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Page1 Chris Giles Ethics Exam Study Guide OST 581 Exam: 1/26/15 Spring 2015 Lectures 1, 2: Law 101 Law Basics o Sources of Law Common Law: made by judge decisions – majority of malpractice cases Statutory Law: made by congressional legislation/bills passed – Affordable Care Act (Obama-care) Administrative Law: made by governing agencies – Licensing, Medicare/Medicaid Constitutional Law: the constitution of the U.S.; highest level of authority o Classifications of Law Civil: b/t 2 individuals, usually involving monetary compensation Types o Breach of Contract o False Imprisonment – patient only needs to think they are being detained o Abandonment (SEE BELOW) Malpractice is normally a civil classification Criminal: b/t society & and individual, usually involving imprisonment & monetary compensation Types o Medicare Fraud o Destruction of Records o Willful Neglect: intentional failure or reckless indifference of an obligation to a patient o Surgeons get sued the most, psychiatrists the least Patient Self-Determination Act o Requirement that health care institutions provide patients with information regarding establishing an advanced health care directive (essentially a medical proxy), in the event they can no longer make health care decisions for themselves due to illness or incapacity, upon admission to a health care facility o Requirements Inform patients of their rights To make health care decisions To accept/refuse treatment Establish a proxy (advance care directive) Outline institutional policies: related to state laws regarding policies Breach of Contract o One party in a contract fails to meet at least one of the contractual obligations Never guarantee results/outcomes NOT a part of negligence o Breach of Contract vs. Breach of Standard of Care (KNOW) Standard of Care: level of care a reasonably competent professional would have rendered in the same or similar circumstances Abandonment o Discontinuing treatment of a patient in need of care without making reasonable arrangements for the continuation of care; or leaving professional employment by a group/practice/hospital/clinic/facility w/o reasonable notice and under circumstances which seriously impair the delivery of professional care to patients or clients A physician can be found liable for abandonment once a physician-patient relationship has been established o To avoid an abandonment claim: give reasonable notice, make a recommendation, provide ample time (30 calendar days is generally accepted as ok) o To withdraw from a physician-patient relationship: notify patient in writing, state reason for dismissal, indicate final date, send a certified letter w/ a return receipt requested, retain a copy of the letter in the patient chart EMTALA: Emergency Medical Treatment and Active Labor Act o Law requiring the medical treatment of anybody in a medical emergency regardless of citizenship, legal status, or ability to pay o Requirements – depend on institutional standards Screen: examination to determine if an emergent medical condition exists Stabilize: treat a patient until their health status is no longer emergent, or until they can provide self-care following discharge Malpractice/Negligence o Parties: plaintiff (patient) & defendant (medical provider) In a lawsuit, the plaintiff is first & defendant second Ex: Roe v Wade (Roe = plaintiff, Wade = defendant) Chris Giles Exam: 1/26/15 Ethics Exam Study Guide o o OST 581 Spring 2015 Statute of Limitations: length of time a patient has to file a lawsuit Begins when Negligent act is committed Discovery or when the act should have been discovered State specific: Michigan is 2 years, or 6 months from when you figure it out o Exception: minors – until they are 18 4 D’s: “Deviation of a Duty leading Directly to Damages” Duty: obligation requiring a physician to conform to a particular standard of care based on the doctor-patient relationship Doctor-patient relationship: created when a physician takes affirmative acts in a patient’s care by examining/diagnosing/treating/or agreeing to treat General rule: physicians can refuse to accept new patients w/o a reason o Exceptions: EMTALA, discrimination, HIV+ Derelict of Duty: breach of appropriate standard of care Standard of Care: level of care a reasonably competent professional would have rendered in the same or similar circumstances Direct Cause: primary cause, w/o which the injury would not have occurred Respondeat Superior: law stating that you are responsible for the actions of your employees Damage: physical/mental/emotional injury or form of loss Damages o Nominal: symbolic gesture – probably won’t make it to court o Actual Economic Non-economic o Punitive: defendant acted intentionally to harm, or w/ gross misconduct, or willful neglect Court will award 3x actual damages Caveat: Res Ipsa Loquitur – “the thing speaks for itself” Something that is very obviously obvious & wrong Lecture 4: Consent Types of Consent o Informed Consent: voluntary affirmation by the patient to allow touching/examination/treatment Expressed: oral or written (written is best for more serious procedures) Implied: patient voluntarily submits to a procedure/examination w/ apparent knowledge of the procedure & the procedure presents slight or no apparent risk Ex: rolling up a sleeve to give blood, holding out an arm for a pulse, opening mouth for a temperature o Uninformed Consent: patient gives permission but does NOT understand/comprehend to what they have consented Informed Consent o General Rules All primary health care providers have a legal/ethical duty to provide patients w/ sufficient information about examination/intervention to allow patients to make a knowing, intelligent decision regarding treatment Only applies to those >18 y/o (there are other exceptions – SEE BELOW) The person performing the procedure should be the one who obtains consent Page2 Lecture 3: Impact of Law on Physicians (Sefcik) Process of A Lawsuit o A patient (plaintiff) files a complaint alleging that damages occurred as a direct result of the physicians breach of standard of care o Evidence is collected by the plaintiff’s & defendant’s attorney’s Documents, SOAPs, progress notes Interrogatories: written inquires requesting answers to specific questions Depositions: oral testimony transcribed to permanent record Expert witnesses are selected by both parties – their testimonies are vital in determination if standard of care was breached o Trial or Settlement is made The day you start residency, you are held to the same standard of care as someone who is board certified in your specialty Ethics Exam Study Guide o o o o OST 581 Spring 2015 Obtaining Informed Consent 3 Requirements Patient has decision-making capacity Consent is given freely Sufficient information was provided o Allow time for ?s o Give info on the most common & most severe complications/consequences o Disclose: Nature of the Tx, Risks, Alternatives, Benefits, Risks to non-action How to know if enough information was provided Reasonable patient/physician: anything a reasonable person in the patient’s position would deem significant in the decision-making process General Rules o Larger risk, larger duty to inform o More elective a procedure, more detailed the description o Provide info relevant to the decision o Remember the purpose of informed consent Ways to Negate Informed Consent Coercion: a threat – unethical Manipulation: non-truth – unethical Documenting Consent Items to document: diagnosis, examination, evaluation, recommended intervention, risks/benefits, prognosis, patient questions & answers given, consequences of inaction Major Exceptions to Informed Consent Emergency: informed consent is not needed when stopping to obtain consent would cause serious harm Good Samaritan Laws: protect providers who act in good faith & w/o gross negligence o You CANNOT take payment from the patient after Waivers: patients may voluntarily & deliberately decline the right to provide informed consent Patient doesn’t want to know Ask the patient who they want to provide consent Incapacity Always assume the patient has capacity Patient must: understand, weigh the information & communicate the decision o If the patient can’t do any of these then they do NOT have the capacity Capacity vs Competence: Capacity is a medical determination, Competence is a legal determination Minors Those <18 y/o are presumed incompetent to make their own decisions d/t cognitive limitations & immaturity o Best interest standard: decision is in the best interest of the patient Exceptions o Emergency situations: can provide treatment w/o parental consent o Mature Minor: individual w/ sufficient understanding/appreciation of the nature/consequences of treatment Patient must be @ least 16 y/o Differs state to state Factors: age, cognitive ability, moral development, current functionality o Emancipated Minor: termination of rights of parents to control/custody/services/earnings of a minor Court ordered Situations w/o a court order: married, parent, armed forces, police custody, self-supporting o Other situations varying by state: mental health, STD treatment, substance abuse, contraception Consequences of NOT Obtaining Informed Consent Medical Negligence & Battery Impacts of Physician Misrepresentations Provide Ample Time Page3 Chris Giles Exam: 1/26/15 Chris Giles Ethics Exam Study Guide OST 581 Exam: 1/26/15 Spring 2015 Informed Refusal o When a patient refuses care despite your best recommendations Have a patient sign Against Medical Advice (AMA) form Chart appropriately: diagnosis, examination, evaluation, recommendation, risks/benefits, prognosis, ask/answer questions, consequences of inaction Lectures 6, 7 – Medical Ethics (Cunningham) Foundations of Medicine o Preservation of Life o Alleviation of Suffering Page4 Lecture 5: Confidentiality Basics o Who – has access? Authority to release/access information rests w/ the patient or guardian o What Obligation of the health care provider to maintain information confidentiality A right of the patient, a duty of the physician o When Always, even after death o Why Patient right to information, patient right to confide, doctor-patient relationship o How – is it protected? Consequences: loss of trust, damage to relationship, ethical violation, discipline from licensure board, invasion of privacy, monetary fine, criminal charges, etc. HIPAA: Health Insurance Portability & Accountability Act o Goals: protect privacy, NOT to impede