Chapter 14: Patient Rights and Responsibilities

Paternalism

Four reasons the paternal physician is deficient: - He acts on his own values - Patients know their own interests better than anyone else - Danger of abuse - The patient's substantive and procedural rights to pursue or reject any course of treatment based on subjective preferences

Respect the Rights of Other Patients

Be considerate of the rights of other patients (e.g., noise control, no-smoking rules, respect for the rights and property of others).

Right to Ask Questions

Because communication is a cornerstone of patient safety and quality care, every patient has the right to receive information in a manner he or she understands. Effective communication allows patients to participate more fully in their care. Patient understands what is being said about his or her care, treatment, and services, that patient is more likely to fulfill critical health care responsibilities.[4] The patient has a right to ask questions and caregivers have a responsibility to listen. A Joint Commission standard provides: The hospital has a written policy that defines patient responsibilities, including but not limited to the following: Asking questions or acknowledging when he or she does not understand the treatment course or care decision.[5] Caregivers must not become dismissive or trivialize the importance of a patient's opinion as to the cause of his or her medical complaints and ailments. Although a patient may be anxious, the questions asked should not be disregarded. Attributed to Socrates, the classical Greek philosopher, is the Socratic method of teaching and learning by asking and answering questions. Patients have the right to ask questions regarding their care from entry to the hospital through the time of departure. Questions regarding care should include, for example, "I saw blood in my IV tubing. Is this okay? Is it infiltrating?" or "My wound dressing seems wet. Is this okay? Should the dressing be changed?" Patients should not hesitate to ask for: clarification of a caregiver's instructions interpretation of a caregiver's handwriting instructions for medication usage (e.g., frequency, dosing, drug-drug or drug-food interactions, contraindications, side effects) clarification of a physician's diet orders explanation of the treatment plan a copy of the organization's handwashing policy a description of the hospital's procedures to prevent wrong-site surgery consultations and second opinions accurate and complete discharge instructions verification that their advance directives are on file (e.g., living will) confirmation that contact information for the patient's surrogate decision maker is on file in the event the patient becomes incapacitated and cannot make healthcare decisions This listing is a sampling of the many questions that patients have a right to ask during the course of their care and treatment. As the information available to physicians for patient care increases, the more important it is for the patient to ask about treatment options and suggested treatment plan. Dr. Ranit Mishori explains in "Don't Let a Hospital Make You Sick," "The problem is not that we have an epidemic of negligent doctors. Rather, it's that the health-care system has grown so complicated that there is a greater chance than ever of things falling through the cracks. Another problem is that hospitals produce massive amounts of data, including lab and X-ray reports, medication lists, doctors' orders, and dietary restrictions. It is easier than ever for critical communications to get lost, and hospitals often don't have thorough backup systems."[6] Sandra G. Boodman, a reporter for The Washington Post writes in an article, "Doctors talk to doctors happily," but "it's sometimes hard to get them to listen to patients." She hoped that such a conversation might lead to an answer that could help spring her from the hospital or at least enable doctors to investigate—or to rule out—a potential disease and get to the bottom of her medical problem.[7]

PATIENT RESPONSIBILITIES

Patients also have the obligation to take on certain responsibilities. The hospital defines these responsibilities and then relays them to the patient. When patients understand and accept their responsibilities, the concept of the patient as a partner in care becomes a dynamic component of the patient's episode of care.[46] Patients have responsibilities as well as rights. One cannot exist without the other in an orderly society. Various patient responsibilities are described next.

Keep Appointments

Patients have a responsibility to promptly notify caregivers whenever they are unable to keep a scheduled appointment. Failure to notify caregivers of a cancellation means longer delays for other patients, who may be finding it difficult to schedule appointments with physicians.

Patients Rights

Patients of the various states have certain rights and protections guaranteed by state and federal laws and regulations. Patients have a right to receive a clear explanation of tests, diagnoses, prescribed medications, prognoses, and treatment options.[1] Most federal, state, and local programs specifically require, as a condition for receiving funds under such programs, an affirmative statement on the part of the organization that it will not discriminate. For example, the Medicare and Medicaid programs specifically require affirmative assurances by healthcare organizations prohibiting discrimination. The continuing trend of consumer awareness, coupled with increased governmental regulations, makes it advisable for caregivers to understand the scope of patient rights. The Patient Self-Determination Act of 1990 (PSDA)[2] describes the rights of patients to make their own healthcare decisions. Healthcare organizations may no longer passively permit patients to exercise their rights but must educate patients as to their rights. The PSDA provides that each individual has a right under state law (whether statutory or as recognized by the courts of the state) to make decisions concerning his or her medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives. Patient rights may be classified as either legal, those emanating from law, or human statements of desirable ethical principles such as the right to be treated with dignity and respect. The rights of patients discussed here do not exist in a vacuum without limitations. They are tethered to moral obligations and responsibilities that have their roots in the law, ethics, moral principles, and religious values. To kill another human being, for example, is wrong, and punishment will follow if the life of another is taken. The Code of Federal Regulations, Chapter 42, provides for the promotion and protection of patient rights, as noted in the Conditions of Participation (42 CFR § 482.13): A hospital must protect and promote each patient's rights. (a) Standard: Notice of rights—(1) A hospital must inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible. (2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital's governing body must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: The hospital must establish a clearly explained procedure for the submission of a patient's written or verbal grievance to the hospital. The grievance process must specify time frames for review of the grievance and the provision of a response. In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. A variety of patient rights are presented here, many of which are required to meet the certification of the Joint Commission, and Medicare Conditions of Participation, Title 42 Conditions of participation for hospitals should not be considered exhaustive as to their rights. The various states have laws that address the rights of patients such as California, where Title 22 and other California laws address patient rights.

