Topics on exams
Yüklə 0,87 Mb.
|
| party examinations!!!
•ACTS THAT CREATE A PPR 15 PPR created when: •scheduling or agreeing to see a walk-in patient, even if done by staff •accepting a referral, even if the patient fails to show •making any contact with a patient of another physician for whom you’re providing coverageCont.: •discussing your medical findings with or providing records to a patient you’ve examined on behalf of a 3rd-party •providing an informal consult and your managed care contract indicates that you have a PPR with all enrollees •if you bill patients for any service •Suggestions ��learn limits of responsibility when giving advice to treating physicians (review contracts!) ��document nature of any consults (may help to limit liability) •Don’t assume because a court in one state has ruled that a physician is not liable in a particular situation that the court in other jurisdictions will reach the same conclusion. The outcome often depends heavily on the facts of the specific case. 16 •Malpractice & “Non-Patient” Emergency Cases ��In most states, physicians are not required to provide assistance, even in an emergency, to a “non-patient.” However, Good Samaritan Laws may protect those who do help. Good Samaritan Laws •Laws that limit a person’s liability when physicians help at an accident (some laws are written to protect anybody who helps; others are specific to physicians) •Every state has its own adaptation of this law. But, typically physicians are shielded from liability if: •there is no PPR •actions are within the scope of physician’s competence/confidence •physician remains at scene after starting tx until relieved by competent personnel •no compensation exchanges hands ��Cases from several jurisdictions in the last few years have extended immunity to physicians who voluntarily respond to non-patient emergencies WITHIN the hospital. 17 Saks Study • A negligent doctor who causes injury has a probability of sued of 3 out of 100. • A non-negligent doctor has a probability of being sued for a non-negligent injury of 13 out of 10,000. • Thus, for every malpractice claim in response to a negligent injury there are 15-30 malpractice victims who bring no suit but there are 4-5 claims brought by non-negligently injured patients.
• In the summer of 1973 Donald "Dax" Cowart was critically injured in an explosion in which his father lost his life. Dax was left blind, with third-degree burns over more than sixty-five percent of his body. Despite his repeated demands that they be stopped, Dax was ignored and forced to undergo excruciating medical treatments and surgeries for more than a year. In the end he suffered severe disfigurement, the loss of his fingers, permanent hearing loss, and blindness. Why have ethical guidelines for clinical practice?
Hippocratic oath- I will prescribe regimens for the good of my patients according to my ability and my judgement and never do harm to anyone (euthansia). To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. Beneficiance (doing good) is closely associated with the traditional hypocratic obligation at least not to harm the patient, or the principle of nonmaleficence (doing no harm).
Bad Blood: The Tuskegee Syphilis Study • For forty years, from 1932 to 1972, 399 African-American males were denied treatment for syphilis and deceived by officials of the United States Public Health Service. • As part of a study conducted in Macon County, Alabama, poor sharecroppers were told they were being treated for “bad blood.” • In fact, the physicians in charge of the study ensured that these men went untreated. In the 25 years since its details first were revealed, the Tuskegee Syphilis study has become a powerful symbol of racism in medicine, ethical
• Tuskegee Syphilis Study • Compensation $10m(equivalent) in 1974 • Unethical cases- Therefore now have Guidelines for Ethics Conduct of Biomedical Research Guidelines for Ethical Conduct of Biomedical Research
In the US…... National Commission for the Protection of Human Subjects of Biomedical & Behavioural Research -1974 • Consist of Internal/Institution Review Board (IRB) • Federally mandated councils • Human clinical studies must elect these committees to oversee all research. • Composed of professionals, attorneys & lay-people • For protection of rights & welfare • Prior approval needed for research Problems with IRBs • Lack training • Overworked • Conflict of interests • No monitoring of IRBs