health care o Rule: providers need to get authorization to disclose protected health information Exceptions Treatment involving other physicians Payment & operations Disclosures: HIPAA doesn’t require consent, the provider does o Protected Information – anything that could possibly identify the patient Photographs, records numbers, phone numbers, geographical divisions, ID numbers/codes, etc. Does NOT cover de-identified information – information that does NOT identify the individual & which there is no reasonable basis to believe the individual can be identified from it o Common Misconceptions (All are FALSE) You cannot communicate health care information via email – lies, yes you can as long as it is secure A provider cannot share information with family/friends – lie, they can give “directory information” (what room they’re in and their general condition – one-word answers: stable, unstable, critical, good, fair, etc.) A provider cannot allow another person to pick up X-rays/prescriptions/supplies/ etc. – false, the person needs the patient’s identifying info to do so Patient authorization is required to disclose medical records to other physicians – wrong, HIPAA does not require this, but most health care providers do Disclosure/Breach of Confidentiality o Required disclosures: serious contagious disease, child/elder abuse (patrens patriae), gunshot wound, serious/immediate threat of harm to identified persons (Tarasoff Duty) o Legal Breaches/Disclosures: if the disclosure… Is necessary to prevent harm If disclosure is an effective tool to prevent that harm If disclosure is proportional to the possible consequences (don’t give the whole chart, just the relevant info) You must be transparent with your patient that you are going to make that disclosure o MI reporting requirements – report to bureau of health professions Domestic violence/intimate partner violence: if an injury by biting/punching/beating/strangling/kicking/slapping Substance abuse Mental health illness Chris Giles Exam: 1/26/15 Ethics Exam Study Guide OST 581 Spring 2015 o o 1 Single unprofessional incident Informal “coffee cup” conversation Page5 Humanitarian: person committed to saving lives & alleviating suffering Physician as a healer Curing: refers to a scientific process of treating a disease Healing: psychological & spiritual process which transforms how the patient responds to his/her disease, family, friends & environment Healing leads to curing but seldom does curing lead to healing Areas of Career Management o Personal – what concerns do I have o Purpose – what are my goals/vision o Performance – how am I doing o Development – how do I need to grow o Assets – what are my strengths o Challenges – how am I preparing for future competence o Relationships – how do I interact with others o Networks – who are my confidants Aspects of Medical Career o Credentialing: process of assessing and validating qualifications of a licensed practitioner to provide health services o Privileging: authorization to provide specific patient care services o Technical Competence Did the physician receive training in an accredited environment Presence of cognitive skills necessary to understand indications & limitations Public Health Code o A duty to report a physician that is impaired and jeopardizes patient care o Common violations: negligence, incompetence, criminal convictions, disciplinary action, substance abuse, drug diversion, failure to complete continuing education o Health Professions Recovery Program (HPRP) Encourages health professionals to seek treatment for substance abuse/mental health BEFORE their impairment harms a patient Steps Referral – evaluation – treatment – monitoring – completion Non-compliant participants are reported to the Bureau of Health Professions for violations of their contract w/ HPRP as required by law Disruptive Behavior o 90% are passive behaviors – lateness, failure to return calls, avoid meetings, non-participation, ill-prepared, inappropriate o Characteristics of a disruptive physician: clever, controlling, charismatic, egotistical, tenacious, explosive, intimidating, vindictive o Tools to handle disruptive behavior Develop employee trust in management staff in handling disruptive practitioners Emphasize this is a system issue, not a personal agenda o Normalized deviance: “what we permit, we promote” o Failure to address Decreased trust among team members Decreased task performance Affects quality & patient safety o Why don’t we report disruptive behavior Fear of reprisal A fearful organization o Consequences control behavior o Disruptive Physician Pyramid Level Behavior Intervention 4 Consistently disruptive Sanction, expulsion, hearing 3 Pattern persists Intervention, awareness, counseling, peer review 2 Pattern identified Chris Giles Ethics Exam Study Guide OST 581 Exam: 1/26/15 Spring 2015 Patient-Centered Care o Interdisciplinary care is the foundation of patient-centered care & the medical home Includes all physicians & non physicians involved in the patient’s care Patient, primary care physician, specialists, nurses, social workers, pharmacist, hospice/palliative care, etc. The patient is to play an active role in treatment o 80% of healthcare dollars is spent on 20% of