The Supreme Court has further interpreted the constitution as guaranteeing:

Right to privacy and self-determination • Right to accept or reject medical treatment

Limitations on Disclosures

Some of the individual rights a patient has regarding disclosure of access to his or her medical information are as follows: Right to request restrictions or limitations regarding information used or disclosed about one's treatment. Right to an accounting of nonstandard disclosures: The patient has a right to request a list of the disclosures made of information released regarding his or her care. Right to amend: If a patient believes that medical information regarding his or her care is incorrect or incomplete, he or she has a right to request that the information be corrected. Right to inspect and copy medical information that may be used to make decisions about one's care. Right to file a complaint with the provider, or the Secretary of the Department of Health and Human Services in Washington, D.C., if a patient believes his or her privacy rights have been violated. Right to a paper copy of a notice pertaining to patients. Right to know of restrictions on rights. Any restrictions on a patient's visitors, mail, telephone, or other communications must be evaluated for their therapeutic effectiveness and fully explained to and agreed upon by the patient or patient representative. In addition to HIPAA, the Code of Federal Regulations provides that: (1) The patient has the right to the confidentiality of his or her clinical records. (2) The patient has the right to access information contained in his or her clinical records within a reasonable time frame. The hospital must not frustrate the legitimate efforts of individuals to gain access to their own medical records and must actively seek to meet these requests as quickly as its record keeping system permits.[26] The U.S. Department of Health and Human Services also states on its website that: Most of us believe that our medical and other health information is private and should be protected, and we want to know who has this information. The Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of individuals' protected health information, whether electronic, written, or oral. The Security Rule is a Federal law that requires security for health information in electronic form.[27] A lack of patient privacy was discovered when hospital records were discovered online. "The breach at Stanford Hospital in Palo Alto, Calif., exposed the names and diagnoses of 20,000 patients who visited the hospital's emergency department between March 1, 2009, and Aug. 31, 2009."[28] In another instance, which came on the heels of its first Health Insurance Portability and Accountability Act (HIPAA) privacy rule, "the Department of Health and Human Services (HHS) has doled out a $1 million fine against Massachusetts General Hospital for a data breach involving 192 patients being treated for infectious diseases."The limitations of space and financial constraints make it difficult to continuously preserve a patient's right to privacy in many hospital settings (e.g., emergency departments). Even so, healthcare organizations have a responsibility to provide for a reasonable amount of privacy for patients.

Autonomy

Adult legal right - To refuse medical treatments - To employ all experimental and heroic measures for as long as humanly possible even in view of a fatal diagnosis....

Right to Complain

Patients have a right to file a complaint when they are dissatisfied with their care and treatment. Some caregivers have in the past objected to notifying patients of unanticipated medical outcomes. They claim that such a practice encourages complaints and can lead to lawsuits. Ultimately the governing body is responsible for establishing a complaint resolution process that it can delegate to a designated complaint resolution committee.[8] The following Reality Check describes how a hospital surveyor was met with resistance to a new accreditation requirement during an educational conference that provided patients have a right to be informed about unanticipated outcomes, sometimes described as medical mistakes or medical errors.

Patient Responsibilities:

To cooperate with all persons providing your care and treatment. - To respect the property, comfort, environment and privacy of other patients. - To try to understand and follow instructions concerning your treatment and ask questions if you do not understand or need an explanation. - To provide accurate and complete information regarding your health problems and medical history by answering all questions as truthfully and completely as you can. - To be responsible in your payment for treatment and to be cooperative and timely in providing insurance information. - To inform the nurse of any medication brought from home. - To accept responsibility for consequences following a decision to refuse treatment or instructions.

Paternalism and Autonomy

- Physicians have lost claim to the moral right to act on a patient's behalf, without need of the patient's consent. - Patient has assumed the role of partner who is capable of and interested in participating in all aspects of care.

Patient Responsibilities

Ask questions if they do not understand what the care giver is describing about how to best manage their pain. • Report their pain to their care givers • Discuss pain relief treatment options with their caregivers • Adhere to the pain control program Remind those who care for them that pain management is an important part of their health care treatment • Inform health caregivers about any other prescriptions or over-the-counter medicines they are taking to control their pain. • Provide caregivers with information about pain control methods that have worked, or not worked, for them • Discuss concerns about taking pain medication Alert caregivers of any allergies they have to any medications • Ask caregivers about the side effects associated with their pain management program • Maintain a record of the effects of medications or other pain relief measures • Participate with caregivers in setting a pain control goal, including their pain ratings and activities that are important to them

Right to Receive Quality Care

Healthcare professionals are expected to monitor the quality of each patient's care beginning with the history and physical, followed by the development of the treatment plan, and ultimately the delivery of care to the patient. The patient has a right to expect that the quality of care rendered will be based on best practices recognized by the medical profession.

Right to privacy and self-determination

Know their rights • Explanation of those rights • Participate in care decisions • Informed consent • Ask questions • Refuse treatment • Execute advance directives - Designate a decision maker Privacy and confidentiality - Disclosures permitted w/o authorization - Limit disclosures • Know of restrictions on rights • Have special needs addressed • Emergency care (EMTALA) • Discharge Transfer • Access medical records • Know of third-party care relationships • Know of caregivers • Sensitive and compassionate care • Timely response to care needs • Pain management

Right to Execute Advance Directives

Patients have a right to execute advance directives. A patient who becomes incapacitated or unable to make decisions on his or her own behalf has a right to appoint a surrogate decision maker to make decisions on his or her behalf. Each patient at the time of admission should be queried to determine if they have executed advance directives and if a designated decision maker has been identified. Patients who have formerly executed advance directives should file a copy with the hospital and primary care physician.

Right to Timely Response to Care Needs

Patients have a right to have their care needs addressed within a reasonable time frame. Delay in responding to patient needs can place a patient's life at risk.

Right to Know Third-Party Care Relationships

Patients have a right to know the hospital's relationships with outside parties that may influence their care and treatment. These relationships may be with educational institutions, insurers, and other caregivers.

Right to Ethics Consultation

Patients' rights in many hospitals allow for patients and/or families to access an ethics committee for consultation when faced with challenging treatment decisions that involve ethical dilemmas. Dilemmas often arise when two or more choices have some degree of a negative outcome. Conflict can arise when there is a difference of opinion between families and care providers, or when the family is unsure about what course of treatment is best for the patient. Ethics committee consultation can provide an objective perspective. Ethics committees are consultative in nature. Recommendations of an ethics committee should not be considered as binding. Ethics consultations are helpful, for example, when making end-of-life decisions.

Report Sudden Changes in Health Status

Relay to caregivers unexpected changes in your health status. Make it known whether you clearly understand the plan of care. Ask questions to seek clarification of concerns when in doubt about the plan of care.

Patients Rights

The Constitution guarantees the right to - freedom of speech - free exercise of religion - association - not be discriminated against on the grounds of race, creed, color, or national origin

Ask Questions

The necessity and responsibility to ask questions cannot be overstated. A knowledgeable patient is a good patient. If you are unsure of a caregiver's instructions, be sure to seek clarification and a written copy of the proposed treatment plan. Ask questions and seek clarification when in doubt about the plan of care. Patients have a responsibility to ask questions and understand explanations. Such questions include: "What is this medication for?" "What diet am I on?" "Since you are going to change my dressing, did you wash your hands?"