Medical Ethics Regulations and Regulatory bodies. AMA Ethical Guidelines • The American Medical Association (AMA) publishes an ethics guide for physicians – Code of Medical Ethics: Current Opinions with Annotations – Standards geared to physicians, but applicable to any health care practitioner AMA Ethical Guidelines • Abortion Encourage minors to discuss pregnancy with parent(s) Parental consent for an abortion is not considered mandatory Not prohibited if performed in a legal manner and consistent with good medical practice • Parental Consent Abuse • Spouses, Children, Elderly Persons, and Others at Risk Recommended intervention: •suggesting abuse has occurred •discussing safety methods available •discussing community resources •providing support •documenting incident for future reference Physicians should should know and abide by state reporting laws - - report incidents even if not required by law Allocation, Cost and Service Issues • Allocation of Limited Medical Resources • Medical Futility in End-of-Life Care • Provision of Adequate Health Care • Unnecessary Services Allocation, Cost and Service Issues Benefit to the patient is the physician’s primary factor in determining resources for medical treatment. Medical treatment should not be provided if, in the physician’s professional judgment, the patient will not benefit. Criminals and Capital Punishment • Capital Punishment • Treatment of Criminals
• Physicians may treat prisoners if • treatment will benefit the patient • informed consent is obtained • treatment is for therapeutic purposes
• Clinical Investigation • Research should produce data that is
• Subjects should be treated with same concern for health and safety as those patients not in a study • Physician-patient relationship must • remain a priority • Written consent must be obtained Research-Related Issues In addition to the clinical research guidelines, • Animal studies should be performed prior to fetal research. • Fetal material should not be purchased. • Fetal Research
• Patenting the Human Genome • Gene Therapy • Genetic Counseling • Genetic Testing by Employers • Insurance Companies and Genetic Information • Genetic Testing of Children Research-Related Issues Granting patent protection should not hinder the development of beneficial technology. Genetic manipulation to enhance desirable characteristics is not acceptable. Genetic counseling may be appropriate for parents with increased risk for genetic disorders. Research-Related Issues Genetic testing should not be used to screen employees Physicians should not perform genetic testing for insurance companies to predict a person’s predisposition for disease Benefits for genetic testing of children should outweigh the risks Assisted Reproduction • Artificial Insemination by Known Donor • Artificial Insemination by Anonymous Donor • Surrogate Mothers • In Vitro Fertilization • Embryos – Frozen pre-embryos • Human Cloning Assisted Reproduction Artificial insemination requires informed consent. Donor sperm must be prescreened for infectious or inherited disease. Surrogacy contracts should allow the birth mother the right to void the agreement. Gestational agreements should not be voidable. Assisted Reproduction Fertilized ova not used for implantation should not be used for research. Both donors should provide written informed consent before disposition of frozen embryos. Physicians should not participate in human cloning at this time. Organ and Tissue Donation & T• rCaonmspmlaenrtcaiatilo Unse of Human Tissue • Financial Incentives for Organ Donation • Mandated Choice and Presumed Consent for Cadaveric Organ Donation • Organ Procurement Following Cardiac Death • Organ Transplantation Guidelines Organ and Tissue Donation & Transplantation • It is unethical to participate in a plan that pays a donor for an organ to be transplanted. • A donor may be reimbursed for the expenses incurred in removal of the organ. • Physicians should encourage voluntary organ donation. Organ and Tissue Donation & Transplantation • Medical Applications of Fetal Tissue Transplantation • Anencephalic Neonates as Organ Donors Organ and Tissue Donation & Transplantation Safeguards should be taken so a decision to have an abortion is not influenced by the decision to donate fetal tissue. Anencephaly is congenital absence of most of the brain, skull, and scalp. Until determination of death is made, lifesustaining measures may be used to maintain organ viability for transplantation. Choices for Life or Death • Withholding or Withdrawing Life-Sustaining Medical Treatment • Euthanasia • Physician-Assisted Suicide
• Treatment Decisions for Seriously Ill Newborns • Do-Not-Resuscitate Orders • Optimal Use of Orders-Not-To-
• Encourage voluntary testing • Testing may be performed without consent when health care workers are at risk because of exposure to body fluids. • Publication of data from unethical experiments should be provided only if human lives could be saved or benefit from findings.
