Download Outpatient Ethics for the Internist

OUTPATIENT ETHICS FOR
THE INTERNIST:
NEGLECTED
PROFESSIONAL DILEMMAS
Cynthia M.A. Geppert, MD, MA, PhD, MPH, MSBE
Chief Consultation Psychiatry & Ethics New Mexico Veterans Affairs Health Care System
Professor of Psychiatry and Director of Ethics Education University of New Mexico School of Medicine
D I F F E R E N C E S I N O U T PAT I E N T &
I N PAT I E N T E T H O S
Inpatient
Outpatient
 Acute crises
 Chronic disease
 Involves technology
 Involves psychosocial
 End-of-life
 Preventive
 Dramatic
 Routine
 Withholding care
 Inappropriate care
 Transient MD-PT relationship
 Ongoing MD-PT relationship
F R E QU E N C Y & T Y P E O F
O U T PAT I E N T E T H I C A L P RO B L E M S
 Little research compared to inpatient dilemmas and much of it
outdated or conducted in Europe.
 1988 study of 562 IM office visits.
 Ethical problems defined as conflicts between other ethical issues
and physician’s moral obligation of beneficence.
 Ethical problems were present in 30% of encounters 84/280
patients and in 21% of office visits.
MOST COMMON ETHICAL
PROBLEMS
 Costs of care (11%)
 Informed consent (5.7%)
 Psychological factors
 Confidentiality (3.2%)
influencing patient preferences
(9.6%)
 More frequently encountered
in patients over 60.
 Competence & capacity to
choose (7.1%)
 Refusal of treatment (6.4%)
(Connelly JE, DalleMura S. Ethical problems in
the medical office. JAMA 1989; 260:812-5.)
TOP 10 ETHICS ISSUES IN
PRIMARY CARE
Physician-Patient Relationship
Confidentiality-Consent
1.
Impaired drivers
2.
Third-party information
3.
HIPAA and privacy
4.
Adolescent confidentiality
5.
Life-threatening non-
adherence
6.
Demands for inappropriate
treatment
7.
Lying for patients
8.
Discharging Difficult patients
Professionalism
9.
PCP versus Consultant
10. Impaired physician
# 1 IMPAIRED DRIVERS
 Case: Mr. F is a 75-year old widower with mild dementia, BPH,
DJD and CAD who presents to your office for an ER follow up visit.
Mr. F was involved in an MVA and sustained some minor lacerations
and contusions. Mr. F wears hearing aids and his vision was recently
checked. MMSE performed in the office is 19. Mr. F lives
independently in an apartment in town but has no family in the state.
DRIVING, CONTINUED
 When you suggest he might no longer be safe to drive, he is
indignant, citing his safe driving record. “If I can’t drive, I might as
well be dead.” He does agree to limit his driving to daytime hours and
short trips. One month later his daughter calls from out of state and
tells you he has hit a parked car and it is time for you to “make him
give up his license.” Can you do that? Is it legal? Is it ethical?
REPORTING PROCEDURES
NEW MEXICO
Physician/medical
reporting
 Driver is informed by mail that
his/her license will be cancelled in 30
days unless he/she submits a medical
Immunity
report stating that he/she is medically fit
Legal protection
license will be cancelled.
DMV follow-up
Other reporting
Not anonymous or
confidential
to drive. If a report is not submitted, the
 Will accept information from courts,
other DMVs, police, and family
members.
ETHICAL ISSUES
 Autonomy of patient versus do
 Work with family to secure
no harm to the public.
keys/cars.
 Confidentiality versus truth-
 Social services for alternative
telling.
 Requires medical assessment
modes of transportation.
for possible reversible causes.
 Be transparent with patient
 Must fail least restrictive
and permit voluntary surrender
alternative.
of license.
# 2 THIRD-PARTY
INFORMATION
 Mrs. C calls and leaves the following message with your nurse: “My
husband is not telling you that he is drinking again even with the pain
medications the doctor prescribed. He is verbally abusive to me when
he is drunk. Please don’t tell my husband I called but I wanted the
doctor to know that my husband doesn’t tell the truth to him.” You
didn’t ask but now do you tell?
CONFIDENTIALITY
 ACP Ethics Manual (6th ed, p. 76) states that the “physician is not
obliged to keep secrets from the patient.”
 MD should recommend the wife encourage her husband to tell the
MD about the drinking and offer to facilitate a conversation.
 Clinical judgment regarding disclosing the information and its
source depends on what is best for the patient, not the wife.
#3 HIPAA IN THE
OFFICE
You just hired a new office
1.
waiting room.
manager who likes to read
technical manuals for fun. She says
You call patients by name in the
2.
Your receptionist leaves
several routine office practices are
appointment reminders on
violations of HIPAA and could
patients’ answering machines.
result in fines or worse. Is she right
or just annoying?
3.
Your nurse regularly
communicates health information
to patient’s spouses.