Phlebotomist Discloses Patient Information at Public Tavern

The phlebotomist, in Bagent v. Blessing Care Corp.,[30] revealed the results of a patient's pregnancy test to the patient's sister at a public tavern. Although the hospital attempted to have the case dismissed for the phlebotomist's breach of confidentiality, invasion of privacy, and the negligent infliction of emotional distress, the appeals court determined that there were triable issues of fact precluding dismissal of the case. It was asserted that the phlebotomist had been trained to maintain the confidentiality of patient information and that she knew that she had violated the patient's rights. Patient information can also be shared with insurance carriers for billing purposes. Patients should be notified as to those research activities that may involve their personal information.

Right to Admission

Whether a person is entitled to admission to a particular hospital depends on the statute establishing that hospital. Government hospitals, for example, are by definition organizations of some unit of government; their primary responsibility is to provide service to the population within the jurisdiction of that unit. Military hospitals, for example, have been established to care for those persons who are active members of the military. Veterans hospitals were established to care for veterans. Although the public in general has no legal right of admission, government hospitals and their employees owe a duty to extend reasonable care to those who present themselves for assistance and need immediate attention. With respect to such persons, government hospitals are subject to the same rules that apply to private hospitals, as noted in the following case.

Right to Emergency Care

Emergency care is well recognized as a patient right. Although regulations and court decisions recognize the right to emergency care, disparaging remarks have been made by some caregivers who resent treating patients they consider nonurgent or emergent in their care needs, as noted in the Reality Check.

When in Doubt, Seek a Second Opinion

When in doubt, seek a second opinion. Participate in marking the site of a surgical or other invasive procedure. Communicate to staff your care preferences, including who you have selected as a decision maker in the event you become incapacitated and unable to make decisions for yourself.

Right to Choose Physician(s)

Generally, patients have a right to choose their treating physician. However, in urgent and emergent cases, there may be no time to identify the physician of choice because of life-threatening injuries, such as may occur in an automobile accident. In an elective surgical case, for example, after choosing a surgeon, the patient has the right to expect that the chosen operating surgeon will actually perform such surgery to which the patient has consented. Such was not the case in Perna v. Pirozzi [13] where, after signing a consent form, the patient was operated on by another surgeon in the same practice. The court had to "determine whether that substitution, even when the 2 surgeons are engaged in a group practice, constitutes malpractice, a battery, or both." The point is that a patient has the right to know who will operate and the consent form should reflect the patient's decision. Where a competent patient consents to surgery by a specific surgeon of his choice, the patient has every right to expect that surgeon, not another, to operate.[15] As with most legal cases, such as in Perna v. Pirozzi, issues of professional ethics can arise. In this case, the Judicial Council of the American Medical Association states that, "To have another physician operate on one's patient without the patient's knowledge and consent is a deceit."[16]

Maintain a Healthy Lifestyle

Living a healthy lifestyle involves both a right and a responsibility. Each person must take responsibility for living well through exercise, diet, stress control, and maintaining positive social relationships, which will be rewarded with a richer and fuller life that should better prepare people for whatever health obstacles the future may hold. Recognizing what is right and what is wrong for one's health is not enough; it must be recognized and practiced.

Right to Discharge

Patients have a right to be discharged and not be detained in a healthcare setting merely because of an inability to pay for services rendered. An unauthorized detention of this nature could subject the offending organization to charges of false imprisonment. Although patients have a right not to be held against their will, there are circumstances in which reasonable detainment can be justified (e.g., a minor may be released only to a parent or authorized guardian).

Right to Know Caregivers

Patients have a right to know the names and positions of the caregivers who will care for them while in the hospital. Patients should know who is treating them by name, discipline, role, and responsibility in their care plan. Caregivers should identify themselves to patients by name and discipline.

ADVISORY COMMISSION DESCRIBES PATIENT RESPONSIBILITIES

A 1997 report to the president by the Advisory Commission on Consumer Protection and Quality in the Health Care Industry clearly describes patient responsibilities: In a health care system that protects consumers' rights, it is reasonable to expect and encourage consumers to assume reasonable responsibilities. Greater individual involvement by consumers in their care increases the likelihood of achieving the best outcomes and helps support a quality improvement, cost-conscious environment. Such responsibilities include: Take responsibility for maximizing healthy habits, such as exercising, not smoking, and eating a healthy diet. Become involved in specific health care decisions. Work collaboratively with health care providers in developing and carrying out agreed upon treatment plans. Disclose relevant information and clearly communicate wants and needs. Use the health plan's internal complaint and appeal processes to address concerns that may arise. Avoid knowingly spreading disease. Recognize the reality of risks and limits of the science of medical care and the human fallibility of the health care professional. Be aware of a health care provider's obligation to be reasonably efficient and equitable in providing care to other patients and the community. Become knowledgeable about his or her health plan coverage and health plan options (when available) including all covered benefits, limitations and exclusions, rules regarding use of network providers, coverage and referral rules, appropriate processes to secure additional information, and the process to appeal coverage decisions. Show respect for other patients and health workers. Make a good-faith effort to meet financial obligations. Abide by administrative and operational procedures of health plans, health care providers, and government health benefit programs. Report wrongdoing and fraud to appropriate resources or legal authorities

Informed Consent

A decision reached by a competent patient to accept a medical treatment or course of treatment.

TEAMWORK AND PROFESSIONAL RELATIONSHIPS

A multidisciplinary approach to patient care improves patient outcomes through a planning and cooperative effort between caregivers and patients. As notably written by Andrew Carnegie, "It marks a big step in a man's development when he comes to realize that other men can be called in to help him do a better job than he can do alone." The success in improving quality patient care is dependent on teamwork. In order to provide seamless care, from admission to discharge, patients and caregivers together must work closely as a team. Employees are responsible for maintaining appropriate professional relationships with patients, families, coworkers, and others with whom they may come into contact in the organization: "When patients experience a well-coordinated journey through the hospital and see staff members working in teams across departments, they feel the hospital is focused on caring for them."

Section 381.026, Florida Statutes, addresses the Patient's Bill of Rights and Responsibilities. The purpose of this section is to promote the interests and well being of patients and to promote better communication between the patient and the health care provider. Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider's or health care facility's right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your health care provider or health care facility. A summary of your rights and responsibilities follows.