Termination of pregnancy 1st trimester: PT has right for abortion, regardless of reason 2nd trimmest: have right of abortion if it is not endangering their life: 3rd trimester: abortion is illegal, unless continuation will cause some threat for the mother before 21 weeks, PT can go for abortion After 21 weeks, PT cannot have abortion
Jehovah’s witnesses- patients reject blood transfusion so you must inform them of the real nature of her condition and the risks of not having transfusion……if they insist on alternative therapy, then try other nonsurgical invasive procedures or embolize the uterine artery. Another acceptable alternative is to collect autologous blood during surgical procedure rather than before, mix the blood with appropriate amount of crystalloid (NOT albumin) to maintain normovolemia and then reinfuse at end of surgery. If patient has cancer then granulocyte colony stimulating factor (GCSF) is used as adjunctive treatment to delay duration of neutropenia. In any case, avoid medical delay…..the patient’s right cannot be ignored however a physician may decide to refuse to administer the alternative treatment, so transfer to another physician.
Informed consent- elements Threshold requirement:- Competence (Determination of whether or not a patient has the capacity to either consent or refuse a proposed intervention ) Information requirement:- Information (Diagnosis, prognosis, risk of no therapy, outcomes), Understanding (How will the available options affect his or her life? ) Consent requirement:- Consent (The voluntary & uncoerced choice of the patient ) and Authorization (This takes place when an individual with the appropriate authority gives approval. It may also be done by patient or a representative of the patient)
–Obtaining agreement for plan of care –Freedom from coercion
Informed Consent 1.Is an ethical standard 2.Respect for patient autonomy 3.2Legal requirement 4.Is a process with several steps: – Deontology: Ethical theory concerned with duties and rights. – utilitarianism the theory that the rightness or wrongness of an action is determined by its usefulness in bringing about the most happiness of all those affected by it. Case
• A 32-year-old female is brought to the ER with headache, nausea, vomiting, and fever. • On physical examination she is having severe rigidity of neck. • An LP was done which showed Gram positive diplo-cocci. • She was prescribed injectible antibiotics which he refused. Case
• She thinks that the nurse is trying to poison her. Case • What is the medical indication for treatment? • Is this a life threatening emergency? • What goals of medicine can be achieved? • Does he has the capacity to make decision? Informed consent • Purpose • Risk • Benefits • Alternative Exceptions • Emergencies • Not competent • Threshold requiremThreshold requirement • Competence • Information requirements • Information • Understanding • Consent requirements • Consent • Authorisation Legal elements of informed consent • Threshold requirement • Competence The legal determination of whether or not a patient has the capacity to either consent to or refuse a proposed intervention Appropriate criteria for determining competence is unclear Once a person reaches the age of majority(18y.o-USA) it is generally considered that they are competent
Legal elements of informed consent • Information requirements • Information A patient is entitled to all the information available about their case which may be pertinent to making a properly informed decision about treatment. Overt attention to cost of treatment by the physician may indicate to the patient that there is a conflict of interest Although financial information should be made available to the patient if requested, it may not be the role of the physician to provide this information The desire to deliver information sympathetically should not preclude the provision of all necessary information The successful delivery of information may be facilitated by involving the patients spouse or adult children in the information process Legal elements of informed consent Has adequate info been provided to pt?
