Week 13 Ethics, Malpractice, and Professional Issues Flashcards
What is an important part of patient care that can minimize the risk of a formal patient complaint even when a mistake is made?
A Ensuring informed consent for all procedures
B Maintaining effective patient communication
C Monitoring patient compliance and adherence
D Providing complete documentation of visits
B Maintaining effective patient communication
Effective patient communication is key to building trust and rapport and ineffective communication is a predictor for malpractice claims. The other items are important aspects of care and may help the provider during the investigation of a claim, but do not minimize the risk.
What are some causes for failures or delays in diagnosing patients resulting in malpractice claims? (Select all that apply.)
A Failing to recognize a medication complication
B Failing to request appropriate consultations
C Improper performance of a treatment
D Not acting on diagnostic test results
E Ordering a wrong medication
B Failing to request appropriate consultations
D Not acting on diagnostic test results
Failing to obtain consultations when indicated or not acting on diagnostic test results can lead to diagnosis-related failures. Failing to recognize medication complications and ordering a wrong medication lead to medication prescribing allegations. Improper performance of a treatment can lead to treatment-related malpractice claims.
malpractice
Must have duty to patient
Must deviated from standard of care
Harm or damage must occur as a result
NO injury, then NO malpractice
A duty owed and duty breach that resulted in harm or injury= Malpractice
most malpractice claims are
dx related
misdiagnosis
Jane is a 30-year-old female, newly married, and not typically a patient of your practice. As your sister, she calls you while at work reporting 3 days of dysuria, typical for her previous experience of UTIs. She expresses frustration about urgent care wait times, ER costs, and unavailability of her primary care provider, which is why she’s asking if you will call-in a prescription for treatment.
All of the following would be concerns you respond to your sister with EXCEPT:
A You do not typically call in prescriptions for patients, so wouldn’t want to for her
B You are concerned that your personal relationship may limit both of your comforts in discussing critical information to treat this case appropriately
C The guiding AMA ethics strongly discourages this practice
D Without appropriate testing and follow-up established, starting an empiric treatment could cause her harm
E All of the above would be concerns to express
A You do not typically call in prescriptions for patients, so wouldn’t want to for her
While calling in such prescriptions for your patients may be part of your typical practice, there are several compelling reasons to object to this request of a family member. While state administrative rules governing the Board of Medicine may vary, the guiding principles from the AMA in this regard are clear. Treating family members is fraught with problems. Most notably is the limited comfort and interrogation of potentially sensitive information such as sexual/behavioral history and potentially relevant but previously unknown medical comorbidities. Physical examination is often sorely limited when involving family members for similar reasons. Furthermore, because of the blurring of personal and professional boundaries, this can introduce a slippery slope where one called-in prescription develops into enabling deleterious healthcare utilization (e.g., missing the opportunity for her primary care provider to track health maintenance and screening exams). Of additional legal and logistical concern is the under-documentation of such encounters.
Under what circumstances may it be appropriate to engage in such treatment of family members?
A. When the patient’s primary physician refuses to provide a prescription for a medicine your family member requests (e.g., Xanax for anxiety)
B. When no other provider is reasonably available due to the isolated, rural community (e.g., nearest primary clinic is 30 miles away and your aging aunt doesn’t drive out of town)
C. The trivially innocuous request on the part of the family member (e.g., left BP medication at home while out of town traveling for the weekend)
D. There is a minor, urgent need of the family member (e.g., needs sutures removed)
E. B, C, and D
E. B, C, and D
The rural family provider may find himself/herself in a unique circumstance of limited alternative resources for patients in the community to utilize. This can create a legitimate logistical exception to the ethical concerns surrounding treatment of family members “B.” It is prudent to anticipate how these relationships should be managed in the healthcare setting, setting up referral alternatives should there be such a conflict.
In addition to this, there may be appropriately innocuous circumstances that can be considered ethically appropriate (Answers “C” and “D”). Documentation of such medical encounters—be them with family or otherwise—should be approached in a consistent way. Particular concern should be paid to controlled substances (e.g., mental health and pain medications) as these often have further legal restrictions. It would also be entirely appropriate, and supported by the AMA Code of Ethics to answer “none of these” as permissable, at least in part because of the risk of such inconsequential encounters escalating to serious problems.
A 54-year-old married female, Charlene, has insulin-dependent diabetes and has seen you for her care for the last 7 years. In the last year, she has developed diabetic retinopathy and neuropathy. To your great frustration, Charlene continues to resist the recommended lifestyle changes required to control her diabetes.