A patient has the right to: Be treated with courtesy and respect, with appreciation of his or her dignity, and with protection of privacy. Receive a prompt and reasonable response to questions and requests. Know who is providing medical services and who is responsible for his or her care. Know what patient support services are available, including if an interpreter is available if the patient does not speak English. Know what rules and regulations apply to his or her conduct. Be given by the health care provider information such as diagnosis, planned course of treatment, alternatives, risks, and prognosis. Refuse any treatment, except as otherwise provided by law. Be given full information and necessary counseling on the availability of known financial resources for care. Know whether the health care provider or facility accepts the Medicare assignment rate, if the patient is covered by Medicare. Receive prior to treatment, a reasonable estimate of charges for medical care. Receive a copy of an understandable itemized bill and, if requested, to have the charges explained. Receive medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment. Receive treatment for any emergency medical condition that will deteriorate from failure to provide treatment. Know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such research. Express complaints regarding any violation of his or her rights.

Adhere to the Treatment Plan

Adhere to and follow the treatment plan recommended. Accept responsibility for the consequences of failing to adhere to the caregiver's instructions. Refrain from self-administration of medications not prescribed by the physician, as well as those you may have brought to the hospital with you. Most importantly, follow the physician's instruction in the self-administration of medications. "Medical noncompliance has been identified as a major public health problem that imposes a considerable financial burden upon modern health care systems. There is a large research record focusing on the understanding, measurement, and resolution of noncompliance, but it is consistently found that between one-third and one-half of patients fail to comply with medical advice and prescriptions." The failure of a patient to follow a physician's plan of care can lead to frustration on the part of the caregiver. Patients who, for example, fail to follow a physician's medication orders for blood pressure medication can lead to erratic spikes in the patient's blood pressure. Should this information come to the doctor's attention, the physician may become less empathetic with patients who complain their blood pressure is out of control. The responsibility for good care rests with both the caregiver, in relating to the patient the importance of complying with the treatment plan, and the patient, who bears a responsibility to comply with the physician's instructions. Ultimately, patient care outcomes can improve if patients adhere to their prescribed treatment plans. Caregivers need to understand the potential for noncompliance and address those concerns when developing treatment plans. This is especially important with seniors and patients with cognitive disorders.

Treat Caregivers with Respect

Disrespect often lies at the boardroom door. Board members often deflect attention from themselves for their failures to lead. Caregivers often feel the burn-out when expectations from leadership are to do more with fewer hands. It is tied to the push by government and board leadership to produce high-quality care in less time for less money. CEOs find themselves caught in the middle of numerous ethical dilemmas, a financial war that is an extension of the board's policy to do less with more. When things go wrong, the board points its finger away from itself and directly at the CEO, whom it appointed to carry out its policies. "Words such as 'burnout' are often employed by medical institutions to shift blame to doctors for their emotional distress while deflecting attention from unsafe working conditions. When doctors are punished with loss of residency positions or hospital privileges for occupationally-induced mental health conditions, they can become even more hopeless and desperate."[54]

Hospital Peer-Review Materials Discoverable: Patient's Right to Know

Florida voters, in November 2004, adopted the "Patients' Right to Know About Adverse Medical Incidents" amendment to Florida's constitution ("Amendment 7"). In a medical malpractice action in which the plaintiffs sought the production of documents relating to the investigation of the decedent's death and any medical incidents of negligence, neglect, or default of any healthcare provider who rendered services to the decedent, the trial court properly held that the Patient's Right to Know Amendment to the state constitution was self-executing and allowed for the discovery during the course of litigation. The patient should have been provided with information and documents that emanate from the self-policing processes of healthcare providers; however, the court's retroactive application of the amendment was found to be improper.[39]

A patient is responsible for:

Giving the health care provider accurate information about present complaints, past illnesses, hospitalizations, medications, and any other information about his or her health. -Reporting unexpected changes in his or her condition to the health care provider. Reporting to the health care provider whether he or she understands a planned course of action and what is expected of him or her. Following the treatment plan recommended by the health care provider. Keeping appointments and, when unable to do so, notifying the health care provider or facility. His or her actions if treatment is refused or if the patient does not follow the health care provider's instructions. Making sure financial responsibilities are carried out. Following health care facility conduct rules and regulations.

Right to Know Medical Errors

In one article in the Journal of the American Medical Association, the authors stated, "Physicians may not be providing the information or emotional support that patients seek following harmful medical errors. Physicians should strive to meet patients' desires for an apology and for information on the nature, cause, and prevention of errors. Institutions should also address the emotional needs of practitioners who are involved in medical errors."[41]

Right to Patient Advocacy Services

Joint Commission standards provide that the "patient has the right to access protective and advocacy services."[19] Most organizations have adopted policies and procedures to address patient complaints. A patient generally addresses patient concerns. Access to a patient advocate is often described in patient handbooks. Patient advocacy services should be available to both patients and families. Many states have mandated by legislation the establishment of ombudsman and patient advocacy programs. In fulfilling their commitments and obligations to patients, healthcare executives function as moral advocates and models. Being a model means that decisions and actions will reflect personal integrity and ethical leadership that others will seek to emulate.[20] Patient advocacy by all caregivers should be considered a routine responsibility. Caregivers are closest to observing the care being rendered to the patient and are more aware of when things are not going right. Intervention earlier in a patient's care is more important than watching a bad scenario in a patient's care unfold.

Right to Pain Management

Pain is the body's way of alerting the patient that something is not quite right. Pain management is the process whereby caregivers work with the patient to determine the cause of pain and develop a pain control treatment plan. The process involves educating the patient as to the importance of pain management in the healing process. With current treatments, pain can often be prevented or at least be better controlled. Patients have a right to have a pain assessment and management of any pain identified. A pain rating scale is a visual tool often used to help patients describe their pain level. It helps the caregiver know how well treatment is working and whether change in the treatment plan is necessary. The pain assessment scale is a tool often used because of its ease of use in performing a task. Just as important as the severity of pain are its locations and type (e.g., burning sensation, throbbing, dull, stabbing, numbing, sharp, shooting). A diagram of the body should be used so the patient can more easily identify the various locations of his or her pain. The severity of pain can be described to the physician to assist in diagnosing and treating the patient. All patients have a right to: a pain control treatment plan developed with the caregiver alternative and/or complementary strategies included in the pain management plan that might help improve the efficacy of traditional treatment options (e.g., pain medications), for example, acupuncture, imagery, meditation, reiki (ancient Japanese touch therapy) inclusion of family and caregivers in the decision-making process an explanation of the medications, anesthesia, or other treatments planned an explanation of the risks, benefits, and alternatives (e.g., acupuncture) to suggested treatment(s) request changes in treatment if pain persists refuse pain treatment(s) recommended receive pain medication in a timely manner

