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Roe vs Wade case- termination of pregnancy
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- Bu səhifədəki naviqasiya:
- Ohio vs akron
- The patient committed suicide.
- Tyrell Dueck
- Fixed false belief
Roe vs Wade case- termination of pregnancy Under Roe vs Wade, a woman in her 1st trimester of pregnancy, in consultation with her physician, has complete discretion as to whether or not to continue the pregnancy. She may have an abortion during this time for whatever reason she chooses. During the second trimester, as maternal risks from abortion increase, the woman’s right to obtain an abortion is accompanied by the interests of the state in protecting her health and well being, and thus ensuring that abortions are performed according to that goal. At this stage, the state has the right to decide depending on the situation, although the woman still has her fundamental rights to abortion. In the third trimester, the interests of the fetus which is approaching viability begins to take hold. A state can withhold abortion at this stage unless to save the life of the mother. Fetal viability is usually considered to occur at approximately the start of the third trimester, even if viability requires advanced medical attention or life support. Most of these restrictions have been upheld by the supreme court, even while it still defines as fundamental the right of a woman to have an abortion. ROE vs WADE: -child may have meningitst: mom calls and says baby has meningitis: brief history of PT and symptoms, then maybe child may have meningitis: meningoc cocus is important Neisir. Mengingitis and can cause skin rash:
Ohio vs akron Ohio vs. Akron involve parental notification as a requirement before an abortion is performed on a minor. The issue of a woman's "fundamental right to an abortion," which is a key element sustaining Roe, may be reexamined by the Court. Abortion
• Prior to 1970’s, there was restriction of reproductive freedom. • Roe vs Wade-1972 • Roe challenged anti-abortion law of Texas (14th Amendment) • Supreme Court supported Roe. • Under Roe the following apply: • 1st trimester- abortion legal (whatever the mothers reason) • A mother call in the middle of night……. Mary Jane is upset because she was turned away from her last scheduled appointment with her doctor. The Case
The Case, continued Upon registration with the receptionist, she was informed of the clinic’s “copayment in advance” policy. Mary Jane did not have money or her checkbook with her. The Case, continued Even though she had a good payment record, her physician refused a request to make an exception to this policy. The physician’s response to this request was, “You take your checkbook with you when you go to the grocery store or gas station, don’t you?” What Do You Think? • Was the physician’s office acting in an ethical manner? • Why or why not? • What legal implications could result from this action? Ethical Issues • Physicians have an ethical duty to treat sick and injured persons. • Does this ethical duty reach to all persons in every circumstance? • What exceptions can you list? Legal Issues • There are often contractual agreements with health plans preventing physicians from waiving co-payments. • It is illegal under Medicare regulations to waive co-payments. What the Experts Say • The challenge is to strike a humane balance between cost control and genuinely needy patients. • Exceptions should always be made for patients who have urgent or emergent symptoms. What the Experts Say, continued • Cooperative and creative solutions from the office staff can result in positive outcomes. For example: • Mary Jane did not appear needy; she just needed to be informed of the policy in advance and to be treated courteously. The Case The patient was brought to the hospital emergency room with a gunshot wound to the chest. Upon arrival, the nurse called the first oncall surgeon on the list. He was at another hospital with an emergency and was not available to operate on this patient. The Case, continued The nurse then paged the second emergency physician on the list. He returned the call but was hesitant to come to the hospital. He did not believe the first on-call physician truly had an emergency at another hospital. The Case, continued The nurse finally convinced the second on-call physician to come to the emergency room and minutes later he was on his way. The Case, continued While the second on-call physician was en-route, the patient was taken to surgery.