She is a casual, friendly woman known as the “candy lady” in her neighborhood where she lives with her husband of 30 years. She loves children and volunteers at the local elementary school, where she is well known for a quick smile, a reassuring hug, and a piece of candy in her large, full pockets. In fact, she is noted during most of her appointments to be munching on M&M’s—her favorite candy. She has had dietary consults and many education-oriented doctor appointments but says, “I know I shouldn’t eat the way I do, but I just don’t have the heart to change who I am, even if it does help my eyes and legs. Who I am is about what I eat and do.”
You wonder about Charlene’s capacity for decision-making, given her frank noncompliance with care, even in the setting of serious complications from her diabetes.
All of the following variables are necessary in decision-making capacity (DMC) EXCEPT:
A. Ability to communicate a choice
B. Voluntary choice (e.g., absence of coercion)
C. Understanding of the variables involved in the decision
D. Ability to appreciate the personal impact of choices
E. Family agreement that the patient is competent
E. Family agreement that the patient is competent
All of the other options are considered important for determining decision-making capacity (DMC). Certainly family concerns need to be addressed, but family agreement has nothing to do with determining a patient’s DMC. One additional necessary element for respecting DMC is freedom from coercion or other external threats to a person’s right to self-determination (autonomy). In this regard, coordinating family agreement to pressure the patient into changing their decisions could be undermining the patient’s autonomy.
Which of the following is TRUE about decision-making capacity (DMC)?
A Patients who have been found legally incompetent do not have DMC
B A patient’s DMC may vary according to the circumstances of the situation
C A minor’s DMC is not clinically relevant since there is a surrogate who bears the responsibility for decision-making
D DMC should not be evaluated in cases in which the patient makes a conventional, recommended choice
E Patients with psychiatric disease, who are involuntarily committed to a treatment facility do not have DMC
B A patient’s DMC may vary according to the circumstances of the situation
DMC is largely considered on a sliding-scale, rather than an “all-or-none” distinction, since the threshold for reaching DMC can vary widely from case to case or setting to setting. Even patients who have been declared legally incompetent or who have been legally and involuntarily committed may still have a measure of DMC (for example, meal choices, etc.). Moral theory typically urges clinicians to consider the wishes and reasoning of their patients as morally and clinically relevant, regardless of the placement of a legal guardian or the state as a surrogate decision-maker. DMC may ultimately be overridden in certain kinds of legal circumstances, but it should not be done lightly as it suggests a fundamental denial of patient autonomy.
Just as no legal determination removes our responsibility to respect a patient’s autonomy, no particular diagnosis does either. As such, many patients with psychiatric illness still have the right to make choices, even with diagnoses such as schizophrenia. Additionally, making unconventional choices can sometimes be a marker that DMC is not intact, but does not automatically lead to this conclusion (a classic example would be an adult Jehovah’s Witness patient who refuses a blood transfusion; while this is an unconventional choice, DMC may be intact). Finally, though minors technically cannot make many healthcare choices, their wishes should be taken into consideration as they are often able to articulate a preference. In minors, this is termed “assent,” rather than consent. Children may not be able to understand enough to consent on their own but they can “assent” to (or protest) a particular plan of treatment.
Charlene continues to have a slow decline over time but remains in good spirits despite the complications of her uncontrolled diabetes. One day her husband brings her to the emergency department. He had found her in the bathroom, unconscious, and called an ambulance. She has had a stroke and remains unresponsive and is on a ventilator in the ICU. Her prognosis is poor.
What are appropriate considerations for making a treatment decision about end-of-life care for Charlene?
A Oral statements to her husband about her end-of-life care
B Her husband’s wishes for her care as designated proxy healthcare decision-maker
C Written advance directives
D Oral statements to her physician about her end-of-life care
E All of the above
E All of the above
Written advance directives are considered the most binding, since they are the patient’s own declaration of their preferences, although all of these considerations are relevant in making end-of-life decisions since all of them could inform the family and treating medical team on what the patient would have wanted given her critical illness. Since the family is likely also grieving about her poor prognosis, emotions could cloud their recollection of her previously informally expressed wishes. This underscores why anticipatory discussions and advance directives can be profoundly helpful.
Which of the following statements can be used to describe medical futility?
A No worthwhile goals of care can be achieved
B The likelihood of success is negligible (any intervention would be “futile”)
C The patient’s quality of life is unacceptably burdensome
D All of the above
D All of the above
All of the above meanings have been explicitly or implicitly drawn into discussions about medical futility. Because of its variable interpretations and explanations, many theorists have objected to the use of the term “futility” as a justification for decisions and urge clinicians to be precise when “futility” is used as an argument to withhold care (e.g., the patient has metastatic lung cancer including to the brain, has been resuscitated two times already, may be resuscitated for this particular cardiac arrest but will never regain consciousness, will likely arrest again within the next 8 hours due to the underlying disease, and will never be able to be weaned successfully from a ventilator).