patients o Patient-centered care outcomes Lower costs Decreased use of health care services Dec unnecessary interventions o Cost-Quality Equation V = Q/C value = quality/cost AOA Code of Ethics o Non-maleficence – do no harm Positive role model, display respect, legal/ethical behavior, manage conflicts of interest o Beneficence – a physician should act in the best interest of the patient o Dignity – patients have the right to dignity, truthfulness & honesty o Autonomy – patients have the right to choose their treatment Summary o What you permit, you promote! o Silence kills! o Always put the patient first! Lecture 8: Medical Professionalism & Conflict of interest (Misra) Professionalism o Virtues & responsibilities that guide one’s actions o Principle-based Principles Humanism: sincere concern for & interest in humanity – respect, compassion, empathy Excellence: commitment to competence & exceeding ordinary expectations Accountability: justifying & taking responsibility for one’s actions ALtruism: selfless concern for others’ welfare; patients’ best interests guide behavior Advantages: focus on higher-level concepts, applies to different scenarios Disadvantages: abstract concepts o Physician Charter Provides an activist approach to altruism; focuses on our commitments & responsibilities to the patient, society, & the profession Commitments Commitment To whom… Honesty w/ patients Patients Patient confidentiality Appropriate patient relationships Just distribution of finite resources People Improving quality of care Improving access to care Scientific knowledge Managing conflict of interest Professional responsibilities Professional competence Conflict of Interest o Circumstances that create a risk that professional judgment or actions will be unduly influenced by a secondary interest o American Board of Internal Medicine (ABIM): charter on professionalism Page6 Profession Chris Giles Exam: 1/26/15 Ethics Exam Study Guide o o Examples Investigator-industry Physician-industry Academic medical center Continuing medical education Stark Law (see BELOW) Approaches to Resolving Journals – require disclosure CME groups – guidelines IRBs – review all research NIH-sponsored research training Stark Law Physician referrals for designated health services (DHS) for Medicaid/Medicare patients is prohibited if the physician has a financial relationship with that entity Summary o Professionalism Includes virtues AND responsibilities HEAAL & the 10 Commitments o Conflict of Interest Your responsibilities might be influenced Can’t be eliminated, but can be managed Lecture 9: Topics in Medical Practice Management (Pirch) Medical Practice Business Models o Sole Proprietorship: business is owned by a single individual who receives all profits & assumes all risks Pros: receive all profits, low operation costs, few regulations, flexibility Cons: assume all risks, need $ to start, must manage own business o Partnership: association of ≥2 co-owners of a for-profit business; a written agreement describes profits/losses, compensation, how new partners are admitted, and how dissolution is conducted Pros: stronger financially, splitting up of work, options for expansion/succession Cons: shared decision making, own assets at risk for others’ performance, requires compatibility among partners o Professional Service Corporation: state regulated legal entity – referred to as PC, PSC, LLC, or SC Pros: individual assets protected, allows deferred compensation plans, benefits programs, ability to raise capital Cons: complex organization, requires legal/accounting/operational services, decision making more complicated o Group Practice: corporation of multiple physicians organized to conduct a larger scale of practice; physicians provide direct medical care & serve other roles (board member, officer, etc.) Single specialty: multiple physicians of same sub-specialty Multispecialty: multiple physicians of related specialties provide a continuum of patient care Primary Care Group: members of various primary care specialties (IM, FM, Peds, OB/GYN) align to provide coordinated care Pros: shared financial burden, consultation/coverage arrangements, less administrative tasks, high peer interaction Cons: high administrative cost, less compensation, “group think” impairs autonomy Health Insurance o History Originally expenses were on the patient prior to 1930 “Great Depression” inspired insurance coverage for hospitalization Blue cross = hospital insurance Blue shield = coverage for physician services post-WWII: employment unions demanded increased health benefits employers tried to control costs via patient cost sharing – premium share, deductibles, co-pays introduced “Managed Care Alternatives” o Managed Care Sought to contain health care costs via Access to preventative care Elimination of unnecessary/overused services Directed providers of service Page7 OST 581 Spring 2015 Chris Giles Exam: 1/26/15 Ethics Exam Study Guide OST 581 Spring 2015 SOAP Article: Medical Malpractice Liability in the Age of Electronic Health Records (EHR) 4 Core Functionalities of EHR o Documentation of clinical findings o Recording of tests/imaging o Computerized provider order entry o Clinical decision support Implementing EHR may put patients @ risk