The patient died a short time later, before the physician arrived at the hospital. A Suit Filed The patient’s family sued the hospital, its emergency nurses, and the physicians for wrongful death. What Do You Think? • What legal term would describe why the family would sue not only the nurses, but the physicians and hospital as well? • What outcome would you expect from this case? The Initial Outcome • All of those involved either settled with the family out of court or were dismissed from the complaint EXCEPT the second on-call physician. • The second on-call physician filed for summary judgment on the ground that he had no physician-patient relationship with the patient and therefore no duty of care. What Do You Think? • Do you think there was a physicianpatient relationship? Why or why not? • Did the physician owe the patient duty of care in this case? Why or why not? • Did the physician fulfill his ethical obligations? Explain your answer. The Court
The family contended that a duty of care was established when the physician agreed to come to the hospital to treat the patient and appealed the case. The Appeal The summary judgment for the physician was upheld for the following reasons: • The physician never saw the patient. • The physician never talked to the patient. • The physician never gave advice to anyone in the ER about him. Ortiz v. Shah, 905 S.W. 2d 609 (Texas Ct. of App., June 8, 1994: rehearing overruled Aug . 31, 1995). The Case
A Boston physician has a patient who has presented with changes in her fibrocystic breast condition. The patient’s insurance covers some examinations for this condition, but the patient fears an early-stage cancer would be easy to miss if she were examined at the frequency allowed by her insurer. The Case, continued The patient states she cannot afford to pay out of pocket for the extra examinations that the physician agrees are desirable. The physician successfully got the insurer to pay for the most recent visit by coding it as an “evaluation for breast mass” rather than as a routine monitoring. • The physician now wonders if this was a correct way to handle this situation and if it is wise to continue this practice. • Do you think the physician handled the situation correctly? Why or why not? • What recommendations would you give this physician?
Legal Issues, continued • Major initiatives against fraud are under way from both federal and private health plans. What penalties can be imposed on physicians found guilty of fraudulent billing?
10 Legal Issues, continued • Penalties include –Loss of participation in insurance plans –Fines –Civil monetary penalties –Imprisonment Legal Issues, continued • There may also be other negative outcomes of miscoding. – In a malpractice suit, a physician’s dishonesty in coding can undermine his credibility. This can occur even if the upcoding does not directly relate to the claim being litigated. Ethical Issues • Deliberate miscoding is dishonest and potentially harmful in several ways. – Mistrust between physicians and health plans – Mistrust between physicians and patients
– Harm to patients Ethical Issues, continued • Mistrust between physicians and health plans fuels a mutual gamesmanship that ultimately makes it more difficult, not easier, to secure the care a patient needs. 11
• Patients may develop the fear that a physician who would openly lie for a patient might also sometimes lie to them.
Ethical Issues, continued • Insurance dishonesty can also harm patients, as in the following case of Stafford v. Neurological Medicine, Inc.
• Physicians performed a CT scan prior to chemotherapy to determine if a patient’s lung cancer had metastasized to her brain. Believing the insurance company would not pay for a “screening” CT scan, the physician entered a diagnosis of “brain tumor” on the claim form.
• The patient was told the exam was negative, but when she received a statement from her insurance company explaining the benefits paid, she saw “brain tumor” under “diagnosis” and became acutely distressed. The patient committed suicide. 12 What Should a Physician Do? • Chronic upcoding is unwise, unethical and illegal. • What options do physicians have? What the Expert Says • Linda Emanual, MD, PhD, director of the AMA Ethics Institute suggests further investigation, combined with some creative problem-solving. • She outlines three areas for problemsolving in this case... What the Expert Says, continued First,
• Establish a reasonable frequency for screening for this patient. • If anxiety is what prompts the patient to request more frequent visits, then more education and reassurance may be in order. This could prevent excessive screening. What the Expert Says, continued Second, • Determine if there actually is a reimbursement problem. • Don’t assume you must upcode to receive payment. Contact the insurer and talk to someone who knows the reimbursement system. More documentation may be required, but there may be reimbursement. 13 What the Expert Says, continued Third, • Find out what the patient means by “can’t afford.” – Today patients are accustomed to first-dollar coverage and may believe they should never have to pay for medical care. What the Expert Says, continued If a physician’s charges are comparable to other costs of everyday living, then a decision not to purchase extra medical services may be just that -- a spending decision. What the Expert Says, continued If this is the case, the patient should be informed by the physician why the exams are important and the consequences of not having the exams.
Payment plans may then be offered. What the Expert Says, continued • When costs present a true obstacle, – A physician may discount her own fees. – A physician may wish to negotiate discounted fees from other required services, such as mammography. 14 Summary
• Physicians must recognize dilemmas such as this cannot be avoided. Patients’ needs are diverse and payers must limit what they will cover. • The challenge is not to bypass the problem, but to live with it in morally credible ways. Ethics Forum, American Medical News, February 23, 1998.
