Physician-Patient relationship and Ethics Flashcards
A patient requires a treatment not covered by his/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
Informed consent (important notes)
- Patient must be informed that he/she can revoke written consent at any time, even orally
- Telephone consent is valid, but it should be documented
- Pregnant women can refuse procedures and treatments for their unborn children
- The health care worker performing the procedure should be the one to obtain consent
- Beneficence does not obviate the need for consent
Physician-patient relationship bounds
- No intimate social contact or dating with patients, parents of pediatrics or children of geriatrics
- Do not treat friends or family
- Do not prescribe for colleagues unless physician/patient relationship exists
- Any gift beyond a small token should be declined
- Physician is not obliged to accept everyone coming to him/her as a patient
- Physician has the right to end the physician/patient relationship but must give the patient sufficient time to obtain another caregiver
Should physicians answer questions from patient’s family without the patient’s explicit permission
No
Patient refuses lifesaving treatment on religious grounds
Don’t treat
Patient is angry about the long time he/she spent in the waiting room
Acknowledge the patient’s anger, but do not take a patient’s anger personally. Apologize for any inconvenience. Stay away from efforts to explain the delay
Organ and Tissue Donation
- Payment for organ donation is unacceptable except for renewable tissues such as sperm and eggs
- Only the organ donor network should ask for consent for the organs
- The family can refuse organ donation even if the patient has an organ donor card
A patient’s family member asks you not to disclose the result 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 info would be detrimental to patient’s condition. Explain that as long as the patient has decision-making capacity and does not indicate otherwise, communication of info concerning his/her care will not be withheld
Physician-Patient relationship Rules Set 3
11- Agree on problem before moving to solution
12- Be sure you understand what the patient is talking about before intervening
13- Patients do not get to select inappropriate treatments (explain why it’s not indicated!!)
14- Best answers serve multiple goals
15- Never lie
A 16-year old daughter refuses medication but her mother consents, do you write the prescription
Yes
Patient has difficulty taking medications
Provide written instructions; attempt to simplify treatment regimens; use teach-back method (ask patient to repeat regimen back to you) to ensure comprehension
Decision Making Capacity
- Competence is the legal term
- It is determined by the physician
- The components are:
- Patient is equal or over 18 years old or otherwise legally emancipated
- Patient makes and communicates a choice
- Patient is informed (knows and understands)
- Decision remains stable over time
- Decision is consistent with patient’s values and goals, not clouded by a mood disorder
- Decision is not a result of altered mental status (e.g., delirium, psychosis, intoxication)
Mother refuses to consent to emergency lifesaving treatment for her daughter on religious grounds
Treat
The order of criteria that the surrogates should use when making a medical decision for a patient
1- Subjective standard
2- Substituted judgment
3- Best-interest standard
Patient states that he/she finds you attractive
Ask direct, closed-ended questions and use a chaperon if necessary. Romantic relationships with patients are never appropriate
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 the right to make decisions regarding her child, even if her parents disagree. Provide info to the teenager about the practical issues of caring for a baby. Discuss options, if requested. Encourage discussion between the teenager and her parents to reach the best decision
A 17-year old girl who is pregnant, from whom do you obtain the consent
Her guardian
Justice
To treat persons fairly and equitably. This does not always imply equally (e.g., triage)
Good Samaritan Laws
No liability if you stop and help in non-medical settings provided that:
- Actions are within your competence
- Only accepted procedures are performed
- Physician remains at scene after starting therapy until relieved by competent personnel
- No compensation asked from the patient
What if the child’s life is at risk, but the risk is not immediate
Court takes guardianship
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 (e.g., “you still look good”)
An invasive test is performed on the wrong patient
Regardless of the outcome, a physician is ethically obliged to inform a patient that a mistake has been made
Confidentiality can be broken in
- Reportable disease (e.g., STDs, TB, hepatitis, food poisoning)- physicians may have a duty to warn public officials, who will notify people at risk
- The Tarasoff decision (detain the patient, call the police, and notify the possible victim)
- Child and/or elder abuse
- Impaired automobile drivers (e.g., epileptics)
- Suicidal/homicidal patients
- A valid warrant or subpoena from the court
Do Not Resuscitate Orders (DNR)
- Also there is DNI which is Do Not Intubate order
- DNR refer only to withholding cardiopulmonary resuscitation
Beneficence
Physicians have a special ethical (fiduciary) duty to act in the patient’s best interest. May conflict with autonomy.