After discussion with her husband, you decide to discontinue ventilation. Charlene dies.
This intervention is appropriately considered:
A Active, involuntary euthanasia
B Physician-assisted suicide
C Withholding medical intervention
D The principle of double effect
E Withdrawing medical intervention (passive euthanasia)
E Withdrawing medical intervention (passive euthanasia)
While the answer might seem intuitive to you, many persons (including physicians) do not recognize the differences between these various interventions. Active euthanasia (“A”) is when the physician both supplies the means of death and is the final human agent in the events leading to the patient’s death (e.g., the physician administers the lethal drug). Whether or not active euthanasia is voluntary, involuntary, or nonvoluntary depends on the DMC of the patient and their consent to the process. Assisted suicide (“B”) occurs when the physician provides the means of death but the patient carries out the act, such as taking an overdose of phenobarbital. Withholding medical intervention (“C”) means not initiating care for a disease state so that the disease itself results in death (e.g., not placing a gastric tube for artificial feeding in a patient with end-stage dementia). Withdrawing medical intervention (“E”) means discontinuing an intervention that has already been used, although the disease state itself results in death with the intervention’s discontinuation. Both of these (“C” and “E”) are forms of passive euthanasia, where withdrawing life-sustaining treatment, or not starting it, leads to death. The principle of double effect (“D”) is an ethical theory that suggests that if there is an unintended but anticipated bad consequence (e.g., earlier death) while pursuing an intended purpose (e.g., pain relief), there is diminished moral responsibility for the unintended outcome. This principle is sometimes used to justify the use of high-dose opiates or sedatives in patients with intractable pain or dyspnea, even when the unintended effect is respiratory depression and death.
Which of the following is TRUE about the role of law in life-sustaining interventions?
A Courts must be involved in decisions after a patient has been declared to not have capacity
B Life-sustaining treatment may be withheld only if patients are terminally ill or permanently unconscious
C Physicians may face criminal charges for providing appropriate palliative care and not treating the underlying disease
D The most prudent legal advice is to continue treatment in medically futile cases
E The law presents few barriers to physicians withholding life-sustaining interventions
E The law presents few barriers to physicians withholding life-sustaining interventions
Sometimes physicians inappropriately provide treatment to patients who have made their end-of-life choices clear and have stated that they do not want prolongation of life. Respecting the patient’s prior wishes will not result in legal liability for the physician, but the converse is not true; one can be legally liable for treating a patient who does not want treatment (e.g., transfusing a Jehovah’s Witness patient who refused transfusion). While they are exceedingly rare, there are case reports of “wrongful life” malpractice suits against providers who ignored advanced directives to withhold life-sustaining treatment. There is still a risk-management, and likely professional and moral preference to “err on the side of life” when there is ambiguity about the patient’s advance directives. While state laws vary, generally speaking “A” is incorrect, since surrogates for the patient have the authority to make decisions after the patient is declared not to have capacity. This may be a relative, a healthcare provider, or court-appointed surrogate. “B” is also incorrect as treatment may be withheld at any time at the request of a competent patient.
Robert, a 27-year-old married nurse from your hospital, is referred to your emergency department for an urgent evaluation by his supervisor. In the past 2 weeks, he has been noted to be increasingly distressed while at work, with occasional tearfulness, distractibility, and irritability.
During the initial assessment, Robert reveals that there is a specific reason that he has been so preoccupied. He indicates that 2 weeks ago he was jailed for operating a vehicle while intoxicated and that he feels ashamed. He is afraid that his coworkers have read about it in the newspaper, although no one on his floor has indicated that this is the case. This is his first legal infraction of any kind and he describes it as humiliating.
On further questioning, Robert indicates that he uses alcohol regularly. While it has not overtly affected his work as far as he can tell, it has caused significant marital strife. He reports that his pattern is to stop by the bar on the way home from work to “relax and let go of the hospital stuff that I worry about.” He typically drinks three beers and then drives home, where he continues to drink beer throughout the evening. He notes that his wife and kids complain that he is emotionally absent and even irritable with them, but he says that his family simply doesn’t understand the stress of the workplace and his need to “forget about it for a few hours.” He and his wife have started arguing lately about his alcohol use, especially since the driving charge. He takes special exception to her stating that he is an “alcoholic.”