Disclosures Permitted

Patient information (e.g., diagnoses, anesthesia history, surgical and other invasive procedures, drug allergies, medication usage, lab test results, and imaging studies) may be disclosed to other providers who may be caring for the patient to provide safe healthcare treatment. The following list describes some of the ways a healthcare provider may disclose medical information about a patient without his or her written consent. Disclosure of information to third-party payers so the providers of care bill for services rendered Disclosure of information necessary to render care and treatment Disclosure of information as may be required by a law enforcement agency Disclosure of information as may be required to avert a serious threat to public health or safety Disclosure of information as required by military command authorities for their medical records Disclosure of information to worker's compensation or similar programs for processing of claims Disclosure of information in response to a subpoena for a legal proceeding Disclosure of information to a coroner or medical examiner for purposes of identification

Spiritual Assessments

Patient spiritual assessments based on the care setting should include or consider the patient's: current religious affiliation place of worship, contact name, and phone number description of areas of spiritual concerns (e.g., loss of meaning of life, unresolved grief, resentment over past experiences, confusion about current religious practices, guilt, feelings of abandonment, fears)

Accurately Describe Symptoms

Patients have a responsibility to accurately describe symptoms, family history, the location and severity of pain.

Maintain Current Medication Records

Patients have a responsibility to maintain a current accurate record of their medications, including dosages, route of administration, and frequency. Drug allergies should be included on the list. Medication records should be reviewed periodically to be sure the listing is current. A copy should be provided to treating physicians and treating facility. A comprehensive list of medications should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions (hereafter referred to collectively as medications). Over-the-counter drugs and dietary supplements are not currently considered by many clinicians to be medications and thus are often not included in the medication record. As interactions can occur between prescribed medication, over-the-counter medications or dietary supplements, all medications and supplements should be part of a patient's medication history and included in the reconciliation process, which in turn creates the potential for error.[48]

Provide Full and Honest Disclosure of Medical History

Patients have a responsibility to provide full disclosure of all information relevant to one's medical condition, medical complaints, symptoms, location and severity of pain, previous pain control concerns, past illnesses, treatments, surgical or other invasive procedures, hospitalizations, medications, and allergies. Information provided must be accurate, timely, and complete. Selectivity in the information provided to the physician or hospital for whatever the reason can lead caregivers down the wrong path when treating the patient. The court of appeal in Fall v. White [49] affirmed the superior court's ruling that the patient had a duty to provide the physician with accurate and complete information and to follow the physician's instructions for further care or tests.

Right to Know One's Rights

Patients have a right at the time of admission to be provided in writing a copy of their rights and responsibilities. The patient's rights and responsibilities are documented in a statement most often referred to as The Patient's Bill of Rights. Access to a copy of a patient rights and responsibilities should be available to the general public when so requested. A limited random sample of three hospitals in two states revealed that staff members were often reluctant and suspicious as to why a copy of the patient's bill of rights was being requested. All three hospitals would not provide a copy on site. One hospital reluctantly provided a copy via email after a second visit.

Right to Freedom from Abuse and Harassment

Patients have the right to receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect, exploitation, and harassment. According to the Medicare Conditions of Participation for hospitals: "The patient has the right to be free from all forms of abuse or harassment."[31] In addition to this right, patients have a right to access protective and advocacy services including notifying government agencies as to neglect and/or abuse. The Joint Commission provides in its standards that "the patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse."[32]

Right to a Safe Healing Environment

Patients have a right to a safe and healing environment. Hospitals that wish to participate in Medicare reimbursement must provide the patient with a safe environment as noted in the Condition of Participation, where it states: "The patient has the right to receive care in a safe setting."[42] Natalie L. Birkelien of the James Madison University in Harrisonburg, Virginia, in her article "A Strategic Framework for Improving the Patient Experience in Hospitals," states that:Provision of timely and responsive care creates an empathetic hospital environment that is patient-centered focused on quality of care and service experience. A hospital's environment is a combination of the physical and psychosocial settings the organization created through clinical and process measures. Although consumers place highest value on human interaction and quality care outcomes, the physical facility does play an important role in customers' impressions. Hospitals have historically been characterized by a lack of provision for ventilation. Dr. W. G. Wylie, writing in 1877, said he favored this type of building, but he advocated that it be a temporary structure only, to be destroyed when it became infected. As noted in the 2007 congressional hearing presented below, the Walter Reed Army Medical Center eventually became an unclean environment for its patients. Six years after treating its last patients, the former Walter Reed Army Medical Center in Washington, D.C., is on the verge of demolition to make way for a new 3.1-million sq ft mixed-use development. Early next year, NorthStar Contracting Group, Baltimore, is scheduled to begin the year-long process of demolishing the 2.7 million sq ft hospital complex, the operations of which were consolidated with the National Naval Hospital in Bethesda, Md., under the 2005 Base Realignment and Closure program.[45] Hospitals are often not always the cleanest of environments and there comes a time that that they need to be replaced. Because of this, physicians often discharge their patients as soon as possible after surgery—not because of financial reasons, but due to the uncleanliness of the hospital environment.

Right to Transfer

Patients have a right to be transferred when the admitting hospital is unable to address a patient's care needs. This is required when a hospital does not, for example, have a neurosurgeon on staff when such is required for a serious head injury. For this reason, it is imperative that hospitals execute transfer agreements for services they do not offer with other healthcare organizations. Transfer agreements help ensure the smooth transfer of a patient from one facility to another when such is determined appropriate by the attending physician(s). Generally speaking, a transfer agreement is a written document that sets forth the terms and conditions under which a patient may be transferred from a facility unable to treat a patient's particular ailment to a facility that can provide the kind of care crucial to the patient's recovery. Transfer agreements should be written in compliance with and reflect the provisions of the many federal and state laws, regulations, and standards affecting healthcare organizations. The parties to a transfer agreement should be particularly aware of applicable federal and state regulations. Patients also have a right to choose a receiving facility, whenever possible. The Medicaid patient in Macleod v. Miller [37] was entitled to an injunction preventing his involuntary transfer from a nursing home. The patient had not been accorded a pretransfer hearing, as was required by applicable regulations. In addition, it was determined that the trauma of transfer might result in irreparable harm to the patient. The appeals court remanded the case to the trial court with directions to enter an order prohibiting the defendants from transferring the plaintiff pending exhaustion of his administrative remedies.

