Download Exam 1 Study Guide OST581

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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
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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
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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
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OST 581
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Obtaining Informed Consent

3 Requirements

Patient has decision-making capacity
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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
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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
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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
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Single unprofessional incident
Informal “coffee cup” conversation
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
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
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Profession
Chris Giles
Exam: 1/26/15
Ethics Exam Study Guide
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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
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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
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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
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Chris Giles
Ethics Exam Study Guide
Exam: 1/26/15
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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
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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