o Technical problems w/ EHR systems o Improper paper-to-electronic data transfers o Unfamiliarity w/ EHR No current evidence that EHR reduces diagnostic errors Ethics of EHR via the AMA o Physicians should NOT use electronic communications to establish physician-patient relationships, only to supplement “other, more personal encounters” o Suggest establishing a protocol for terminating email relationships May affect the risk of a lawsuit May affect the course of malpractice litigation by increasing availability of documentation Page8 Types of Managed Care Organizations (definitions from healthcare.gov) Health Maintenance Organizations (HMO’s): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness. o Models Staff Model: provides clinical facilities & employs physicians/staff Network Model: provides care through a contracted physician/hospital network Mixed Model: provides care through owned clinics & contracted providers Preferred Provider Organizations (PPO’s): A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost. Modified Fee For Service (FFS): A method in which doctors and other health care providers are paid for each service performed. Examples of services include tests and office visits. o Costs of insurance premiums rises with freedom of access to providers FFS > PPO > HMO Current Issues Affecting Medical Practice o Patient Protection and Affordable Care Act (PPACA) – “Obamacare” Set of reforms which affects all aspects of health services, reimbursement & delivery Up to the year 2020 Requires insurers to modify exclusions for pre-existing conditions & lifetime caps on coverage Expands Medicaid eligibility Physician payments based on quality of care By 2018, all existing insurance plans must cover preventative care w/o co-pays o Patient Centered Medical Home (PCMH) Implements outcomes-based compensation plans for physicians Compensation based on performance measured by medical records analysis Will require adoption of high standards patient outreach and education o Accountable Care Organizations A group of health care providers who give coordinated care, chronic disease management, and thereby improve the quality of care patients get. The organization's payment is tied to achieving health care quality goals and outcomes that result in cost savings. o Projected Physician Shortage Estimates additional 16,643 primary care providers needed now, and an excess of 46,000 by 2025 o Electronic Health/Medical Records (EHR/EMR) Will become essential to participation in reimbursement services Single largest line item of medical practice operations OST 581 Spring 2015 Lecture 10: Medical Malpractice in Michigan (Schlotterer) 4 Elements of a Malpractice Case o Duty Comes from a professional relationship – either action or inaction of duty Distinct from Good Samaritan law: a doctor does not have a duty to act in a medical emergency involving a person they do not have a professional relationship established with Protects doctors in these type of situations in which they give reasonable assistance to someone in need o Breach/Deviation/Derelict Straying from the Standard of Care Standard of Care: what a physician of ordinary learning judgment and skill would do or would not do under the same circumstances o Direct Causation Physicians actions lead to damage – “but for” the alleged malpractice the injuries would not have occurred w/o expert testimony establishing causation there is no viable claim Expert witness must match the defendant – similar training, same certifications, similar scope of practice o Damage The patient was damaged in some way – physically, emotionally, psychologically Types of damage Non-economic damages: damages that you can’t put a specific number on o Ex: pain, suffering, shock, fright, embarrassment o There is a 2 tiered cap which is adjusted annually Lower tier = $440,200 Higher tier = $786,000 Must fit 1 of 3 categories to qualify for higher tier o Loss of ability to procreate – regardless of the person o Brain injury w/ loss of cognitive ability making them unable to make independent life decisions o Injury w/ loss of motor abilities – paraplegia, quadriplegia, etc. Economic Damages: damages that are accounted for monetarily o Ex: medical bills, lost wages o NO cap o Wrongful Death Statute: in the case of a death, the estate of the patient can file a suit asking for compensation (medical expenses, funeral expenses, etc.) if the patient had dependents (typically children under 18) Lawsuit o General Info Inaction is the largest percentage of claims Common claims: failure to act, informed consent, delay in Dx or Tx, delay in consultations/referral Risk Avoidance Timely documentation is critical!! o Late entry vs record alteration Record alteration: altering a document after you receive the Notice of Intent - illegal Late entry: altering a document after the patient encounter but before receiving a Notice of Intent – legal Communication Consent forms Non-compliant patients – DOCUMENT THIS o Steps Pre-suit Requirements Statute of Limitations: serving a Notice of Intent must be w/in 2 years of the incident o Exception: wrongful death = 5 years Page9 Chris Giles Ethics Exam Study Guide Exam: 1/26/15 Metadata: info on physician activities o Must surrender to