Right to Have Spiritual Needs Assessed and Addressed

Patients have a right to chaplaincy services and to have their spiritual needs assessed and addressed. The purpose of a pastoral care program is to affirm the valuable role of spiritual care as an integral part of a patient's healing process. Accordingly, the program will make available to patients and their families spiritual support while they are in the hospital, in accordance with their wishes. The hospital supports the role of the clergy and pastoral care volunteers as important members of the healing team. A multi-faith chapel as well as televised services are available in many hospitals. Some hospitals provide spiritual devotions and reflections that are broadcast daily. Music and meditation are often provided as an adjunct for pain management and stress reduction at the bedside. Chaplains are often available as a first call option for ethics consultations. The hospital chaplain coordinates liaison between patient and area clergy. Consultations with the patient care team contribute to the holistic care of patients, family, and staff through assessment, pastoral conversation, and other interventions. Caregivers often refer patients to a chaplain for: patients/families/caregivers who are experiencing life-changing events patients who lack effective social, psychological, or spiritual support patients who have complicated personal relationships patients who express spiritual or religious concerns patients who are in a remorseful state of mind patients who express hopelessness, worthlessness, anger, or depression patients who receive news of life-threatening conditions families at times of death of the patient Hospital pastoral care departments should provide a patient information brochure at the time of admission that describes the services offered. For example, an introductory statement to such a brochure could be worded to include: When a loved one is hospitalized—or when you require hospitalization yourself—it is perfectly normal to feel anxious, worried, and sometimes overwhelmed. We know how you feel. At times like this, it's good to have a helping hand. The hospital's pastoral care department is here to help you cope with the emotional struggle associated with hospitalization. No matter what your religious affiliation, a representative of the pastoral care department is always available to offer spiritual and emotional support. Someone will lend an ear and offer comforting words. He or she will help you draw on your spiritual strength in these times of need. Services offered by a chaplaincy program should: offer pastoral support to patients and their families at time of crisis, which may include prayer, scripture reading, and counseling provide for enhanced communications between patients, their families, and hospital personnel be available to clinical staff by providing counseling and support during or after emotional emergency situations provide appropriate referrals to the social service department, the local clergy, and community agencies as needed

Privacy and Confidentiality

Patients have a right to expect that their healthcare information will be kept private and confidential as required by law. A copy of the hospital's privacy practices should be provided to patients at the time of admission and include provisions protecting patient information from unauthorized access. Hospitals that wish to participate in Medicare reimbursement must provide the patient with privacy as noted in the Condition of Participation.[24] Caregivers must be careful not to discuss any aspect of a patient's case with others not involved in the case. Written permission must be obtained before a patient's medical record can be made available to anyone not associated with the patient's care. The Health Insurance Portability and Accountability Act (45 CFR 164.520) provides that patients have a right to receive a "Notice of Privacy Standards." The HIPAA Privacy Rule gives individuals a fundamental new right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information. Health plans and covered health care providers are required to develop and distribute a notice that provides a clear explanation of these rights and practices. The notice is intended to focus individuals on privacy issues and concerns, and to prompt them to have discussions with their health plans and health care providers and exercise their rights.[25] The issues of confidentiality and privacy have both ethical and legal implications. Caregivers must safeguard each patient's right to privacy and the right to have information pertaining to his or her care kept confidential.

Right to Examination and Treatment

Patients have a right to expect the physician will conduct an appropriate history and physical examination based on the patient's presenting complaints. The assessment is the process by which a physician investigates the patient's state of health, looking for signs of trauma and disease. It sets the stage for accurately diagnosing the patient's medical problems, which leads to an agreed-upon treatment plan. A cursory assessment can lead to a misdiagnosis and inappropriate treatment plan. As reported by Karen Asp in Shape Magazine, "It took almost my whole life to get the right diagnosis because no one person had asked me enough questions." Primary care physicians often refer complex patients, such as those with autoimmune diseases with multiple systems failure, to specialists when their disease processes become too complex for them to treat. Unfortunately, challenging patients are often sent on a seemingly endless, discouraging journey from specialist to specialist. The patient can feel as though he or she is on a merry-go-round, answering the same routine questions by consulting physicians, residents, and medical students. Medical students may be ill-equipped to conduct an adequate history and physical on patients with multiple diagnoses. Patients trapped in the referral merry-go-round become discouraged to find that they often know more about their disease processes than many of the caregivers to whom they have been referred for help, as noted in the letter to the patient's physician in the following Reality Check.

Right to Informed Consent

Patients have a right to receive a full explanation of treatment options in order to make an informed decision prior to consenting to a proposed procedure or treatment. The physician has responsibility to provide the patient informed consent that includes the risks, benefits, and alternatives of each procedure or treatment option. The right to receive information from the physician includes information about the illness, the suggested course of treatment, and the prospects of recovery in terms that can be understood. The physician must objectively balance the risks and benefits of each treatment option. This balancing act can lead to a dilemma where the physician's recommended procedure differs from the procedure the patient is willing to accept. Pressing a patient to undergo an unwanted procedure is a form of paternalism that could represent a failure to respect the patient's right of self-determination.

Right to Explanation of One's Rights

Patients have a right to receive an explanation of their rights and responsibilities. The rights of patients must be respected at all times. Each patient is an individual with unique healthcare needs. The patient has a right to make decisions regarding his or her medical care, including the decision to discontinue treatment, to the extent permitted by law.