As you take the history, Robert begins to be more guarded in his responses and more restricted in his affect. Suddenly, he blurts out, “I don’t think I’m an alcoholic, but I don’t want you to put anything in my record about any of this stuff! And I want you to tell my supervisor that there are some personal problems going on at home and that I’ll be fine in a few days.”
Which of the following statements is TRUE about your obligation with regard to documentation in the chart?
A You are obligated to document the visit as it occurred so far as the medical facts are concerned, including the concern about alcohol abuse
B You can enter incorrect information into the chart in order to protect the patient
C You are under no obligation to document anything said and can withhold information from the chart at the patient’s request
D Hospital administration or legal counsel should be involved if information is going to be purposefully left out of the chart
E You can lie in the medical record … we’re pretty sure perjury, liable, and slander don’t apply to doctors
A You are obligated to document the visit as it occurred so far as the medical facts are concerned, including the concern about alcohol abuse
The ethical principles of beneficence, nonmaleficence, and justice drive the decision here. A patient may legitimately ask for nonactive medical problems (e.g., distant history of sexual abuse) to be withheld from current documentation of an active problem. However, a patient cannot legitimately ask to have information withheld from the record if that information is pertinent to an ongoing condition currently being evaluated and treated. In this case, Robert is receiving care simply by virtue of being seen in the emergency department and disclosing the chief complaint and its associated variables. It is important for you to be forthcoming in explaining why the information may not be withheld from the medical record and also in reassuring him that irrelevant medical information will be omitted from the record if he feels that this is necessary. For example, the specifics of the argument with a wife need not be detailed beyond the comment that there is nonviolent marital conflict over the patient’s alcohol use—important because it supports an alcohol abuse disorder. Furthermore, the patient can be reassured that many institutions have specific policies on managing sensitive medical information and there may be a formal mechanism for increasing the security of the patient’s medical record.
Why is protection of confidentiality important in medical practice?
A It shows respect for patient autonomy
B It helps prevent stigmatization and discrimination against patients based on private medical issues
C It helps solidify trust within the physician–patient relationship
D It helps establish a boundary between the physician–patient relationship and the rest of the medical system
E All of the above
E All of the above
The physician–patient relationship is a long-honored tradition in medicine that is increasingly fragile in a medical system with numerous competing obligations. Nevertheless, it is prudent to remember the aspect of the Hippocratic Oath, which states, “What I may see or hear in the course of the treatment … which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.” This is not only important to the tradition of medicine itself but also to the physician–patient relationship. There is no doubt that loss of confidentiality may cause harm to the patient when others are in possession of confidential medical information. Such harms may be as overt as denying insurance coverage for certain genetic conditions or as subtle as devaluing a person waiting to see the psychiatrist. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) codified confidentiality and disclosure of protected health information to respect individual privacy.
Which of the following are legally protected exceptions to the rule of maintaining patient confidentiality?
A Reporting tuberculosis to public officials without patient consent
B Warning a third party at risk of imminent and serious bodily harm from the patient without patient consent
C Reporting a patient’s alcohol abuse to a work supervisor without the patient’s consent
D A and B
E All of the above
D A and B
Under current national and state laws, physicians are mandatory reporters of some infectious diseases, of intent to harm another, and of child / dependent-adult abuse. In most other cases, provision of protected health information without the patient’s written consent is not legally protected, although there may be cases in which it is felt to be morally justifiable. Physicians need to weigh violations of patient confidentiality very carefully, even when legally sanctioned. Ethicists typically agree that if a physician is going to compromise a patient’s confidentiality for an overwhelming moral obligation, the patient needs to be notified out of respect for his/her autonomy. In many situations in which a physician hopes to communicate confidential information to a third party even when the patient is unwilling, a process of education and negotiation with the patient occurs such that respect for autonomy is acknowledged while simultaneously making the patient aware of competing moral obligations.
Which of the following interferes with protecting patient confidentiality in the medical structure?
A Involvement of managed care organizations in patient care and medical payments
B Electronic records and transmissions
C Group practices and/or teaching hospitals with multiple care providers
D A and B
E All of the above
E All of the above
While individual physicians and patients continue to prize the tradition of respect for confidentiality, the multiple players in healthcare make it nearly impossible to restrict all information to the dyad of physician and patient. Insurance companies will not provide payment without, at least, information about the diagnosis, and notably, insurance companies are not legally bound by the same codes of conduct that apply to physicians regarding patient privacy. Electronic records and transmissions by e-mail, cellular phones, faxes, and other means are much more easily accessed by the curious or unintended recipients who have no reason to have confidential information. Open waiting rooms and multiple providers of care mean that larger and larger numbers of the community are aware that a patient is being seen in certain clinics for certain purposes. Once information is in written form, it is more difficult to control who might, either now or in the future, have access to the details of the report. For this reason, some physicians try to err on documenting only that which is considered absolutely necessary to patient care, although the distinction between the “absolutely necessary” and unnecessary can be a difficult line to draw in the sand, especially without the ability to appreciate how multiple variables may play out in the patient’s future medical care.