Tyrel Dueck: 1999
Tyrell Dueck- osteosarcoma- when the patient is a competent adult, there is legal mandate and moral obligation to involve him in decisions that affect his care. Patient involvement should also be a guiding principle for physicians who care for children. While parents are usually the integral part of the decision making process for a minor, it is essential for physicians to remember that it is the child who is their patient and to whom they have the greatest obligation., limb sparing surgery and intensive preoperative and postoperative chemotherapy have improved the outlook for many patients with osteosarcoma. Alternative treatment- DIALYSIS in anticipation of a possible kidney transplant and better health may be better for him than no future at all. Substitute Decision Making • Parents make decisions • Based on best interest (not substituted judgement) • Extensive legal authority parents have (not absolute) • If not in “best interest” parental wishes may be disregarded. • Eg’s…. Examples of violating best interest • Tyrell Dueck- 1999 • Canada • 13 y.o. boy • Bone cancer-Knee • Parents refused medical/surgical rx (& child agreed with parents) • Want alternative rx/medicine(like vitamins) • Case evaluation by courts. • Patient asked/evaluated understanding of medical condition • Father had not told truth to child & not explained seriousness of cancer. Child was unduly influenced) • Court ordered RX b/c best interest to rx & patient not mature enough • Due to parents & court delays cancer later spread to lungs. • Since 10% survival rate now, court said do what you want. For behavioral science we will discuss those on Thursday; for BS 09-02-06 BS review tt1 There are 40 questions from BS: What to focus on: All 40 are not from topics, but most of them from the things I’m telling you: if you focus on this you’ll be alright
• INTRODUCTION • I. PURPOSE OF EVALUATION • A. General psychiatric evaluation • B. Emergency evaluation • C. Clinical consultation • D. Other consultations • II. SITE OF THE CLINICAL EVALUATION • A. Inpatient settings • B. Outpatient settings • C. General medical settings • D. Other settings Outline of Psychiatric History • Identifying data • Chief complaint and Problem • History of Present illness – Onset – Quantity – Severity – Aggravating and alleviating factor – Associated manifestations
– Psychiatric – Medical – Personal developmental history – Previous admissions, surgeries, accidents – Allergies • V. Personal history ( anamnesis ) A. Prenatal and prenatal B. Early childhood (through age 3) C. Middle childhood (ages 3–11) D. Late childhood (puberty through adolescence) • Family history • Ob/Gyn history • Sexual history – Sexually active – No. of patners – Male/female – Contraception – STD’s
• Social History: – Smoking – Alcohol (Cage questionaire) • Need to cut down • Feels angry due to criticism • Feel guilty • Need an eye opener – Use of recreational drugs – Work situation – Home life Psychiatric Questions: • Source of unhappiness • Support system • Appetite and weight • Daily routine • Sleep pattern • Interest/activities • Concentration and memory • Optimism/Pessimism • Suicidal Ideation and Plan • Abuse • Delusion • hallucinations • III. DOMAINS OF THE CLINICAL EVALUATION • A. Reason for the evaluation • B. History of the present illness • C. Past psychiatric history • D. General medical history • E. History of substance use • F. Psychosocial developmental history (personal history) • G. Social history • H. Occupational history • I. Family history • J. Review of systems • K. Physical examination • L. Mental status examination • M. Functional assessment • N. Diagnostic tests • O. Information derived from the interview process • IV. EVALUATION PROCESS • A. Methods of obtaining information • B. The process of assessment • V. SPECIAL CONSIDERATIONS • A. Interactions with third-party payers and their agents • B. Privacy and confidentiality • C. Legal and administrative issues in institutions • D. Evaluation of elderly persons • VI. DEVELOPMENT PROCESS KNOW THESE TERMS: what’s the meaning of these terms and significance of these terms: i.e. different types of dlusion and illusion and their significance Transference: Transference • generally defined as the set of expectations, beliefs, and emotional responses that a patient brings to the doctor–patient relationship. Transference reflects not necessarily who a doctor is or how a doctor acts in reality but, rather, what persistent experiences a patient has had with other important authority figures throughout life. TRANSFERENTIAL ATTITUDES. • A patient's attitude toward a physician is apt to be a repetition of the attitude he or she has had toward authority figures. • The attitude may range from one of realistic basic trust, with an expectation that the doctor has the patient's best interests at heart, through one of overidealization and even eroticized fantasy, to one of basic mistrust, with an expectation that the doctor will be contemptuous and potentially abusive.
• Inappropriate for level of education – Ex. A High School graduate still believes in the tooth fairy • Incorrigibility: not altered with proof to the contrary • Preoccupies the patient More on Delusions • Egocentric: patient is center of events • Range from implausible (unlikely but Yüklə 0,87 Mb. Dostları ilə paylaş:
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