Right to Compassionate Care

Patients have a right to receive considerate and compassionate care from caregivers. There appears to be less time for compassion in the practice of medicine than at the turn of the 20th century. Providers of care seem to have taken the assembly-line approach to patient care with little thought to the need to help alleviate patient fears. Dr. Robert E. Rakel, Department of Family Medicine at Baylor College of Medicine in Houston, wrote, "It has been said that more mistakes in medicine are made by those who do not care than by those who do not know." The caring function of family medicine emphasizes our personalized approach to health care and our commitment to understanding the patient as a person, respecting the person as an individual, and showing compassion for his or her discomfort. Compassion, from the word patior, literally means "to suffer with," to share in another's distress and to be moved to give relief. Compassion reflects the physician's willingness to share the patient's anguish and to attempt to understand what the sickness means to that person.It seems with the progress of medicine there has at the same time been a decline in compassion for the patient. Patients fill out numerous forms prior to their visit to the physician's office and yet the caregiver often fails to read the information the patient has provided, as noted in the preceding Reality Check. Ms. Ying Tai Choi's daughter, Ching Cheung, described how a hospice nurse failed to stay and care for her 85-year-old mother during the last hour of her life. The hospice had promised to be there for Cheung's mother and to provide the care she needed as she passed from this life to the next. They were not there. The nurse left Choi and her daughter during the final hour of need.Reading this news clipping, one quickly realizes that not much has changed over the years. This is unfortunately the real world in which we live. The article is so descriptive of how humanity fails itself over and over again. It was as timely in the 20th century as it is now in the 21st century. Although compassion is not so easily taught to an adult as it is to a child, the struggle and the need to bring life to the study of ethics and the law are clearly borne out in this article.

Right to Know Hospital Charges

Patients have a right to transparency when requesting information about hospital emergency room, outpatient, and inpatient treatment charges. The North Carolina Senate is considering a bill titled the Health Care Cost Reduction and Transparency Act to be effective, which is intended to allow patients to compare treatment costs among different providers. Hospitals and ambulatory surgical facilities would be required to annually provide financial information for their 50 most common episodes of care to the North Carolina Health Information Exchange (Exchange), which allows free public access to its most current information. The Act is intended to allow patients to compare treatment costs among different providers.[40] As noted in the Reality Check, hospital charges are necessarily transparent.

Right to Trust Caregivers

Patients have a right to trust the caregivers who provide their care. Forty-three-year-old William McCormack found that where trust should be at its peak cannot always be presumed. When he had his appendix removed in 2013 and the hospital bill was settled, he at least could feel at ease knowing his appendix was removed in time and that was one less medical problem he would have to concern himself with in the future. That unfortunately was mistaken trust in this case. The pathology report showed the appendix had not been removed, and no one informed him that he still had an appendix. Specimens sent to pathology for microscopic examination must be labeled as to the tissue being sent for review by a pathologist. This is in accordance with national standards and hospital practice. What happened here was a failure to follow up and let the patient know that tissue had been removed, but it was not his appendix. In a different case, 18-month-old Josie King suffered third-degree burns after she had crawled into a hot bath at home. She was taken to a hospital, where she died of dehydration despite the mother's concern that Josie was dehydrated.

Right to Choose Treatment

Patients have the right to choose the medical care they wish to receive. They have a right to know their treatment options and to accept or refuse care. As medical technology becomes more advanced, care decisions become more complicated to make. Should I have the surgery? Do I want to be maintained on a respirator? Frequently, these decisions involve not only medical questions but moral and ethical dilemmas as well. What has the greater value, the length of life or the quality of life? What is the right choice? Although patients have a right to make their own care and treatment decisions, they often face conflicting religious and moral values in their decision-making process. Often, it is difficult to make a choice when two roads may seem equally desirable.

Right to Try Experimental Drugs

Patients now have the right to try experimental drugs in the research stage that do not yet have FDA approval for trials. The House of Representatives passed a bill on March 21, 2018, that gives terminally ill patients the right to try unproven experimental treatments. President Trump stated that if "There's good progress made with a certain drug. We're going to make it possible for that patient to get that drug. And maybe it's going to work. It's hope."[21] It's an interesting ethical dilemma that a healthy, unborn child with his or her full life ahead cannot choose life over death, because of his or her inability to make such a decision based on developmental factors, and yet the adult patient facing the end of life now has the right to try an unproven experimental drug to extend his or her life for an uncertain future or in some states to choose death by assisted suicide. A troubling ethical dilemma at best. Is this a paradox, a contradiction of right and wrong reasoning? And thus, we have the ultimate ethical dilemma in constitutional law and the rights of the individual that traverses the spawning of life to the end of life. At best, divisive and controversial issues continue to work their way through state legislatures and court systems, and ultimately to those who sit on the United States Supreme Court, while Congress is at an impasse in creating any new legislation that may upset their respective contingences.

Right to Have Special Needs Addressed

Patients who have language barriers or hearing or vision impairments have a right to special help to have their needs addressed in order to ensure proper care. Many healthcare organizations maintain a list of employees with various language competencies and sign-language skills in order to provide patients with high-quality care.

Right to Refuse Treatment

Stroke Patient Refused Treatment For example, the patient plaintiff in Stoick v. Caro Community Hospital [12] brought a medical malpractice action against a government physician alleging the physician determined that she was having a stroke and required hospitalization but refused to hospitalize her. The plaintiff's daughter-in-law called the defendant, Caro Family Physicians, P.C., where the patient had a 1:30 p.m. appointment. She was told to take the patient to the hospital. On arriving at the hospital, there was no physician available to see the patient, and a nurse directed her to Dr. Loo's clinic in the hospital. On examination, Loo noted right-sided facial paralysis, weakness, dizziness, and an inability to talk. He told the patient that she was having a stroke and that immediate hospitalization was necessary. Loo refused to admit her because of a hospital policy that only the patient's family physician or treating physician could admit her. The plaintiff went to see her physician, Dr. Quines, who instructed her to go to the hospital immediately. He did not accompany her to the hospital. At the hospital, she waited approximately 1 hour before another physician from the Caro Family Physicians arrived and admitted her. Loo claimed that he did not diagnose the patient as having a stroke and that there was no bad faith on his part. The court of appeals reversed, holding that the plaintiff did plead sufficient facts constituting bad faith on the part of Loo. His failure to admit or otherwise treat the patient was a ministerial act for which governmental immunity does not apply and might be found by a jury to constitute negligence.

Right to Be Free from Restraints and Seclusion

The Code of Federal Regulations, Chapter 42 CFR § 482.13(e), provides that patients have a right to exercise their rights:

Right to Exercise Rights

The Code of Federal Regulations, Chapter 42 § 482.13(b), provides that patients have a right to exercise their rights: (b) Standard: Exercise of rights. The patient has the right to participate in the development and implementation of his or her plan of care. The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with § 489.100 of this part (Definition), § 489.102 of this part (Requirements for providers), and § 489.104 of this part (Effective dates). The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

Right to Access Lab Reports

The Department of Health and Human Services (HHS) released a statement on February 3, 2014, that strengthens the right of patients to access their lab test reports. As part of an ongoing effort to empower patients to be informed partners with their health care providers, the Department of Health and Human Services (HHS) has taken action to give patients or a person designated by the patient a means of direct access to the patient's completed laboratory test reports. "The right to access personal health information is a cornerstone of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule," said Secretary Kathleen Sebelius. "Information like lab results can empower patients to track their health progress, make decisions with their health care professionals, and adhere to important treatment plans."[38] Some hospitals have made it easier for patients to access their lab results by either hard copy or through electronic access.