plaintiff lawyers on request HER may change how courts determine standard of care Chris Giles Exam: 1/26/15 Ethics Exam Study Guide o OST 581 Spring 2015 Notice of Intent: legal document an attorney writes Provides an extra 182 days in which to file suit (on top of the 2 years) Requirements Alleged applicable standard of care How the standard of care was allegedly breached What the healthcare professional should have done How the alleged breach caused the injuries Suit Plaintiff: must file an Affidavit (“aff-a-dave-it”) of Meritorious Claim (the suit) executed by a qualified expert o Comes after the Notice of Intent Defendant: must file an Affidavit of Meritorious Defense w/in 91 days of service (being served) also executed by a qualified expert o Qualified Expert In the year prior to the alleged malpractice, the expert must spend the majority of his/her professional time in active clinical practice or teaching in an accredited program w/in the same specialty(-ies) of the defendant provider Must have same board certifications, must currently practice the same specialty PA’s, nurses & nurse practitioners are NOT considered specialists in Michigan o General Liability/Negligence An injury which occurred as a result of breach of a duty but eh issues are in the common knowledge of the average juror Ex: assault, common fall w/in the office d/t puddle on floor, etc. – basically obvious things NOT subject to damage caps Expert testimony NOT required o Physician’s Role in a Lawsuit Complaint: states the factual basis Answer: states the defendant’s position – deny, admit, or say you don’t have the info to do either Discovery: interrogatories, requests for production of documents, physician meetings, depositions Exceptions to Patient-Physician Relationship – When you can breach it o Child Protection Law – required when you think that a child is subject to abuse Ex: sexual abuse, physical abuse, exposure to meth production o Elder Protection – when you think an elderly person is subject to abuse o Wound or other injury inflicted by: knife, gun, deadly weapon, or other means of violence Required to report to the chief of police o You must disclose a patient’s medical records to a court unless there is a formal objection by the patient’s attorney…but the judge may make you testify or release records anyway Page10 Lecture 11: Online Modules – Physician Communication Essentials Module 3: Inter-Professional Healthcare Delivery o Definition: care provided by a team composed of various specialized members in which all members are actively involved o Important to include the patient & their advocates o Leads to: more effective care, fewer errors, inc morale & satisfaction o Barriers: time, hierarchy, fears, different responsibilities, personalities Most exist b/t doctors & nurses Module 4: Communication from the Patient’s Perspective o Physicians talk 60% of the time, patients only 40% o Patients who: ask more questions, had more concerns, are more anxious – get more information Info received Verbal (7%) – words Vocal (38%) – tone, pitch, rate Visual (55%) – body language o Information given is directly related to patient satisfaction Chris Giles Ethics Exam Study Guide Exam: 1/26/15 Module 5: Why do providers get sued? o Risk of being sued has little to do w/ # of mistakes Causes Failure to provide an apology/explanation Concern for future patients Compensation Accountability Poor communication o Basic interpersonal skills (listening & respect) are just as important as clinical skills in preventing lawsuits Suggestions: slow down, be empathetic, keep it simple, be aware of non-verbal cues OST 581 Spring 2015 Lecture 12: Depositions Depositions o What are they? Testimony: everything is recorded, time to ask questions Given under oath – everything you say must be true Used for fact finding o Expectations Number of people may be present – you, your attorney, plaintiff’s attorney, court reporter, others You will be answering questions – be truthful, concise (you don’t have to give details that aren’t asked for), never guess, listen to your attorney, be polite, do not joke, listen carefully Also, don’t answer hastily, give your attorney a moment to speak up Length can vary widely Lecture 13: Movie – Dax’s Case Movie was about a patient named Donald Cowart who was severely burned in an accident involving a car and an explosion o Dax had 3rd degree burns over 65% of his body including his face and hands o Before help arrived and during treatment he only wanted to die, as to escape the pain he was in o Mother wasn’t informed enough about his condition and treatment to make a decision o Doctors initially blamed the shock phase & narcotics for his behavior Later they thought it was him trying to gain control of his environment & manipulate those around him o Mom agreed he wasn’t in a place to decide his right to die 3 weeks into rehab he gave up and refused treatment, but was given it anyway o 2 psychiatrists agreed he was competent to make the decisions but his Tx was forced on him and he was not allowed to leave o He was left blind, scarred, and w/o fingers Eventually he was allowed to return home; didn’t like the restrictions, worried about intimate relationships, thoughts of suicide Eventually went to Baylor