HIPAA THE HIPPO
 She is wrong. Physicians’ offices can use patient sign-up sheets or
call out patients’ names so long as the information disclosed is
appropriately limited e.g., no medical diagnoses.
 These are both what is technically called “incidental disclosure,”
when other patients hear or see another patient’s name
 Disclosures are only permitted if other reasonable safeguards and
the minimum necessary standard has been met.
MESSAGES ON MACHINES
 HIPAA permits a physician’s office staff to leave a message on a
patient’s answering machine so long as the message limits the
information to the appointment time reminder or request for a call
back.
 Unless the patient has previously requested confidential contact,
such as by mail to the patient’s office rather then his home.
COMMUNICATING TO
FAMILY
 HIPAA allows physicians to communicate information to family members
or significant others about the patient’s care even if the patient is NOT present
or has not given explicit permission for the physician to disclose health
information, IF:
 In her professional judgment the physician believes such disclosure is in
the patient’s best interest.
 NOT if the patient has explicitly instructed the physician not to disclose
any health information to specific family members or friends.
#4 ADOLESCENT
CONFIDENTIALITY
 Miss R is a 17-year-old high school junior whose mother has been
in your practice for years. Miss R comes to the office requesting birth
control because she is sexually active with her long-time boyfriend
and doesn’t want to “get pregnant and mess up the college thing.” She
asks that you not tell her parents she requested contraception because
as you know they are strong Christians and would not approve of her
sexual activity. Do you give the pill?
T H E L AW: C O N F I D E N T I A L S E RV I C E S
FOR MINORS IN NEW MEXICO
 § 24-8-5 NMSA 1978 … Contraception
 Neither the state… nor any health facility furnishing family
planning services shall subject any person to any standard or
requirement as a prerequisite for receipt of any requested family
planning service…[exceptions do not address age of client].
THE ETHICS
 Adolescent privacy and autonomy versus the rights of parents to
decide what is best for their children.
 Try to persuade the adolescent to tell their parents and offer to
mediate meeting.
 Suggest a public health clinic so that the parents do not get the
insurance bill but the adolescent gets the contraception.
#5 LIFE -THREATENING
NON-COMPLIANCE
 Mrs. S is a 64-year-old woman with alcohol dependence and a
personality disorder, who is on coumadin for a DVT and PE 6
months ago. She has been erratic in her adherence to coumadin
monitoring and is now admitted to the hospital with an INR of 7
thought secondary to heavy alcohol use and overtaking her coumadin
when intoxicated. Do you continue coumadin?
STEPS PRIOR TO STOPPING
 Assess decisional capacity
 Strongly counsel substance use treatment including anti-craving
medication.
 Consider a coumadin agreement with the patient so you an
document a trial before discontinuation.
 Enlist family or friends to help her monitor her coumadin at home.
DISCONTINUATION
 Are there any other anticoagulation options to minimize the danger?
 Conduct an evidence-based assessment of the risk/benefit profile of
continuing coumadin.
 Obtain a consultation from a colleague.
 Extensively document the informed consent discussion with patient.
 Advise of warning signs and symptoms of thrombosis or bleeding.
#8 DEMANDS FOR
INAPPROPRIATE TREATMENT
 Miss A is a 37-year-old unmarried woman with BMI of 26,
requesting thyroid medication. She has seen TV advertisements for
thyroid hormone clinics but none of them are on her insurance plan.
She denies constipation, cold intolerance, skin/hair changes, and
other symptoms, aside from inability to lose weight. Her physical
examination is normal and TSH is 1 U/ml. Why does she want the
thyroid and do you prescribe it?
STANDARD OF CARE
 ACP Ethics Manual (6th edition, p. 75-76) “Although the physician
must address the patient’s concerns, he or she is not required to
violate fundamental personal values, standards of medical care or
ethical practice or the law.”
REFUSING INAPPROPRIATE
REQUESTS ETHICALLY
 Try to understand the patient’s needs and beliefs – here Miss S
clearly wants to lose weight the easy way.
 Educate patients regarding the risks of inappropriate treatments
such as osteoporosis with thyroid replacement.
 Attempt to come to a mutually acceptable resolution.
 If you cannot agree, then offer to refer.
#7 LYING FOR PATIENTS
 Mr. K is a 38-year-old father of 3 whose wife, also in your practice,
has lupus. Mr. K was recently laid off from his warehouse job. He
comes asking if you can fill out workman’s compensation forms
indicating his knee was injured on the job. This will give him time to
go back to school in information technology. Your records show that
on his initial visit 2 years ago Mr. K reported he injured his knee
playing high school soccer. Do you fill out the forms?
PHYSICIAN DECEPTION OF THIRD
PA R T I E S
 169 board certified internists surveyed

 57% for cardiac bypass
on whether they would use deception
 56.2% for arterial vascularization
in 6 clinical scenarios.
