Ethics
Patient is angry about the long time he or she spent in the waiting room.
*Acknowledge* their *anger* but do not take it personally. *Apologize* for any inconvenience. Stay away from efforts to explain the delay.
Family members ask for information about patients prognosis
*Avoid* discussing issues with relatives without the patients permission
*Breach of duty*
*Breach of Duty* refers to the negligence of the physician to an established patient, which *results in direct harm to to the patient*
Gifts from pharmaceutical companies
*It is ok to accept *medically related gifts, *it is NOT ok to accept* money or gifts unrelated to your medical education
A patient requires a treatment not covered by his or her insurance
*Never limit or deny care* because of the expense in time or money. *discuss all treatment options* with patients even if some are *not covered* by their insurance companies
An invasive test is performed on the wrong patient.
*Regardless* of the outcome, a physician is ethically *obligated to inform a patient that a mistake has been made*.
Rule: when a resident physician is negligent, the attending (supervising) physician is held responsible for direct negligence in failing to provide proper supervision. This is know an *Vicarious Liability*
*Vicarious Liability* refers to an *attending physician* being *responsible for negligence committed by any resident he supervises* *Rouse v Pitt County Memorial Hopsital* Supreme Court Decision:
A 17 year old girl is pregnant and requests an abortion
*assuming no state law* Unless there are specific medical risks associated with pregnancy, a physician *should not* sway the patients decision for an elective abortion (*regardless* of maternal age or fetal condition)
Rule 3: avoid goign to court. Decision making should occur in the clinical setting if possible
*consider going to court ONLY IF*: >intractable disagreement about a patients competence, who is the surrogate, or who should make the decision about life support. >you perceive a serious conflict of interest between surrogates and patients interests *there must be an indication that the patient has NOT acted in the patients best ineterst in the past* ... *we trust that surrugates are making decisions in the best interest of the patient unless there is evidence to the contrary >court approval or decision to terminate life support is therefore, *rarely required*
What situations would make a patient *not capable of making decisions*
*delerium, psychosis, intoxication, mood disorder that clouds judgement.*
What action should a physician take when parental consent is not required in regards to a minor
*encourage healthy minor-guardian communication*
In the case of *reportable diseases* the physician must notify the people at risk. True or false?
*false*. The Physician must notify the *public officials* and the public officials will notify the people at risk
Rule 1: Competent Patients have the right to refuse medical treatment
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Rule 23: Physicians must alert law enforcement of any violence related injuries
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Components of *decision making capacity*
1 .>18 or legally emancipated 2. pt makes and communicates a choice 3. patient is informed (knows and understands) 4. decision remains stable over time 5. decision is consistent with patients values and goals and is *not clouded by a mood disorder* 6.decision is not a result of an *altered mental state* (delierium, psychosis, intoxication)
Rule 4: When surrogates make decisions for patients, they should use the following criteria and in this order: *there is an ethical basis for surrogate decision making*
1 Subjective Standard: *first, surrogate should make medical decisions mbased on patients previous expressed wishes* >actual intent, advance directive >what did the patietn say in the past? 2. substituted judgement *if patients wishes are not known, we ask the surrogate to to use substituted judgement, which means the surrogate should consider all that is known about the patient and make a medical deiciosn that the patient would likely make* >who best represents the patient >what would patient say if he or she could? 3. Best interests standard *If the surrogate has no knowledge or prior whishes and no basis ofr substituted judgement, then the decision should be based on the bsete interests staandard. Here, surrogates should consider the risk and beneifts of prposed treamtent and make decisions based on what is in the best ineterst of the patient* >burdens vs benefits >interests of patients, *not* preference of the decision maker
Exceptions to Informed Consent
1. Pt lacks decision making capacity/ legally incompetent 2. implied consent in an emergency 3. *therapeutic privilege*- witholding info when disclosure would severely harm the patient or undermine informed decision making capacity 4. *wavier*- patient explicitly waives the right of informed consent
Exceptions to Consent for *minors*
1. emancipation ( ie. *married*, *self supporting*, in the *military* 2. if *emergent treatment* required (*EVEN IF* it goes against parents religious or cultural beliefs 3. *SEX* (contraception, STI, pregnancy) 4. *DRUGS* (substance abuse) 5. *ROCK AND ROLL* (trauma/emergency
Patient is not adherent
> attempt to ID the reason for non adherence and determine their willingness to change; * do not* coerce the patient into adhering and *do not* refer the patient to another physicians
Rule 13: special rules appy to chidren
> children <18 y/o are minors and are *legally incompetent* >*Exceptions*: 1. patient >13 y/ and is taking care of self i.e. living alone. Treat as an adult 2. Marriage makes a child emancipated, as does serving in the military 3. Pregnancy or having a child. *Partient emancipation* 1 Generally age 14 and older 2 Consetn for certain issues only: substance drug treatment, prenatal care, STI treatment, birth control
Negligence
>Harm must be done to a patient in order for malpractice >Residents *CAN* be sued.