A 17-year old girl who has been living on her own and taking care of herself, from whom do you obtain the consent
The girl herself
A 17-years old girl’s parents are out of country and the girl is staying with a baby sister, from whom do you obtain the consent
If a threat to health, the physician can treat under doctrine of in locum parentis
Nonmaleficence
“Do no harm”. Weighing the benefits vs risks. Most surgeries and medications fall into this category.
Order of Decision Making
1- A patient with capacity supersedes all else
2- Healthcare proxy that includes an agent (person) to carry out wishes (health power of attorney)
3- Living will
4- Persons clearly familiar with the patient’s wishes
5- Family in the following order (spouse, adult children, parents, then siblings)
6- Ethics committee (medical futility)
7- Court order
Note: last 2 points when the family is split and both of them not for step 1, just for step 2
The 4 D’s of malpractice
- Duty
- Dereliction
- Damage
- Direct cause
Physician-Patient relationship Rules Set 1
1- Patient is #1
2- Nothing should be between you and patient (ask family members to leave the room)
3- Tell the patient everything
4- Work on long-term relationships with patients (eye contact, defined touch, and same eye level)
5- Listening is better than talking (ask what the patient knows before explaining, end encounter by “Is there anything else?”, and allow silences while patients search for words)
Informed Assent
- It’s a child agreement to medical procedures in the situation that he/she is not legally authorized or does not have the capacity to give consent competently (e.g., clinical trials and terminal illness)
- You should take it in all children over the age of 12 y
- This form is in addition to, and does not replace parental consent on an Informed Consent Form
- Assent that is denied by a child should be taken very seriously
Family members ask for info about patient’s prognosis
Avoid discussing issues with relatives without the patient’s permission
From whom do you get permission to treat a girl who is 17 years old
Her guardian
Can you get informed consent from a schizophrenic patient
Yes, unless there is clear behavioral evidence that he is incompetent
Should physicians answer questions from insurance companies or employers
Not without a release from the patient
What if the family requests that certain info be kept from the patient
Tell the patient, but first find out why they don’t want the patient told
Informed consent (special rules for children)
- Children younger than 18 y are minors and are legally incompetent
- Exceptions are emancipated minors: 1) Older than 13 y and taking care of self (living alone) 2) Married 3) Serving in the military
- Pregnancy is a medical emancipation (the pregnant minor can just make medical decisions for her and her baby while she is pregnant)
- Partial emancipation: the minors can make decisions in theses 4 areas 1) Substance abuse treatment 2) Prenatal care 3) STDs treatment 4) Birth control
Patient is suicidal
Assess the seriousness of the threat. If it is serious, suggest that the patient remain in the hospital voluntarily; patient can be hospitalized involuntarily if he/she refuses
Must informed consent be written
No
Physician-Patient relationship Rules Set 4
16- Accept the health beliefs of patients
17- Accept patients’ religious beliefs and participate if possible (do nothing against your own religious or moral beliefs or anything which risks patient’s health)
18- Anything that increases communication is good
19- Be an advocate for the patient (never refuse to treat a patient because he/she cannot pay)
20- The key is not so much what you do, but how you do it (the right choices are those that are humane, sensitive, and put the patient’s interests first. Also treat family members with courtesy and tact, but wishes and interests of the patient come first)
A 16-year old daughter consents, but the mother refuses, do you write the prescription
No
Execution of prisoners and Torture
- The physician should never participate in executions at any level
- The physician are never to participate in torture even if they are a military doctors (Obligations as a physician supersedes the obligation to military). You should keep the torture “safe” so that it is not fatal or damaging and you are obliged to report it
What info can the physician withhold from the patient
Nothing. If patient may react negatively, figure out how to tell patient to mitigate negative outcome
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 sister’s death. Avoid cliches and euphemisms. Reassure that the boy is not responsible. Identify and normalize fears and feelings. Encourage play and healthy coping behaviors (e.g., remembering her in his own way)
Informed consent exceptions
- Patient lacks decision-making capacity or is legally incompetent
- Implied consent in emergency
- Therapeutic privilege (withholding information when disclosure would severely harm the patient or undermine informed decision making capacity)
- Waiver: patient explicitly waives the right of informed consent