Law School o Lived w/ married couple to help him, severe insomnia, grades were good o d/t relationships & other issues he became majorly depressed & “gave up” – tried to OD on sleeping pills Wasn’t able to successfully end his own life w/o inflicting further injury & possibly making life worse Later life o Got married, now he enjoys life & work as a lawyer o Mom never should have made decisions, they should have been up to him o Acceptable quality of life: when a person can no longer tolerate the situation they are in Issue: when does one stop treatment and allow a person to die? Page11 Depositions Article: 8 Things to Never do at your deposition Always be professional Cooperate w/ co-defendants Don’t guess @ answers – say “I don’t know” Don’t answer any more than the specific question asked Don’t simplify medical language for the plaintiff attorney Never answer compound questions Don’t skim over labs, review them thoroughly Don’t respond to double-negative questions Lectures 15, 16: Reproductive Rights Assistive Reproductive Technologies o Sperm by husband or donor o Issue: to whom should it be made available? – married couples?, non-traditional families?, women over a certain age? Who decided: Law vs Providers? o Surrogacy: a woman carries and delivers a child for another NOT available in Michigan Gestational: surrogate provides ONLY the womb, parents supply sperm & eggs Traditional: surrogate provides eggs & womb o In Vitro Fertilization (IVF): sperm and egg are combined outside the body and implanted into a uterus Issues Who pays? – insurance or mother? Right vs Privilege – do people have the right to be parents What happens to unused fertilized eggs? o Legal solutions: so far only California has made a ruling – fertilized eggs are property, NOT life o The law has placed no formal restrictions on the availability of reproductive techniques Some clinicians have refused services to single people or non-traditional families Page12 Chris Giles Ethics Exam Study Guide OST 581 Exam: 1/26/15 Spring 2015 Lecture 14: Medical Ethics Core Ethical Principles o Nonmaleficence: do no harm o Beneficence: moral obligation to take positive & direct steps to help others o Autonomy: the ability to make one’s own health decisions, self-rule Patient autonomy trumps physician beneficence Exceptions Preventing harm to others – Tarasoff Duty Stop spreading deadly disease Therapeutic privilege: a physician does not have to disclose information to a patient that may do severe psychological harm to the patient, thus protecting the patient from immediate harm o Justice: treat similar cases the same unless there is a relevant reason to discriminate Distribute benefits & burdens fairly Reasons to discriminate/differentiate (treat them differently) What a person deserves – works hard, puts forth effort, did not contribute to the condition o Ex: give the guy who takes care of himself the liver transplant, not the alcoholic What a person needs – special abilities or talents, past discrimination, misfortune o Ex: triage Law vs Ethics: What do you do? o Before analyzing an ethical dilemma, make sure one exists – Do you have sufficient information? Is there an interpersonal conflict? Is there incomplete awareness of the situation? o One Potential Analysis – all must be “yes” Is it legal or in accordance w/ policy? Promote a win-win situation? Can I look myself in the mirror? o Another Potential Analysis Examine the facts – consider stakeholders/interests – evaluate options – make a decision – justify your decision – take action – evaluate outcome – move toward prevention o Guidance: review past similar situations, legal implications, sensibility of decisions, possible impact on me personally Disclosure of Medical Mistakes o Reasons Patients Sue: not giving them what they desire, perceived dishonesty, perceived lack of explanation, someone advised them to sue o Apology Statutes Apologies are declared inadmissible in civil actions arising out of alleged medical errors Michigan: does NOT apply to statements of fault, negligence, or culpable conduct o You can say: “I’m sorry this happened, we will do our best to fix it.” o You CANNOT say: “It’s my fault, I did the wrong thing.” Chris Giles Exam: 1/26/15 Ethics Exam Study Guide OST 581 Spring 2015 o Lecture 17: End of Life End of Life: medical & psychological care given in the advanced or terminal states of an illness or condition Applies to all ages, not just geriatrics Is it ok to end life to alleviate suffering? o Patient Rights Patient Self Determination Act For institutions that receive Medicare/Medicaid Provides information on admission or initial enrollment about… o Legal rights to make health care decisions & to be informed of a provider’s policies o Advance care directives & documentation o No discrimination based on their advanced care directive o Steps the provider takes to ensure compliance Page13 Ethical vs Legal Issue? Uniform Parentage Act: attempts to determine parentage Donor is NOT a parent Sign a contract: what did the parties intend w/ the child – in case one parent backs out Residence of the child: for best interests of the child – in case the parents split up Women, Pregnancy & Abortion o Preemptive Imprisonment: some states allow up to 9 