Back to the patient at hand … Robert is asking you to be deliberately deceptive with the supervisor. You disagree with this.
Which of the following is FALSE?
A Trust in the physician–patient relationship depends on allowing the patient to make such a directive about communication with outside persons
B A physician who establishes a precedent for deception may be expected to practice deception in a future situation in which the harms greatly outweigh the benefits
C A physician who deceives may undermine general trust in the profession
D All of the above
A Trust in the physician–patient relationship depends on allowing the patient to make such a directive about communication with outside persons
Another way of phrasing the question is, “What drives a physician to be honest even when what the patient really wants is not honesty?” Will the patient trust you more if you are deceptive for him? Will this help him (aside from allowing him to keep his job)?
The physician–patient relationship is generally not considered an adequate reason to lie to a third party about the nature of a patient’s illness and treatment. There has been concern that a physician who deceives a third party, even in the immediate interest of the patient’s confidentiality or other concerns, establishes himself or herself as a physician who may not be trustworthy in other matters. A patient may not consider this at the time a deception is requested. These kinds of ripple effects from the decisions of an individual physician can affect the profession in general, ultimately producing fears that physicians will take the self-serving path rather than the higher moral ground.
You tell Robert that he has alcohol dependence and then provide education about the diagnosis and treatment options. You recommend outpatient treatment in Alcoholics Anonymous (AA) and a chemical dependency program. Robert agrees, more for the sake of his family stability rather than because of any true insight into the severity of his problem. You then arrange for follow-up with one of your partners.
At the next appointment, Robert meets his new physician, Dr. Pincus. At this appointment, Robert indicates that he did attend two AA meetings but was very uncomfortable with the aspect of the 12-step program that requires acknowledging a “higher power.” Robert indicates that he is an atheist and secular humanist, believing that the locus of self-control comes from within the individual human spirit. He has refused to continue in AA due to his rejection of its theistic foundation. He has had no further legal problems and reports that work is still going fine, with diminished irritability once he resolved in his mind that his coworkers were unaware of his previous driving violation. However, he continues to drink six to nine alcoholic beverages per night and admits that he occasionally needs a shot of whisky in the morning to “make sure I don’t lose it with all the work stress” (this is where his self-control theory really comes together). He also works a night shift about once per week and does use approximately the same amount of alcohol before beginning the night shift, although he denies being intoxicated while on the job on these nights (“My tolerance is high and six beers are no big deal”). He doesn’t think this is a problem because “things are quiet at night and everyone just helps each other keep the patients comfortable.” He reports that his family is satisfied with the decrease in consumption and that he considers the matter of alcohol abuse resolved.
Dr. Pincus has had her own problems with alcohol in the past. She has had a rocky course over the past many years but found AA to be very helpful. She has become very active in her Jewish synagogue and community, where she receives support and is accountable to her friends. Her own alcohol history has been marked by difficulty with alcohol bingeing, such that when she starts to drink, she drinks to intoxication. Only with aggressive honesty at a professional-group AA, as well as a substance abuse protocol through the state board of medical examiners, does she feel that she’s been able to remain completely abstinent for the last 4 years.
Dr. Pincus is considering revealing to Robert some of her own struggles as a healthcare professional with a substance abuse disorder. She believes that this will help him reevaluate the role of AA in sobriety and the importance of very tight control of alcohol consumption to prevent relapsing illness.
Self-disclosure is best described as involving the ethical issues of:
A Deception and nondisclosure
B Privacy and boundaries
C Informed consent
D Impaired colleagues
E Autonomy
B Privacy and boundaries
There are explicit and implicit boundaries that exist between a physician’s private experiences and the physician–patient relationship. One of these boundaries has to do with preventing physician needs and private matters from encroaching into the visit in a way that is not therapeutic to the patient and does not respect the physician’s boundaries. While it would appear that Dr. Pincus has therapeutic reasons—for Robert, not for herself—for crossing the boundary of self-disclosure, both physician motivation for self-disclosure and the immediate and potential effects of the self-disclosure need to be weighed very seriously before private matters are revealed. If there is even a potential of harm, crossing the boundary in this way should be considered a violation of professional norms.