*Emergency Medical Treatment and Labor Act* - ensure public access to ER services regardless of their ability to pay.
>Medicaid participating hospitals that offer ER serices *must provide* 1. a medical screening examination when a request is made for examination or treatment for an emergency medical condtions, including active labor 2. requred to prove stabilizeing treatment for patients with emergency medical conditions
Rule #5: if the patient is incompetent, physician may rely on advance directive
>advance directs *can* be oral >living will ;written document expressing wishes >health power of attorney: designating the surrogate decision maker, "speaks with the patients voice"
Exceptions to *confidentiality*
>potential physical *harm to others* is serious and *imminent* >high liklihood of *harm to self* >No alternative means exist to warm or protect those at risk >physician can take steps to prevent harm >child who is being sexually abused etc Examples include >reportable diseases- physician have duty to *warn public officials* who then notify the people at risk >child and or elder abuse >impaired automobile drivers (epileptic) >suicidal/homicidal patients
Rule 6: Feeding tube is a medical treatment and *can be withdrawn* at the patients request (If competent)
A competent patient can *refuse even lifesaving hydration and nutrition*. This is *NOT* considered to be "killing the patient", but rather, terminating treatment at the patients request
Surrogate Decision Maker
An individual who knows the patients must determine what the patient woudl have done. A surrogate decision maker is appointed *only if no advanced directive was prepared* prior to incapcitatoin
A 7 year old boy loses a sister to cancer and now feels responsible
At ages 5-7, children begin to understand that death is permanent, that all life functions end completely at death, and that everything that is alive eventually dies. Provide a *direct, concrete description* of his sisters death. *Avoid* cliches and euphemisms. *reassure* the boy that he is not responsible. Identify and *normalize* fears and feelings. *encourage* play and healthy coping behaviors (remember her in his own way)
A patients family member asks you *not* to disclose to results of a test if the prognosis is poor because the patient will be "unable to handle it"
Attempt to identify *why* the family member believes such information would be detrimental to the patients condition. *explain* that as long as the patient ahs decision making capacity and does not indicate otherwise, communication of information concerning his or her care will not be withheld.
Patient desires and uncessary procedure
Attempt to understand *why* the patient wants the procedure and address udnerlying concerns. *Do not* refuse to see the patient and *do not* refer them to another phsyician. *Avoid* performing unnesseary surgeries
Rule 11: *stop* any harm from happening
Beyond "Do no harm": you must stop anyone from hurting your patient OR your patient from hurting anyone else. Stopping harm *may require breaching confidentiality* Harm can mean spreading disease, physical assault, abuse, neglect, infliction of pain, etc.
*Know to distinguish a reasonable declination Vs. abandonment/negligence.
Can a physician turn away *new* patients without a referral? YES! both ethically and legally. (regardless if it is an underserved area, or an elderly patient or circumstances) Physicians are NOT obligated to evaluate and treat anyone who seeks their services. This is true even in cases where one physician may specifically recommend or refer a patient to another If a patient is acutely ill and beign referred tot he ED, it wold not be ethical to deny access to care.
Rule 19: COmmited mentally ill patients retain their rights.
Committed Mentally ill adults are legally entitled to the following > the must have treatment available >the can refuse treatment >they can command a jury trial to determine "sanity". They *only lose civil liberty to come and go*
Rule 2: Assume that the patient is competent *unless* clear behavioral evidence indicates otherwise
Competence is a *legal* not medical issue. A Diagnosis, by itself tells you little about a patients competence. *clear behvioarla evidence would be* >attempted suicide >grossly psychotic and dysfunctional >physical/mental status prevents simple communication
Rule 18: Patients should be given the chance to state DNR *do not resuscitate* orders, and physicians should follow them
DNR *ONLY* refers to *cardiopulmonary resuscitation* Continue with ongoing treatments DNR decisions *can be made by pt or surrogate* Have DNR discussions as part of your first encounter with the patient.
If you have a patient who needs therapy and a consultant is unwilling to treat, it is necessary to refer the patient to another consultant for care
Do this before you speak to the Chief Medical Officer of the consultants hospital, etc.
Rule # 20: Detain patients to protect them or others
Emergency detention can be effected by a physician and or law enforcement person for *48 hours* pending a hearing A physician can detain; only a judge can commit.