Right to Know Hospital's Adverse Events

The Florida Supreme Court ruled in the cases Florida Hospital Waterman, Inc., etc. v. Teresa M. Buster, et al. and Notami Hospital of Florida, Inc., etc. v. Evelyn Bowen, et al. [33] that hospitals under Amendment 7 (approved by the voters on November 2, 2004, and codified as Article X, Section 25 of the Florida Constitution) must reveal their records of past acts of malpractice that have been performed at the hospital. In Florida, patients now have a right to know about, ask for, and/or receive records about adverse medical incidents that have occurred at the hospital. Amendment 7 to the Florida Constitution reads in part: Section 25. Patients' right to know about adverse medical incidents. (a) Patients have a right to have access to any records made or received in the course of business by a health care facility or provider relating to any adverse medical incident. (b) In providing such access, the identity of patients involved in the incidents shall not be disclosed, and any privacy restrictions imposed by federal law shall be maintained.

Right to Access Medical Records

The courts have taken the view that patients have a legally enforceable interest in the information contained in their medical records and therefore have a right to access their records. Some states have enacted legislation permitting patients access to their records. Patients may generally have access to review and/or obtain copies of their records, X-rays, and laboratory and diagnostic tests. Access to information includes that maintained or possessed by a healthcare organization and/or a healthcare practitioner who has treated or is treating a patient. Organizations and physicians can withhold records if it is determined that the information could reasonably be expected to cause substantial and identifiable harm to the patient (e.g., for patients in psychiatric facilities, institutions for the mentally disabled, alcohol and drug treatment programs).

Follow Discharge Instructions

The patient has the responsibility to follow up on physician instructions. Patients are not always reliable about following up on physician and/or hospital discharge instructions. Both hospitals and physicians are advised to have a follow-up process for their patients. The process should include a written discharge plan that is signed by the patient. A copy of which should be provided to the patient. Tom A. Augello, in his article "Diagnostic Failures Prompt Referral Changes," writes: When we looked at that and we thought about our referrals, we have actually quite a few and that's not unusual. We have 500 physicians, 17 locations, 350,000 patients, but each one of those referrals is an opportunity for an error. As Jessica mentioned, CRICO highlighted our need to really look at closing the loop on referrals, particularly making sure that when a referral is made that there is appropriate work done to ensure that the referral actually did happen. • • • To the complaint that this puts all the onus on the PCP and not the specialist or the patient him or herself, Dr. Lopez sympathized. But he said the system is designed only to involve the referring PCP when a high-priority referral is overdue. He said most of the specialties and their staffs in the Atrius Health system are integrated within the sites and within the electronic record system. So the specialty staff shares the monitoring of the referrals and does the initial patient follow-up. According to the experience of professional liability experts, patients are not reliable partners to ensure the referral is completed. The courts and juries often put the responsibility for follow-up on the physician who made the referral in the first place.[53]

Show Compassion for Caregivers

The public has an obligation to demonstrate the same respect, compassion, and empathy toward physicians as the public has come to expect for itself. These compassionate men and women have been committing suicide at such an alarming rate that there is a documentary soon to be released to bring awareness of the growing problem. Dr. Pamela Wible, a family practitioner, has researched the problem and found that: "patient deaths hurt doctors; malpractice suits push them over the edge; academic distress kills a medical student's dreams; assembly-line medicine kills doctors because a caring compassionate doctor can't take care of a complex patient in 15 minutes. He may be fired for lack of productivity or inefficiency."[55] They don't seek help when they need it because they fear retaliation or loss of privacy; long, stressful work hours breed post-traumatic stress syndrome.

Right to Respect

The right to respect is a common right enjoyed by patients, families, and caregivers. Respect is more than a two-way street. It is not just about what is right for you and me but requires respect of all persons regardless of culture and religious beliefs.

INTRODUCTION

This chapter provides an overview of the rights and responsibilities of patients. Every person possesses certain rights guaranteed by the Constitution and its amendments, including freedom of speech, religion, and the right not to be discriminated against on the basis of race, creed, color, or national origin. In addition, citizens have a variety of rights and responsibilities as provided for in federal, state, and local laws that are not in conflict with the Constitution. The Supreme Court has interpreted the Constitution as also guaranteeing certain other rights not expressly mentioned, such as the right to privacy and self-determination and the right to accept or reject medical treatment. A professional relationship between the physician and the patient is essential for the provision of proper medical care. Both staff and patients should be aware of and understand not only their own rights and responsibilities but also the rights and responsibilities of one another.

Stay Informed

Understand caregiver instructions. Consider the following case where a patient had been sedated during the performance of a colonoscopy at an endoscopy center. He decided to drive himself home against medical advice. Claims against the clinic and a nurse were dismissed with respect to fatal injuries that the patient received during a one-car collision. The trial court correctly ruled that the nurse had no duty to prevent the patient from leaving its premises once she repeatedly warned the patient not to drive. The nurse was justified in relying upon the patient's false representations that he had a friend available to drive him home. She was not required to keep the patient in a gown in the recovery room once she learned the truth, and she was not required to use other options to prevent him from driving, such as putting him in a taxicab, putting him in a hotel, calling the police, admitting him to the hospital, personally driving him home, taking his keys away from him, or physically restraining him. The center and the nurse owed no legal duty to the patient to do more than warn him that he should not drive. The center is not an insurer of the patient's safety. The patient acted recklessly in ignoring the advice he was given and suffered the consequences. The circuit court correctly found no duty to ensure that no patient drives after the procedure.[52]

Discharge Orders

When discharging a patient, a physician should issue and sign all discharge orders. If there is no need for immediate care, the patient should be advised to seek follow-up care with his or her family physician. The American Medical Association states in a 2012 report on Physician Responsibilities for Safe Patient Discharge from Health Care Facilities that "Physicians' ethical obligation to promote the well-being of patients includes the obligation to collaborate with other health care professionals to develop discharge plans that are safe for patients. The discharge plan should be developed without regard to the patient's socioeconomic status, immigration status, or other clinically irrelevant considerations."[34]