Remove from patient contact health care professionals who pose risk to patients (Types of risks and actions)
- Types of risks are: infectious diseases (TB), substance abuse, depression (or other psychological issues), and incompetence
- Actions: insist that they take time off and contact their supervisors if necessary
Assume that every patient is competent except
- Suicide attempt
- Gross psychosis
- Decreased cognitive capacity (like dementia) that prevents communication
Informed consent requirements
The patient should receive and understand the following:
- Nature of procedure
- Purpose or rationale
- Benefits
- Risks
- Availability of alternatives
- Possible effects of no treatment
- The patient should be competent and make the decision free of coercion
A 17-year old girl who is married, from whom do you obtain the consent
The girl herself
Physician-Assisted suicide, Euthanasia, Terminal sedation and law of double effect, and Futile Care
- Physician assisted suicide is always wrong
- Euthanasia (administrating treatment intended to end or shorten life of patient) is always wrong
- Terminal sedation: it is acceptable to give pain medications to person with COPD who has metastatic cancer even if the only way to relieve pain is to give enough opiates that breathing may be impaired, causing the patient to die earlier
- Futile care: the physician is not obliged to render care that is futile (including tests and treatments)
Patient desires an unnecessary procedure
Attempt to understand why the patient wants the procedure and address underlying concerns. Do not refuse to see the patient and avoid performing unnecessary procedures
Parents rights in making medical decisions for their children
When parents refuse to give you a permission to treat:
- If immediate emergency, go ahead and treat
- If not immediate, but still critical, generally the child is declared a ward of the court and the court grants permission
- If not life- or limb-threatening, listen to the parents
Wife refuses to consent to emergency lifesaving treatment for unconscious husband citing religious grounds
Treat, no time to assess substituted judgment
Who owns the medical records
Health care provider, but patient must be given access or copy upon request
The mother of a minor consents, but the father refuses, do you write the prescription
Yes, only one permission needed
Must you get informed consent from a prisoner if the police bring in the prisoner for examination
Yes
Physician-Patient relationship Rules Set 2
6- Negotiate rather than order
7- Solve the problem presented (don’t assume that the patient likes or trusts you, and treat difficult or suspicious patients in a friendly, open manner)
8- Admit to the patient when you make a mistake
9- Never “pass-off” your patient to someone else
10- Express empathy, then give control: “I’m sorry, what would you like to do?”
Wife produces card stating unconscious husband’s wish to not be treated on religious grounds
Don’t treat
Autonomy
- The patient has the right to choose (accept or refuse) treatment
- Physicians are obliged to respect patients’ autonomy
- Exception are:
- The patient is infected with a highly infectious and dangerous disease (e.g., HIV)
- The patient has a greatly impaired decision-making capacity (e.g., a delusion impairing understanding of the condition)
- The patient’s autonomy is legally waived by the US government (e.g., epidemics)
A terminally ill patient requests physician assistance in ending his/her own life
In the overwhelming majority of states, refuse involvement in any form of physician-assisted suicide. Physicians may, however, prescribe medically appropriate analgesics that coincidently shorten the patient’s life
Patient is upset with the way he/she was treated by another doctor
Suggest that the patient speak directly to that physician regarding his/her concerns. If the problem is with a member of the office staff, tell the patient that you will speak to that person
A 17-year old girl is pregnant and requests an abortion
Many states require parental notification or consent for minors for an abortion. Unless there are specific medical risks associated with pregnancy, a physician should not sway the patient’s decision for an elective abortion (regardless of maternal age or fetal condition)
Can written consent be revoked orally
Yes
Patient is not adherent
Attempt to identify the reason for nonadherence and determine his/her willingness to change; do not coerce the patient into adhering or refer him/her to another physician
When should the physician provide informed consent
Always
Components of the Sick Role
- Two Rights
- The sick person is exempt from normal social roles
- The sick person is not responsible for their condition
- Two obligations
- The sick person should try to get well
- The sick person should seek technically competent help and cooperate with the medical professional
- Three variations: 1) Conditional 2) Unconditionally legitimate 3) Illegitimate role
- Does not apply to chronic illness or very minor illnesses