 47.5% for intravenous pain medication
More likely to use deception if less
and nutrition
time in practice, clinical situation more
 34.8% for screening mammography
severe, managed care penetration
higher
Freeman VG et al. Lying for patients. Arch Intern Med.
1999;159:2263-70.
 32.1% for emergent psychiatric referral
 2.5% cosmetic rhinoplasty
DOES USING DECEPTION
SOLVE ETHICAL PROBLEMS
 Represents a conflict between traditional patient advocacy and
newer professional obligations of just resource allocation.
 Lying for patients can have unintended and opposite effects of
compromising physician integrity and diminishing public trust in the
profession.
 Reflects burdens and unfairness of reimbursement systems best
addressed through policy reform.
ACP ON DISABILITY
 “Physicians may see a patient whose problems do not fit standard
definitions of disability, but who nevertheless seem deserving of
assistance. Physicians should not distort medical information or
misrepresent the patient’s functional status in an attempt to help
patients. Doing so jeopardizes the trustworthiness of the physician as
well as his or her ability to advocate for patients who truly meet
disability or exemption criteria.” (p.80)
#8 DISCHARGING
DIFFICULT PATIENTS
 Miss Y is a 31-year-old with fibromyalgia, migraine headache, and
benzodiazepine dependence, who has repeatedly no-showed scheduled
appointments and then demanded urgent visits. She calls the office
multiple times a day and when staff cannot immediately attend to her
needs becomes abusive. She has refused to follow an exercise plan or
accept referrals for mental health care and threatens to sue if she is not
given alprazolam. Can she be legitimately discharged from the practice or
is this patient abandonment of a challenging patient?
ABANDONING A PATIENT
 Neither ethical nor legal when:
 There is an urgent or emergency situation.
 No other clinician can provide a necessary service in the
area/setting.
 Would compromise the patient’s health.
 You do not follow appropriate steps.
DISCHARGING A PATIENT
 You can ethically and legally discharge a patient, IF you:
 Have documented attempts to resolve conflicts.
 Transfer records and care to another provider.
 Copies of all records: information belongs to patient; record to the
practice.
#9 CONSULTANT VERSUS PCP
 Dr. S practices in Rio Rancho. He has been treating Mr. C for many
years for chronic pain from severe spinal stenosis, most recently with
oxycodone 10 mg QID, with only modest relief.
 Dr. S sends Mr. C to a local pain specialist, Dr. I, for further work up
and treatment recommendations. Dr. I documents in his consultation that
the patient is receiving a dangerous amount of short-acting opioids and
recommends immediate and complete taper off opioids.
 Is Dr. S ethically or legally obliged to follow the consultant’s
recommendations?
PCP RULES
 ACP Ethics Manual (6th edition, p. 92)
“The physician who does not agree with the consultant’s
recommendations is free to call in another consultant. The interests
of the patient should remain paramount in this process.”
“Unless authority has been formally transferred elsewhere, the
responsibility for the patient’s care lies with the principal physician.”
#10 IMPAIRED PHYSICIAN
 You work in a small group primary care practice. Dr. Z is 52 with
well-controlled diabetes and been a good partner for 10 years. Over
the last few months he has been showing up late for work, not
reachable on call, and your nurse has complained he is irritable and
tremulous at work. You have told him you are worried about him, but
he denies there is any problem, saying he is just having trouble with
his blood sugar. Where do you go from here with your concerns?
ETHICAL OBLIGATION
 ACP Ethics Manual (6th ed. P. 92) “Every physician is responsible
for protecting patients from an impaired physician and for assisting an
impaired colleague. Fear of mistake, embarrassment or possible
litigation should not deter or delay identification of an impaired
colleague.”
REPORTING A COLLEAGUE
 First try informal intervention, perhaps with the entire group or a
trusted colleague.
 Offer to assist in referring to treatment, including monitored physician
treatment program.
 Consult legal counsel, hospital chief of staff, or clinic administrator on
process.
 Let the physician know you will have to report him if he does not take
preventive action.
PRIMARY CARE ETHICS
 “Because primary care is characterized by many repeated
episodes of relatively mundane events instead of a few sharply
defined crises requiring instant decisions, the way in which
these ethical issues arise and the peculiar flavor they develop in
a primary care setting may be more difficult to discern than the
way in which ethical issues crop up in intensive care unit.”
(Brody H, Tomlinson T. Ethics in primary care: setting aside common misunderstandings.1989;
Primary Care 1986;13:225-240.)
RESOURCES FOR ANSWERS
 American Board of Internal Medicine Advancing Professionalism to Improve
Health Care http://www.abimfoundation.org
 AMA Virtual Mentor for Ethics and Professionalism http://www.amaassn.org/ama/pub/physician-resources/medical-ethics.page?
 American College of Physicians Center for Ethics and Professionalism
http://www.acponline.org/running_practice/ethics/
 University of Washington Ethics in Medicine
http://depts.washington.edu/bioethx/index.html