Ethics/Practice of EM/Medical Legal Flashcards
This deck covers the relevant legal and ethical principles and laws relevant to the practice of emergency medicine.
What is the age of consent for sex in Canada?
- <12 yo = Can’t be capable
- 12-13 yo = <2 years older
- 14-15 yo = <5 years older
- 16-17 yo = Anything not exploitive (eg. sex trade)
- >18 yo = Fully capable
We are not obligated to report
What phases of lab processes can result in error?
- Collecting the tubes/sample/tissue
- Analyzing/interpreting the tubes/sampes
- Inputting the results
What is the SDM hierarchy?
- Legal Guardian (parent)
- Appointed Power of Attorney
- Consent and Capacity Board representative
- Spouse/Partner
- Child >16/Parent not estranged
- Parent with right of access
- Sibling
- Another relative
- Public Guardian and Trustee
Define an adverse event. Define intrinsic and extrinsic sources of error. Provide 3 examples of each.
Adverse Event
- Injury that was caused by medical management, both preventable and non-preventable
Intrinsic Source of Error
- Part of the nature of emergency care/can’t change it
- Examples
1. Decision burden
2. Patient factors (delirium, language, acuity)
3. Uncertainty
4. “Low signal to noise” eg. a 2/10 SAH headache
Extrinsic Source of Error
- Resource constraints
- Preventable
- Examples
1. ED design
2. Crowding
3. Fatigue
4. Teamwork
5. Information gap
Violation Producing Factors
- Make someone more willing to break protocol
- Violations undermine safety
- Opposite to workarounds which increase safety
- Gender
- Maladaptive behaviour
- Over/underconfidence
- Authority gradient
What 4 humanitarian principles do responders adhere by?
- Humanity - you’re there to address suffering
- Neutrality - never take a side
- Impartiality - aid is base on need alone
- Independence - autonomous from influence
What is the formula to calculate the G -Force of an accident?
g = Delta(v2) / (Stopping distance * K)
It means that the G force is inversely related to the stopping distance
Outline the Universal Declaration of Human Rights
All human beings are born free and equal in dignity and rights and are entitled to life, liberty, security of person, and “a standard of living adequate for… health and well-being
Draw a Haddon Matrix using an MVC as an example. What are 3 tenants the matrix relies on?
Approach to injury prevention that demonstrates interaction
Column Headings
- Host
- Agent/Vector
- Environment
Row Headings
- Before event
- During event
- After event
Tenants
- Injuries are preventable
- Injuries follow patterns
- Can’t rely on human factors alone
What are the 6 domains for quality in healthcare?
Safe
- Avoiding harm from care that is meant to help patients
Effective
- Care based on scientific knowledge
Patient-centered
- Care that is responsive to and respectful of individual patient preferences, needs, and values
Timely
- Reducing waits for those who receive and give care
Efficient
- Avoiding waste of equipment, supplies, ideas, and energy
Equitable
- Care not different due to personal characteristics
In ethical dilemmas what is meant by the impartiality test, the universality test, and the interpersonal justifiability test?
Impartiality
- Would you the doctor accept this action done to you?
Universality
- Would you the doctor feel comfortable with another doctor doing this if they were seeing a similar patient?
Interpersonal Justifiable
- Would it be accepted by your peers?
What are the 5 elements of informed consent?
- Capable patient
- Voluntary
- Informed about risks/benefits
- Specific to situation and treatments
- No misrepresentation
Define:
- Autonomy
- Beneficence
- Non-maleficence
- Distributive Justice
Autonomy
- Patients can make their own decisions about themselves
Beneficence
- Do good
Non-maleficence
- Don’t do evil
Distributive Justice
- Resources are allocated to all
What are the top 5 causes of death in Canada?
- Cancer
- Heart Disease
- CVA
- Injuries
- Chronic lower respiratory disease
What are the guidelines for child seats?
- <9 kg (usually <1 year old)
- 9-18 kg (<6 years old)
- 18-36 kg (<8 years old)
Errbuddddy get in the back until 13 yo
- <9 kg (usually <1 year old)
- Rear-facing seat
- 9-18 kg (<6 years old)
- Forward-facing seat
- 18-36 kg (<8 years old)
- Booster seat
How do you help a colleague you think is struggling with drugs/addiction and you’re even concerned about their patients?
- OMA/CMA
- CPSO
- Talk to them privately
- Speak with site chief
What are 7 steps to disclosing adverse events as per CMPA?
- First attend to their safety/care
- Plan this disclosure
- Invite
- Actually do it
* Sympathize, outline the investigative process - QI review
- Conduct the post-analysis disclosure
* What was learned, what’s changed, you’re sorry - Document
What were the significant results of the landmark Harvard
Medical Practice Study (NEJM 1991)?
1991 Harvard Medical Practice Study
- 4% of hospitalized pts had significant adverse events
- 30% of adverse events from “human error”
- Only 3% of adverse events occurred in the ED
- 90% of ED adverse events were “preventable”
2000 Institute of Medicine Report
Failures or “errors” were the result of intrinsic properties of
the processes of care in which health care professionals work
Efforts to reduce failures should focus on changing the
processes of care, rather than identifying, retraining, and
punishing the workers
A colleague is drunk or high at work. What do you do?
-
Ensure patient safety
* Chart review/call all patients back for reassessment -
Permissive Reporting
* CPSO: professional and ethical obligation to report -
Ensure your colleague is safe
* Not drinking and driving
What does it mean in Canada to have capacity?
