbeing) I wait for a doctors note/phone call. I have refused many a client over the years for being a chemo patient & having just had major surgery as well.
Although I have certainly lost a few clients over the years because of this, in the end I knew I was doing the best thing for that individual and that meant more to me than losing a client. Its someone's safety and their life! I make no excuses for that. Many times later on, that person would come back to me thanking me for refusing to work on them. -
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This topic certainly hit a nerve ... or several nerves.
First, Vanessa is right to not do a massage if she is not comfortable. There are clearly facts that we don't know and makes advice difficult (was this a condition of working there? was it stated upfront? is it in the employee handbook? Just a few questions.)
I work in a spa and therapists have, on occasion, chosen not to give a massage mostly for medical reasons. In those situations either the therapist will switch with another therapist or the client will be offered an alternate service. That being said, the place where I work absolutely does not allow ANY massage until the client is 6 months post-chemo for reasons that are based in myth. Regardless, that is their policy and we are obliged to abide by it.
Occasionally a client does not reveal their cancer treatment until they are on the table and the massage is set to begin. In those situations the client was asked to leave. Thank god this has not happened when I was the therapist.
I have had training in Cancer/Mastectomy Massage and I am also a cancer survivor (surgery and chemo). In those situations where the client has had cancer (and chemo more than 6 months ago), they are usually assigned to me. The other therapists are reluctant to work on them, mostly out of concern for harming the patient.
Bottom line -- any place that offers massage needs to be clear about these issues both for the sake of the therapists and the clients (anyone have a newly pregnant client that you had to turn away?). A detailed list (without being ridiculous) should be posted in the employee room as to the company's policy on massage for certain medical issues and any modifications/limitations. Furthermore, a reference text should be available for quick reference. In addition, when the client calls for an appointment, why not ask them "are there any issues we should know about beforehand?" or something similar.
Good luck, Vanessa. Don't give up being a massage therapist ... the world needs thoughtful people like yourself.
Carolyn -
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Carolyn- as you are familiar w/ massaging masectomy patients I would love to get your input on how to assist my dear friend who just had a double masectomy last week, What is your proticol for massing in this instance? She is officially cancer free (only a few weeks). How long would you wait to work on her? She is complaining of extreme pain in her chest, neck, shoulders- as should be expected. I told her we cannot do anything for awhile yet. She is also experiencing quite a bit of edema. Looking for your thoughts. Thank you kindly.
Carolyn Adams said:This topic certainly hit a nerve ... or several nerves.
First, Vanessa is right to not do a massage if she is not comfortable. There are clearly facts that we don't know and makes advice difficult (was this a condition of working there? was it stated upfront? is it in the employee handbook? Just a few questions.)
I work in a spa and therapists have, on occasion, chosen not to give a massage mostly for medical reasons. In those situations either the therapist will switch with another therapist or the client will be offered an alternate service. That being said, the place where I work absolutely does not allow ANY massage until the client is 6 months post-chemo for reasons that are based in myth. Regardless, that is their policy and we are obliged to abide by it.
Occasionally a client does not reveal their cancer treatment until they are on the table and the massage is set to begin. In those situations the client was asked to leave. Thank god this has not happened when I was the therapist.
I have had training in Cancer/Mastectomy Massage and I am also a cancer survivor (surgery and chemo). In those situations where the client has had cancer (and chemo more than 6 months ago), they are usually assigned to me. The other therapists are reluctant to work on them, mostly out of concern for harming the patient.
Bottom line -- any place that offers massage needs to be clear about these issues both for the sake of the therapists and the clients (anyone have a newly pregnant client that you had to turn away?). A detailed list (without being ridiculous) should be posted in the employee room as to the company's policy on massage for certain medical issues and any modifications/limitations. Furthermore, a reference text should be available for quick reference. In addition, when the client calls for an appointment, why not ask them "are there any issues we should know about beforehand?" or something similar.
Good luck, Vanessa. Don't give up being a massage therapist ... the world needs thoughtful people like yourself.
Carolyn -
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It is good during this discussion to refer back to the basics from time to time.
1. Our focus must be on the patient's physical welfare first and psychological welfare second. Further, we can not ethically do anything that may injure the client physically while helping them psychologically.
2. What is legal, what is insurable and what is ethical are independent parameters. Our actions must be all three. What is legal and what is insurable changes from state to state. What is ethical does not change. We must "First of all, do no harm.". In practice, this means, "Do only what you are positive will not cause harm."
3. There are numerous conditions and combinations of conditions that dictate modifications to massage for cancer patients, both in treatment and long out of treatment. Some modifications are minor, some are major. You have to know what you are doing to do this work.
4. Knowing what to do and what not to do is not difficult. You can learn the basics in a single 24 hour training. See the Society for Oncology Massage website for such classes (http://www.s4om.org/div1/trainings.htm)
For 7 years I have treated only oncology patients in my massage practice, both in a hospital and in my own office. I have walked with patients from diagnosis into long term survival and with others from diagnosis to death. I certainly haven't seen it all, but I have seen a big slice of the oncology world.
In those 7 years I have never seen a patient/client who could not and did not benefit from massage. But the variety of massages dictated by the patients'/clients' medical conditions has been remarkable. It is easy to imagine the damage I might have done without the specialized training.
The training is so easy to get. It is offered all over the country and all during the year. Make it part of your regular continuing education. Then the strengths and weaknesses of this discussion will become obvious to you.
Bruce Hopkins, LMT, NCTBM, S4OM -
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I don't know if this the right section to ask this question but i'm a LMT and i live in Indiana. I am very interested in oncology massage but i don't know where to go for more training. Would anyone have any ideas for me? Thank you!
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Hi Linda,
Wow. I was still on alert for message updates to this thread. It was a surprise after so long.
To answer your question, the top instructors are:
Gayle MacDonald, she literally wrote the book. http://www.medicinehands.com/
Tracy Walton, she also has some basic online instruction via AMTA and Ben Benjamin if you want to try that first, but ultimately you want real classroom time before touching real survivors. http://www.tracywalton.com/
then
Cheryl Chapman http://www.cherylchapman.com/
They travel around the country teaching.
Gayle and Tracy tend to be more clinical and I recommend that first if you are going to be in clinical setting.
I'm not VP of S4OM (Society for Oncology Massage) www.s4om.org anymore, but they also have a reference list of instructors. I highly suggest my first recommendations, however, as I know their programs. I also hope to be starting one soon.
If you have any questions, feel free to contact me at handsoncancer@gmail.com
George
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Permalink Reply by Gary W Addis, LMT on
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About that letter to paper: Careful! a counter-suit could be costly if your comment is deemed defamation of the business' reputation. If you don't have documentation to support your position, don't publicize.
Amanda Cizek said:I am just a lowly student, but in my first term we learned that you absolutely have the choice to refuse massage to anyone, so the franchise is in the wrong right there. We also learned from the beginning to NOT work on anyone going through chemo until next semester when we learn more about it, the contraindications and the various effects. This was taught to us by instructors who work on cancer patients on a regular basis and stress the need to be knowledgable and cautious.
You had every right to refuse and I may have as well if I felt that I lacked the knowledge & did not feel secure. The lack of security would have inhibited your intuition and would have been felt by the client.
Shame on your former employer. They should have respected your choice and handed the client on to someone else. It sounds like they don't give a crap what is wrong with someone, so long as they get their $60.
I wouldn't let them get away with it. Not that you need to sue... just write a little letter to your local paper :) -
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