Week 4 Bioethics & Health Systems (DLA16, L32, L34, L36, L38) Flashcards
In the US, what is the most uninsured ethnicity and what is the predominate reason why
- Hispanics, 24% (followed by Black 16%, Asian 15%, Whites 10%)
- many are only employed in a part-time status
what are the financial barriers causing Underinsurance
- health insurance does not guarantee financial access to care
- limitations of coverage restricts access to necessary services
- prohibitive insurance deductables, copayments
- gaps in Medicare coverage
- lack of coverage for long-term care
what are the non-financial barriers to Health Care (not the 4 A’s)
lack of prompt access, gender, race, literacy, disability, sexual orientation, geography, age
what are the 4 A’s of non-financial barriers to Health Care
- Accommodation: people are busy with work/commitments
- Availability: appt not soon enough
- Accessibility: took too long to Dr’s office/clinic
- Acceptability: Dr/hospital doesn’t take health insurance
describe the parameters of the Children Health Insurance Program
- low income children <19 y/o; not eligible for Medicaid and cannot afford health insurance
- federal funding covering up to 300% of FPL (Federal Poverty Line)
what is COBRA
Consilidated Omnibus Bidget Reconcilation Act (1985)
- workers who lost their job can continue health coverage for up to 18 mos
- must continue to pay premium
what is EMTALA
Emergency Medical Treatment and Active Labor Act (1986)
- prevent hospitals from dumping indigent/uninsured patients
- all hospitals that receive federal payments must screen and stabilize ER patients
Pts with least access to care (uninsured included) in general have the following outcomes
- more likely poor health status
- less likely receive medical care
- more likely Dx later
- more likely die prematurely
what are the causes of health disparities
behavioral, environmental, social, biological/genetic determinants of health
what are the two main causes of death in the US (include %)
- tobacco 18%
- diet/activity 17%
list some reasons for why death certificates are important
- burial permit
- settlement of deceases’s estate
- life insurance claim
- obtain death benefits
- termination of government services/obligations
- closure / peace of mind
- public health
crude death rate
deaths / population (usually per 100,000)
disease-specific death rate
deaths due to one disease / mid-yr population (in given time period- usually per 100,000)
age-specific death rate
deaths in age group / mid-yr population (in given time period- usually per 100,000)
- Neonatal Mortality Rate
- Infant Mortality Rate
- Under-five mortality rates
- NMR- deaths during first 28 days of life per 1000 live births
- IMR- deaths in 1st yr of life per 1000 live births
- <5- deaths in first 5 yrs of life per 1000 live births
maternal mortality rate
maternal mortality ratio
rate: maternal deaths / women of reproductive age
ratio: maternal deaths /live births
case fatality rates
deaths by one disease / total number of people with disease (as a percentage)
proportionate mortality rate
deaths by one disease / total deaths (as a percentage)
list the 5 bioethic principles
- Respect for persons: fidelity to Pt, respect for dignity/autonomy
- Beneficence: act in Pt interest
- Nonmaleficence: avoid harm to Pt
- Utlility: balance benefit, harm
- Justice: be fair
list the 3 common bioethic theories
- Duty-based (deontological): act to fulfill moral obligations
- Outcome-based (consequential): act to maximize outcomes
- Virtue-based: act from virtuous character and intention
list the 4 professional competencies
- cognitive
- integrative
- relational
- moral
list the 4 goals of medicine
1) prevention of disease & injury & promotion / maintenance of health
2) relief of pain & suffering caused by maladies
3) care and cure those with malady and care for those who cannot be cured
4) avoidance of premature death and the pursuit of a peaceful death
list the 3 common types of Justice
- Procedural: fairness of law/policy
- Distributive
- Social: improve conditions for those least well off
list the 4 elements of Respect for Persons
- Fidelity: loyalty, keeping promises
- Autonomy
- Veracity: truth telling (with almost no exceptions)
- Avoidance of killing
what are 4 key ways in showing respect to patients
1) attention to needs and individuality
2) empathy
3) information (disclosure)
4) dignity
compare positive and negative rights
Pos, requires actions: right to good/service, truthfulness (veracity), being fair (justice), acknowledge Pt preference, beneficience
Neg, requires no action: right to be left alone, protect privacy, avoid killing, nonmaleficence
list the 4 limits to Respect for Persons
- Harm Principle: actions taken on Pt to avoid harm to others
- Diminished Autonomy: no capacity to make decisions
- Paternalism: Dr knows best
- Public Health Protections
list the 5 values and behaviors of medical professionalism (according to WHO)
- responsible
- pyschologically mature
- possessing communication skills
- respectful
- smart