months of imprisonment to protect a fetus from abuse – prevent women from harming a fetus o Abortion Why is this an issue: definition of life – when does it begin? Roe v Wade: reaffirmed woman’s right to terminate pregnancy Planned Parenthood v Casey: right of a woman to have an abortion before viability w/o undue interference State has the right to limit an abortion after viability if there is a provision to protect the safety/health of the woman o Basically: If the mother is in danger, she can have an abortion even if the child is viable Undue Burden: purpose/effect of placing a substantial obstacle in the path of a woman seeking an abortion of a nonviable fetus o ONLY one = consent/notification of the partner – woman does NOT have to do this o NOT: brochures, 48hr waiting period b/t consult & procedure, listening to child’s heartbeat Funding: what if a woman cannot pay for an abortion? Ethical implications Any reasons to justify an abortion – possible death of the mother?, child of rape?, etc. Are current laws consistent/fair/just? Is abortion an appropriate method of birth control Parent’s Rights o Neonatal Care Historically, decisions were deferred to parents b/c it was assumed parents were making decisions in the best interests of the child – beneficence Trends: parents of seriously ill newborns should not make life/death decisions Child Abuse Amendment of the Child Abuse Prevention and Treatment Act Hospitals treat “all conscious, viable, premature newborns, even if they are likely to have severe physical & mental disabilities.” o Exceptions: irreversibly comatose, prolongs death, treatment is futile, virtually inhumane o Vaccinations: 48 states allow for parents to refuse child vaccinations for non-medical reasons o Ability of a minor to consent to an abortion State specific laws MI: need parental consent or a judicial waiver Physician’s Rights o Conscientious Objection: refusal to perform a legal action d/t personal beliefs Examples: abortion, contraception, withdrawing life-sustaining treatments MI: Michigan Conscience Clause – physicians can refuse to give an abortion o How to counsel/treat patients who have different values/ethical beliefs Suggestions: polite, courteous, understanding, never judgmental, listen, referrals Chris Giles Exam: 1/26/15 Ethics Exam Study Guide OST 581 Spring 2015 o Advanced Care Directives Documents designed to allow competent adults to make healthcare plans in advance of future incapacity Types o Instructional: specify treatment wishes prior to a terminal illness or period of incapacity a.k.a. Living Will, Terminal Care Document Features: written, signed, witnessed, articulates wishes, take effect upon incapacity o Proxy: choose another person to make decisions on one’s behalf a.k.a. Durable Power of Attorney for health care Rules: patient must have capacity to make, effective upon incapacity, revocable States differ in laws Flaws o Patient avoidance: nobody wants to prepare for death o Future is uncertain: can’t always predict what may happen o Family disagreement Right to Die Adult w/ capacity – decision of the patient Adult who never had capacity o Substituted Judgment Standard: what would this patient have wanted? o Best Interest Standard: benefit to the patient prevails Newborns o Beneficence = key o Traditional view: parents have child’s best interests at heart o Trending view: side step parents due to conflict Adult w/o capacity & NO Advanced Care Directive – use surrogate or close family member Physician Rights Physician-Assisted Suicide: physician provides patient w/ a lethal dose of medication, but the patient administers it Crime in almost every state – prison sentence, sanctions, license revoked Cases – the most common reason for wanting to die was loss of autonomy o Oregon’s Death w/ Dignity Act o Washington state’s Assisted Suicide Law Euthanasia o Active Euthanasia: you prescribe, but not administer the medication yourself as the doctor “mercy killing” Illegal & condemned by the medical profession o Passive Euthanasia: allowing someone to die by not doing something that would have prolonged life “letting die” Legal & endorsed by the medical profession Withholding vs Withdrawing Care o Withholding: decision to refrain from giving permission for treatment o Withdrawing: decision to discontinue activities or remove forms of care Double Effect Doctrine It is wrong to intentionally harm someone to produce a good result, but it is permissible to do something intended to produce a good result even if the action leads to unintended but foreseen harm o It is all about the intent – did the physician perform the action w/ the intent to cause death Futility: a condition in which physiological systems have deteriorated so drastically that no intervention can reverse the cline; no hope for improvement of an incapacitating condition “trying to fill a bucket w/ a hole in it” General rule: physicians are not obligated to provide futile interventions that have no physiologic rationale or have already failed o “you don’t have to give treatments that you think are unnecessary or have no logical basis Steps to take o Adhere to policies o Allow yourself to withdraw o Provide for transfer to another physician/institution o Legal proceedings Page14