3.2 sorts of information: 4.1)Professional Practice Standard- same medical info given by all other physicians e.g. appendicits. 5.2)Reasonable Person- Dr provides enough info so reasonable person can decide to consent RX. Pt can make prudent decision • Information requirements • Understanding A patient may not always be able to adequately understand medical processes, and thus it may not be possible to fully inform them of the exact nature of a specific course of treatment – this draws into question the whole notion of informed consent Information should be conveyed in functional rather than scientific terms so that the patient is at least able to understand the principle of how a speciiffiic ttrreattment will affect their life. Written info/leaflets. Don’t ask,just give patient the leaflet. Legal elements of informed consent 10 • Consent requirements • Consent The voluntary and uncoerced choice of the patient Should involve deliberation and reflection based on one’s own values The effect overt and covert constraints and facilitators, such as medication, mechanical restraint, family pressure, financial pressure, have on the patients choices should be considered by the physician Legal elements of informed consent • Consent requirements • Authorisation The presence of a written declaration of consent will not be ethically or legally valid if it does not represent actual informed consent(clearly state rx/side effects) The verbal declaration of consent may be a valid, even in the absence of a written document, however, the latter usually supports the former Witnessing the signing of a consent form does not ensure that the patient has actually understood the nature of their consent, only that they did actually sign on the dotted line. Eg of consent form:
Legal elements of informed consent Emergencies • What if not able to give consent in emergency? • Beneficence overrides autonomy in life threatening case. Dr has right to rx in this case without consent. • Time is critical(VF-defibrillate) • Incompetent pt without substitute decision maker (transfusion/intubate) Substitute Decision Makers • Supports autonomy- Dr & family make decision, not just Dr. • Surrogate Decision Makers: • 1)Legal guardian with express authority to make health care decision • 2)Adult child of the patient • 3)A parent of the patient • 4)Domestic partner 11 • 5)Brother or sister • 6)Close friend • If no friends/no family: Ethics committee(2 DR’s consultation). Decision based on substitute judgment & best interest. • Best interest Standard= quality of life vs treatment If quality decrease significantly ,is the rx best interest? Involuntary Hospitalization • Ethical justification- beneficence overrides autonomy • Standards- – mental illness – Dangerous: to others or self – grave disability Commitment Process • 1)Application for admission • 2)Examination • 3)Court hearing • 4)Right to least restrictive environment • Physician detains 72hrs (hold until judge says otherwise) • Court Judge committs 60-90 days • Then another hearing for reassessment for further necessary hospitilization • Note: hospitililization vs Treatment – Not the same – eg. 72hrs-court order for committing due to danger. But if now pt refuses treatment, then:
– Is pt competent to refuse treatment? – Now another hearing takes place(wks…) 12 Case
“Do everything”: Physician obligations in the face of family demands • Evelyn, 86y.o. widow • Dementia, severe ischemic cardiomyopathy • Nursing home,bedridden 1 yr • Poor communication • Recognize loved ones-uncertain • SOB developed & increasing- Admitted • Rxed for pneumonia & CHF • Despite resolution of conditions,still poorly- dypnea,tachycardia,bilateral pleural effusions. EF=18% • Thoracentesis-200ml fluid removed. Tolerated well but no significant improvement. Pulse ox^/sat rate= 70- 80% on O2 • Physician decides to speak with family regarding resus status since poor short & long term prognosis. • Family want “everything done” • Grandson dermatologist insists on cardilogic & pulmonary consultation & ICU transfer. Wants 2nd thoracentesis to drain completely effusions. • Requests chemical pleurodesis to prevent fluid reaccumulation or drum catheter inserted for withdrawal of fluid PRN. • Evelyn’s DR is hesitant. States fluid will raccumulate & mechanical restraints needed to keep devices in-situ. Pleurodesis painful & unsafe • Certain cardiac or respiratory arrest soon. • CPR would fail. But if revived would face uncomfortable few days on respirator. • Family adamant. “nothing worse than death” Admit Evelyn did not express RX wishes. • ICU attending physician refuses to admit. States family is crazy. • ICU Dr advises Evelyn’s physician to not do ABG, since poor result gives family more ammunition. 13 Medical considerations • What is the prognosis for a pt with advanced CHF who is 80yrs old? • Has intractable,chronic CHF & class iv sx of New York Heart Association • Cardiac mortality highest in pt’s with EF