list some of the components of good first impressions
- attire / appearance
- voice
- level of attention: eye contact, prescence, friendliness, touch
- addressing the person: ask 1st, observe titles, cultural considerations
medical error is the __ leading cause of death in the US
3rd (communication between providers can reduce errors 30%)
list some communication basics and techniques
- nonverbal language / active listening
- adaptive questioning: open/closed-ended Qs
- facilitation: ‘go on’
- echoing
- validation
- reassuance
- summarization, empathetic responses
- highlighting transitions
- conflict management
define Informed Consent
process by which the treating health care provider discloses appropriate information to a competent patient so the patient may make a voluntary choice to accept or refuse treatment
list the 4 types of medical battery
1) no consent to any procedure
2) consent to a different procedure
3) same procedure, different body part
4) same procedure, same body part, different doctor
list the 5 elements of informed consent
- voluntarism
- capacity
- disclosure
- understanding
- authorization
what are the 4 components of Informed Consent that a physician must address
1) alternatives (including doing nothing)
2) inherent risks: probability, severity
3) who is providing treatment and their role(s)
4) physician experience
define capacity
ability to understand, make a decision, and communicate decision
compare capacity v insanity v competence
- Competence- legal determination (by court), applies to all decisions
- Insanity- legal determination, applies to criminal responsibility
- Capacity- clinical determination, decision specific
list reasons why a patient would lack capacity
- had it, lost it (ex. dementia)
- not yet acquired (ex. minors)
- never had capacity (ex. mental disability)
what is the hierarchy in a substitute decision maker
1) subjective: follow Pt’s instructions
2) substituted judgement: know the Pt well, decide as if they were the Pt
3) best interests: burden of Tx v benefits assessment
list criteria(s) for emancipated minors
- > 13 y/o
- married OR financially self-sufficient
- military service (17 y/o) with no parental support
list the Tx types where minors don’t need a SDM
- contraception, STDs, pregnancy
- mental health, EtOH/substance abuse
- emergency / trauma
- public health policy
describe physician detainment
- used if physician suspects harm to self/others OR infectious disease of great civil peril
- up to 48 hrs pending court hearing
- Pts lose the right to leave, right to refuse Tx remains
what are the 4 critical components of the patient-physician relationship once a relationship is formed
- standard of care
- confidentiality
- non-abandonment
- informed consent
what are the 5 exceptions to confidentiality
1) GSW or knife wounds
2) abuse, neglect (low threshold of reasonable suspicion)
3) communicable diseases
4) neurological impairment – affects driving
5) Pt poses threat to others
define medical malpractice
breach of any duty owed as a physician
list the 5 elements of respect for persons related to malpractice
1) commitment (don’t abandon Pt)
2) autonomy (informed consent)
3) fidelity (promise keeping & confidentiality)
4) veracity (truth telling)
5) competence (standard of care)
list the most prevalent fields by Medical Malpractice claims
- Neurosurgery, 19%
- Thoracic-CV surgery, 19%
- Gen. Surg., 15%
- Family Med., 5%
- Peds, 3%
- Psych., 2.6%
- All Others, 7.4%
Inpatient: (1) accounts for 34% of medical malpractice claims
Outpatient: (2) accounts for 46% of medical malpractice claims
1- surgical errors
2- diagnostic errors
list factors that are high risk for predicting malpractice
- inc age
- surgical specialty
- emergency department coverage
- inc days away from practice
- previous malpractice suit
list factors that are low risk for predicting malpractice
- scheduling enough time to talk to Pts
- answering phone calls directly
- satisfactory practice arrangements
- acknowledge one’s own emotional distress
what are methods or characteristics doctors that have never been sued have
- spent 3+ mins longer with Pts
- more likely to make orienting comments
- more likely to engage in active listening
- more likely to laugh during visit
what are common reasons patients sue for malpractice
- concern with standard of care
- need for explanation (how injury happened/why)
- compensation (for actual losses, pain, suffering)
- accountability
what are the four elements of malpractice litigation
1) duty- provide a certain standard of care
2) breach of duty
3) causation- Dr’s actions/negligence inc chances event
4) damages- to Pt
list some characteristics of typical Malpractice Patient Profiles
- majority female (60%)
- median age 38 y/o
- 20% were newborns
- ~12% >65 y/o
what are the 3 sub-elements of Breach of Duty in relation to Malpractice and lack of disclosure
1) had disclosure been made would Pt have consented
2) had disclosure been made would a reasonable person/patient have consented
3) was the materialized risk caused by the intervention