*Federal Privacy Rule*
Established to assure that individuals health information is proerly protected while allowing the flow of health information needed to provide and promote high quality health care. >*an exception exists for mental health records in cases where the information contained within them may cause harm tot he patient*
A woman who had a mastectomy says she now feels "ugly"
Find out *why* the patient feels this way. *Do not offer falsely reassuring statements*. ("You still look good")
Resident work hours
First years residents are allowed to work up to *80 hours per week* and be scheduled for *shifts up to *16 hours* >Moonlighting counts towards the 80 hour maximum weekly limit for resident.
*HMO* vs *PPO*
HMO: patient must get referrals to see a specialist. They may select a physician from a list of approved health care providers. PPO: a premium is paid on a month or quarterly basis and patients are allowed to refer themselves to a specialist physician outside of their network.
Rule 14: parents *cannot* with hold *life or limb saving* treatment from children
If parents refuse permission to treat child: 1. If immediate emergency, * go ahead and treat* 2. If not immediately, but still critical (e.g. Juvenile Diabetes), generally the child is declared a *ward of the state* and the *court grants permission* 3. If non life or limb threatening (e.g. the child needs minor stitches) * listen to the parents*
A terminally ill patient requests phsycian asistance in ending their own life
In the the overhwlming majority of staes *refuse involvement in any form* of physician assisted suicide. Physicians may, however, *prescribe* medically appropriate analgesics that *coincidentally* shorten the patients life.
Advance Directive
Instructions given by patient in anticipation of the need for a medical decision in a situation in which they are incapacitated. May be: >oral >written (living will( >proxy (medical power of attorney)
Rule 10: Keep the physician- patient relationship within bounds
Intimate social contact with anyone who *IS OR WAS* a patient is prohibited. Do NOT date family members of patients. Do NOT treat family members. Do NOT write prescriptions for colleagues. When patients act inappropriately, make clear to them what appropriate behavior would be. > Any gift, beyond small tokens, should be declined. *EXCEPTION TO GIFTS* >part of maintaining a health doctor/patient relationship is being * able to accept SMALL gifts form patients* (such as cookies, which are of *low monetary value*) I
Elder mistreatment (elder abuse) is defined as elder neglect, or a failure to provide what is needed to maintain health or to protect one from harm.
It is *ethically impermissible* to discharge a patient *who lacks capacity* back to their home, to an unsafe environment in which the patient may suffer from elder neglect In general, physicians are obligated to report neglect or abuse to the approrpiate authorities. *the exception to elder abuse reporting* is if the patient has intact capticyt and refuses reporting. (*informed capacitated refusal*
If a patient refuses to be evaluated or treated by a trainee, *the attending physician should be notified* (per the AMA)
It is the attending physicians responsibility to speak with the patient about the nature of a teaching service and determine the best course of action. Physicians at teaching hospitals have a few ethcically sound options if a patient refuses to be cared for by a trainee: see the patient alone, transfer care to another provider, or transfer care to another facility
RULE 9: *never abandon* a patient
Lack of financial resources or results are never reasons to stop the treatment of a patient. An annoying or difficult patient is still your patient. Abandonment is defined as when a phycian *without giving timely notice in writing* ceases to provide care for a patient who is still in need of medical attention. *OR* when nthe physciain is careless. A physician *is allowed to terminate care IF* patient is provided with a *WRITTEN* notice of withdrawal of serves. *No legal obligation for providing a referral* however, there is *legal obligation to provide medical records to new physciain* *Abandonment is NOT* considered refusing to see any patient or accept new patients into their practice, PRIOR to the establisment of a physician/patient relaitionsip. THis is both ethical AND legal, even in an understerved area*
*GINA* Genetic Information Nondiscrimination Act
Makes it unlawful empyloyment practice for an employer to discirminate based on genetic information or to request genetic information.
Rule 7: Do nothing to *actively* assist the patient to die sooner
Passive, i.e., allowing to die is *OK* Active, i.e., killing is *NOT OK* But do all you can to reduce the patients suffering (e.g., giving pain medications
Rule 17: confidentiality is (*almost always*) aboslute
Physician cannot tell anyone anything about their patient withotu the patient permission. Physician must strive toensure that others cannot access patient information. Getting a consultation is permitted, as the consultant is bound by confientiality too. However, watch the location of the consultation. Be careful not to be overheard (e.g. in an elevator or cafeteria) If you receive a court subpoena, show up in court but *do not divulge information about your patient in court* If a patient is a threat to self or others the *physician MUST break confidentiality* > Duty to warn and protect (*Tarasoff Case*) >Specific threat to a specific person > suicide, homicide, child and elder abuse are obvious threats >infectious diseases may need to be reported to public officians or an innocent third party >impaired drivers
Rule 16: Good Samaritan Laws limit Liability in nonmedical settings
Physician is not required to stop and help. If help is offered, shielded from liability provided: >actions are withins physicians competence. >only accepted procedures are performed >physician remains at scene after starting therapy until relieved by competent personnel >no compensation changes hans
HIPPA: Health INsurance Portabilty And Accountability Act
Prohibits gropu health plans rom using any health status related factor, inclduing genetic informatio as a basis for denying or limitng eligibility to coverage or for charging an indivudal more for coverate.