• Medicare aged people CHF prognosis is limited- 6yr survival= approx 13-25% (ist hospitilization) • Evelyn is very elderley, functionally impaired & intractable sx of HF. Satisfies all National Hospice Organization prognostic criteria for early mortality in heart dz & has grave prognosis. • 2)What benefit could Evelyn derive if she were admitted to an ICU? • For chronic CHF has no benefit. No palliative advantage to an ICU admission. • Invasive rx,noisy monitoring devices, frequent • Monitoring & overall ICU environment may reduce comfort level. • NO CLINICAL BENEFIT • 3)What would be the value of a drum catheter or chemical pleurodesis? • Procedure to prevent fluid accumulation • Temporary & partial palliation prodused but no long-term benefit in this incurable illness. • Painful procedure • Better= drug management of HF & O2 nasal cannula • 4)What would be the rationale for performing an ABG? • To determine the need for intubation • Supply important info about pt’s prognosis • Will define how to proceed BUT reluctance in Evelyn’s case because a poor ABG result might fuel the family’s demands 14 What needs to be frankly defined with the family? • 1)Which interventions,if any provide relief of sx’s or restoration of funx & • 2)Which prolong her dying & in fact may cause discomfort in the process Ethical & Legal considerations • 1)How should discussion proceed with this family? • Need meeting with key involved family members & critical members of health care team. • Involved physicians explain objectively & in understandable language the pt’s current clinical status,short & long term prog & options available for sx management. • Explain clinical experience has shown that pt’s in Evelyn’s condition survive few days-weeks only • Clarify motivation behind family’s demands(“everything be done”) – Based on religion? – Do they feel Evelyn would wish to be alive for family occasion-wedding/birth? – Explain their emotional needs may obsecure best interest of pt • Tell family directly, Evelyn is dying regardless of rx rendered. • Family role is to illuminate as best as possible what Pt would want for herself given her fatal condition. Role is not to prevent her from dying. • 2)Are the physicians obligated to follow the demands of this family? • Evelyn’s physicians are under no obligation to eccede to either pt’ or family demands 15 • For rx that is useless in the context of the pt’s illness. • Physicians can not be forced to provide rx they believe is outside of the accepted standard of care under the circumstances. • Accepted standard is derived from physicians medical expertise & not from personal value system Jehovah’s witness
• 1999-USA • Severe asthma • Did not want intubation. • Attendant intubated • At approximately 7 A.M. on Sunday, March 18, 1990, twenty-nine year old Catherine Shine arrived at the MGH emergency room seeking medical help for an asthma attack. Catherine had been asthmatic throughout most of her life, a condition she controlled through prescription medication. The daughter of a physician, Catherine had educated herself about her condition and was well informed about her illness. Her asthmatic attacks were characterized by rapid onset, followed by a rapid remission. She had never required intubation in the past. Earlier that morning, Catherine had suffered a severe asthma attack at her sister Anna's apartment. Despite believing that her condition was improving after using her prescription inhaler, Catherine agreed with Anna's suggestion to go to MGH, but on the condition that she be administered only oxygen. After Anna received assurances from an MGH representative that Catherine would be treated with just oxygen, Catherine entered the MGH emergency department, accompanied by Anna. Catherine initially was given a nebulizer, a mask placed over her mouth which delivered oxygen and medication. She complained to Anna that the medication was giving her a headache, removed the mask and indicated that she wished to leave the hospital. Catherine's behavior alarmed the nurse who was treating her. An arterial blood gas test, measuring the levels of oxygen and carbon dioxide in her blood, was drawn at approximately 7:15 A.M. The results, obtained at approximately 7:30 A.M., showed that Catherine was "very sick." Dr. Vega, the only emergency room attending physician on staff at MGH that morning, examined Catherine and concluded that she required intubation. Catherine resisted, and Dr. Vega initially agreed to try more conservative treatment with the oxygen mask. Catherine continued to disagree