A person is capable of consenting to treatment if the person is able to:
- Understand the information that is relevant to making a decision about treatment, and
- Appreciate the reasonably foreseeable consequences of a decision or lack of a decision
CURVES
- Choose and Communicate
- Understanding the disease
- Risk benefits and alternatives
- Value
- Emergency
- Surrogate
What is the difference between competence and capacity?
Competence
- Ability to partake in legal proceedings
- Determined in court
Capacity
- Ability to make decisions
- Everyone assumed to have capacity
What are the 3 E’s of injury prevention?
- Education
- Enforcement of Laws
- Engineering Modification
What are 3 exceptions to informed consent?
- Emergency
- Mental health (does not make someone incapable)
- Communicable disease
Define refugee and internally displaced persons (IDP)
- IDP stays in own country
- Refugee crosses border
Define a humanitarian emergency. What makes it a complex emergency?
A critical threat to health, safety, or security of a community
- Can be natural disaster or man-made
What makes it a complex emergency?
- Total breakdown of authority from conflict
What are 3 problems that can occur during handover and how can we mitigate those effects?
Handover Issues
- Getting interrupted
- Inconsistent format
- Patient labels (bias)
Mitigate with standardized formats (SBAR)
- Situation
- Background
- Assessment
- Recommendation
How do we incorporate Injury prevention into practice? What are two broad categories with 3 examples in each?
Clinical
- Document
- Systemic trauma care
- Counsel on injury prevention
- Code ICD-10 injuries
Policy
- Advocate
- Lead policy development
- Do research
- Educate others
Name 10 medical infections that are reportable?
Think of all the vaccine-preventable…
- HIV
- Gonorrhea
- Chlamydia
- Syphilis
- Hepatitis
- TB
- Measles
- Mumps
- Rubella
- Diptheria
- Tetanus
- Pertussis
- Polio
- Anthrax
- Botulism
- Salmonella
- Cholera
- Giardia
The Institute for Healthcare Improvement (IHI) had developed something called the triple aim framework. What is it?
- Improving the patient experience of care
* Quality + Satisfaction - Improving the health of populations
- Reducing the per capita cost of health care
List 6 mandatory reporting indications
- Child abuse/neglect
- Impaired driving
- LTC and RH patients being abused
- Sexual abuse of a patient
- Births, Still-births, and deaths
- Communicable disease
- Controlled drugs missing
- Gunshot wounds
- Healthcare Fraud
- Privacy breaches
- Any condition that could impact:
* Pilots or ATC people
* Railway safety
* Maritime safety - Serious injury in Correctional Facility
- Violated community treatment plans
What are 4 indications to call the coroner?
- Non-natural death (homicide)
- Death if non-natural event contributed (fall then septic)
- Pediatric
- Pregnant
- Unexpected
- Family concerned
- Institutionalized (jail, group home, psychiatric)
- Suspicious
What is the SPHERE handbook? List 6 components of it.
A collaborative project of humanitarian response experts, sets
international standards for the provision of humanitarian aid.
Provides minimum response standards for water and sanitation, food and nutrition, shelter, health care, and protection.
- Water
- Sanitation
- Hygiene
- Food security
- Nutrition
- Shelter
- Settlement
- Non-food items
- Health
What is a general approach to an ethical dilemma at work?
- Maintain confidentiality
- Consider mandatory reporting
- Consider permissive reporting
- Consider ethics/SW
- Consider the CMPA
- Consider CAS
- Assess capacity
* If incapable, find an SDM
What does it mean to be negligent and how is malpractice (a type of negligence) determined?
Negligence
- Failure to exercise the care that a reasonable person would provide in the circumstance
Requirements
- You had a duty of care
- Breach in the standard of care
- Harm or injury suffered
- Causal connection
List 3 risk factors for injury
- Male
- Young
- Low SES
- Substance abuse
- Previous arrest
How is wellness promoted personally and professionally?
Professionally
- Education
- Interventions
- Handbooks
Personally
- Sleep
- Exercise
- Diet
- Vacation
- Self-monitoring
- Practice mindfulness
How is an injury defined?
A harmful event where energy is transferred resulting in tissue or organ damage
What are 5 ways the CMPA wants you to chart when a patient wants to LAMA?
- Patient is capable
- Discharge instructions given
- Signed AMA form is nice but useless
- Document the reason for care, their capacity assessment, and the reason for leaving
- Welcome them to come back or direct them to other care
What is resiliency?
Resiliency
- Adapting well to stress
Components
- Attitudes
- Balance and prioritization
- Practice management
- Supportive relationships
What are the 3 dimensions of burnout according to CAEP?
- Emotional exhaustion
- Depersonalization
- Reduced sense of personal accomplishment
What are 6 ways medication errors can occur?
- Prescription errors
- Transcription errors
- Dispensing errors
- Administration errors
- Monitoring errors
- Discharge errors
What are 5 strategies to manage conflict?
- Establish common goals
- Communicate effectively
- Do not take it personally
- Avoid accusations and public confrontations
- Compromise
- Establish commitments
- Accept differing opinions
- Ongoing communication/follow up
- Be pleasant
- Consider a mediator
If a child has a life-threatening condition can we hold this kid against their parent’s will? What about if it’s not life-threatening?
Life-Threatening
- Yes you can (even Jehova’s witness)
Non-life threatening
- Call CAS and report this is neglect/abuse of the child
List 4 adverse events that can occur with ED crowding?
- Mistriage of atypical presentation
- Delays to care of time-sensitive diagnoses
- Increased LWBS
- Delay in transfer to appropriate care