Good Samaritan Law
Protect indivudals who help those that are injured or in danger from legal liability. It serves to protect the individual who helps from being sued for wrongdoing or any mistakes made while helping. *include situations of drug or alcohol overdose and also include administration of naloxone*
Ptaient has difficuty taking medications
Provide *written instructions*. attempt to *simplify* treatment regiments use *teach back* method (ask patient to repeat regiment back to physician to ensure comprehension
Hierarchy of of surrogacy
Spouse> adult children > parent > adult sibling >other relative
Patient is upset with the way he or she was treated by *another* doctor
Suggest that the patient *speak directly* to *that physician* regarding their concerns. If the problem is with another* member of the office staff*, tell the patient *you will speak to that person*
The *Tarasoff Decision*
Supreme court decision requiring *physicians to directly inform and protect potential victim from harm*
Rule 22: Focus on what is best ethical conduct, not simply the letter of the law
The best conduct is both legal and ethical
Rule 12: always obtain informed consent
The patient *must receive and understand* five pieces of information: 1. Nature of procedure 2. Purpose or rationale 3. Benefits 4 Risks 5. Availability of alternatives Four *exceptions to informed consent* 1. Emergency 2. Waiver by patient 3. Patient is incompetent 4. Therapeutic privelage
A 15 year old girl is pregnant and wants to keep the child. Her parents want you to tell her to give the child up for adoption
The patient retains teh right to make decisions regarding her child, *even if the parents disagree*. Provide *information* to the teenager about *practical issues* of caring for a baby. Discuss the options, *IF* requested. *Encourage discussion* between the teenager and her parents to reach the best decision.
Rule 15 Organ donation usually requires patients and family consent
The patients advance directive is key Prior discussion with family members eliminates confusion regarding wishes. If the family refuses, *do not cause them stress by insisting*
When a medical error has occured, *the patient must be informed* and the physicians are *obligated to report medical errors*- both those that cause harm to patients as well as those that ave the potential to cause harm to a patient
This should be followed even if the medical error did not cause harm to the patient.
A *medical power of attorney* can be revoked by patient id decision making capacity is intact. True or false?
True.
Rule #21: Remove from patient contact health care professionals who pose risk to patients
Types of risks: >infectious disease (e.g. TB) > Substance abuse >depression (or other psychological issues) >incompetence *a physician is responsible for protecting patients from impaired physicians and reporting the impaired physician to the appropriate authority
Rule 8: The Physician decides when the patient is dead
What is there are no more treatment options (the patient is cortically dead) and the family insists on treatment? *if there are no options, there is nothing the physician can doe; the TREATMENT MUST STOP* What if the physician thinks continued treatment is futile (the patient has shown no improvement) but the surrogate insists on continued treatment? *THE TREATMENT SHOULD CONTINUE*
Paternalism
acting without a patients conset or overriding a patients wishes, for the patients own benefit or to prevent harm to the patient. ex. An obstetrician perform a medically necessary C section, despite the patients objection
Medical Records
are the *property of those who prepared them* (medical professional) and NOT about whom they are concerned (patients) >patients have a right to see and get a copy of their records >*Federal Privacy Rule* (2001). >Providers are *required to obtain written consent* before sharing information regarding treatment payment and health care options, but *provider is required to comply with patients wishes*. Failing to due to results in *criminal penalty* >*an exception exists for mental health records in cases where the information contained within them may cause harm tot he patient*
Patient states that he or she finds you attratice
ask *direct, close ended* questions and use a *chaperone* if necessary. Romantic relationships with patients are *never appropriate*
Patient is suicidal
assess the seriousness of the treat. If it is serious *suggest* that a patient remain in the hospital *voluntarily*. Patient may be hospitalized *involuntarily if they refuse*
*patient self determination act* - requires at * at the time of admission, heal care instituations tha tparticipate in medicaid/medicare programs* 1) ask the patient whether they have an advanced directive 2) inform patients of their rights to accept or refuse medical treatments and to create and execute an advance directive 3) incorportate advanced directives in a patients medical records
passed by congress in 1990 in reponse to the Cruzan deicio
*Public Health Service Act*
provide that the secretary of teh department of health and human services shall lead all federal public health and medical resposne to publi health emerencies and cidents covered by the national response framework. This covered public health and medical response, includign mass care, emergency assistance, housing and human services
*breach of duty*
signifies failing to follow through on a health care obligation at a level of quality comparable to other reasonable practioners Ex. PCP widely spacing PE visits for a seriously ill patient on account of he or she being unfriendly or frustratng