with the medical staff concerning her treatment. • Anna, frustrated by what she felt was a medical staff unwilling to listen to her sister, telephoned their father, Dr. Shine, who was in England. Dr. Shine had treated Catherine when she was a child and was familiar with Catherine's condition. Dr. Shine spoke to an MGH physician and told him that Catherine was intelligent and "very well-informed" about her illness, and he urged the physician to listen to Catherine and to try to obtain her consent for any treatment. Dr. Vega testified that he told Dr. Shine that Catherine was in "the midst of an extremely severe asthma attack," and that he unsuccessfully had tried to avoid intubation. Dr. Vega testified that Dr. Shine asked him to wait until he flew to Boston before intubating Catherine. He also testified that he had made a "conscious decision" not to tell Catherine that her father had opposed intubation. • Anna returned to Catherine's room to find her in a "heated" argument with the MGH staff. Catherine's condition had improved somewhat, and she was able to talk and to breathe more easily. At approximately 7:40 A.M., during a moment when the doctors left Catherine and Anna alone together, Catherine told Anna to "run." They ran down the corridor to the emergency room exit doors, where they were forcibly apprehended by a physician and a security guard. Catherine was "walked back" to her room where Dr. Vega immediately ordered that she be placed in fourpoint restraints, in part because she had refused treatment and attempted to leave the emergency room. Catherine and Anna were forcibly separated. Dr. Vega initiated the process of having Catherine intubated. At approximately 8 A.M., the results of a second blood gas test became available, showing that Catherine's condition had improved somewhat. Dr. Vega testified that the results, even if he had read them (he had not), would not have changed his decision to intubate Catherine. At approximately 8:25 A.M., the intubation procedure commenced, approximately forty-five minutes after Catherine had been strapped in four-point restraints. Catherine never consented to this treatment. Dr. Vega testified that he never discussed with Catherine the risks and benefits of intubation. Neither Anna, who was still at the hospital, nor Dr. Shine was asked to consent to the intubation. Catherine was released from MGH the following day. 17 • In this death case, we must resolve the conflict between the right of a competent adult to refuse medical treatment and the interest of a physician in preserving life without fear of liability. Dr. Jose Vega, an emergency physician at Massachusetts General Hospital (MGH), initiated the intubation without Catherine's consent and over her repeated and vigorous objections. In 1993, Dr. Ian Shine, Catherine's father and the administrator of her estate, brought a multi-count complaint against Dr. Vega and MGH seeking damages for tortious conduct and the wrongful death of his daughter.He alleged that Catherine was traumatized by this painful experience, and that it led to her death two years later. On that occasion, Catherine again suffered a severe asthma attack but refused to go to a hospital because, it was claimed, she had developed an intense fear of hospitals. Her father alleged that Catherine's delay in seeking medical help was a substantial factor in causing her death.
• At trial the defendants took the position that, confronted with a life-threatening emergency, Dr. Vega was not required to obtain consent for treatment from either Catherine or her family. A Judge in the Superior Court agreed, and charged the jury that no patient has a right to refuse medical treatment in a lifethreatening situation. She also instructed that in an emergency the physician need not obtain the consent of the patient or her family to proceed with invasive treatment. A jury returned verdicts for the defendants on all counts. • The jury returned a verdict in favor of Dr. Vega and the hospital, and Dr. Shine appealed. • There is an emergency exception to the "informed consent" requirement, said the Supreme Court. If it is impractical to confer with the patient and a splitsecond decision must be made in order to save her life, consent is not necessary. • To determine whether an "emergency" existed sufficient to insulate Dr. Vega and the Hospital from liability, the jury should have been required to decide whether Catherine was capable of consenting to treatment, and, if not, whether the consent of a family member could have been obtained. • In short, was there an emergency and did Catherine have the capacity to consent? • The Massachusetts Supreme Court therefore disagreed with the trial judge's instructions and sent the case back for retrial.
|
Case