Flashcards in Legal and Ethical Issues in Medicine Deck (77):
All adults (18 or older) are assumed to be ...?
LEGALLY COMPETENT to make health care decisions for themselves.
Legal competence - Minors:
Usually NOT considered legally competent.
EMANCIPATED minors are people ...?
To be considered an emancipated minor an individual must meet AT LEAST 1 of the following criteria:
1. Be self-supporting.
2. Be in the military.
3. Be married.
4. Have a child for whom he or she cares.
Questions of decision-making capacity and competence - If an adult's competence is in question (mental retardation or dementia), physicians involved in the case ...?
Can evaluate + testify to the CAPACITY of the patient to make health care decisions.
HOWEVER --> ONLY A JUDGE (with input from the patient's family or physicians) can make the LEGAL DETERMINATION of competence.
If a person is found to be INCOMPETENT, a LEGAL GUARDIAN will be ...?
Appointed by the court to make decisions for that person.
--> MAY OR MAY NOT BE A FAMILY MEMBER.
A person may meet the LEGAL standard for competence to accept or refuse medical management EVEN IF ...?
1. She is mentally ill.
2. Has mental retardation.
3. Is incompetent in OTHER AREAS of her life (eg with finances).
What correlates to some extent with clinicians' evaluation of capacity?
The Folstein MMSE.
23 of higher = Competence.
18 or lower = Incompetence.
--> CANNOT BE USED ALONE TO MAKE A DETERMINATION of legal competence.
Informed consent - With the exception of LIFE-THREATENING emergencies (eg when the time taken to obtain consent would further endanger the patient), a physician must ...?
INFORM + OBTAIN consent (VERBAL or NONVERBAL) from a COMPETENT adult patient before proceeding with ANY medical or surgical treatment.
Informed consent - Signature?
May NOT be required for minor medical procedures.
--> Patients usually sign a document of consent for MAJOR medical procedures or for surgery.
Informed consent - Can be obtained by nurses?
NO - Cannot be obtained by other hospital personnel.
Components of informed consent:
1. The patient must be informed of and understand the HEALTH IMPLICATIONS of their diagnosis.
2. Patients must also be informed of the health risks and benefits of treatment and the alternatives to treatment.
3. They must know the likely outcome if they do NOT consent to the treatment.
4. Must also be informed that they can WITHDRAW consent for treatment AT ANY TIME before the procedure.
Physicians must also obtain informed consent before ...?
ENTERING A PATIENT IN A RESEARCH STUDY.
If a patient's condition worsens during the study as a result of lack of treatment, placebo treatment, or exposure to experimental treatment, the patient must ...?
Be taken OUT of the study + Given the standard treatment for his or her condition.
Informed consent - Special situations - Competent patients have the right to refuse to consent to a needed test or procedure for religious or other reasons, EVEN IF ...?
Their health will suffer or death will result from such refusal.
Informed consent - Special situations - Although medical or surgical intervention may be necessary to protect the health or life of the fetus, a competent PREGNANT WOMAN has the right to ...?
REFUSE SUCH INTERVENTION (eg cesarean section) even if the fetus will die or be seriously injured WITHOUT the intervention.
Informed consent - Special situations - While all of the medical findings are generally provided to a patient, a physician can ...?
DELAY telling the patient the diagnosis IF the physician believes that such knowledge will ADVERSELY AFFECT THE PATIENT'S HEALTH (eg a coronary patient), or until the PATIENT indicates that he or she is ready to receive the news.
Informed consent - Special situations - The opinions of family members, while helpful for info about the patient's state of mine, ...?
CANNOT DICTATE what info the physician tells the patients.
--> AT THE PATIENT'S REQUEST, family members may be present when the physician provides the diagnosis.
Treatment of minors - Who can give consent for surgical or medical treatment of a minor?
Only the PARENT or LEGAL GUARDIAN.
Treatment of minors - Parental consent is NOT REQUIRED in the treatment of minors in the following instances (5):
1. Emergency situations (eg when the parent or guardian cannot be located and a delay in treatment can potentially harm the child).
2. Treatment of STDs.
3. Prescription of Contraceptives.
4. Medical care during pregnancy.
5. Treatment of alcohol or drug dependence.
Most states require PARENTAL notification or consent when a minor seeks an ...?
What can be obtained if a child has a life-threatening illness or accident and the parent or guardian REFUSES consent to an ESTABLISHED (not experimental) medical procedure for RELIGOUS or other reasons?
A COURT ORDER can be obtained from a judge (within HOURS if necessary).
Because the likelihood of a poor outcome is extremely HIGH, non-initiation of resuscitation AFTER DELIVERY is usually appropriate for ...?
1. Infants born before the 23rd gestational week.
2. Birth weight less than 400g.
4. Trisomy 13 or 18.
Testing for genetic disorders - When to test?
1. Disorder has pediatric onset.
2. Preventive therapy or treatment is AVAILABLE (Eg CF).
Testing for genetic disorders - If there are NO preventive therapies or treatments for the disorder and it has a pediatric onset (eg Tay-Sachs), ...?
PATIENTS SHOULD HAVE THE DISCRETION as to whether or not to test the child.
Because the child can make the decision to be tested or not when he or she is an adult, genetic testing should generally NOT BE DONE if:
1. The disorder has an adult onset and there are no preventive therapies (eg Huntington disease) or.
2. To determine whether a prepubescent child is a carrier of a genetic disorder that will affect his or her offspring (eg, fragile X syndrome).
If the genetic testing reveals info (eg issues of paternity) UNRELATED to the presence or absence of the genetic disorder, ...?
IT IS NOT NECESSARY for the physician to divulge such info to anyone.
Confidentiality - Although physicians are expected ethically to maintain patient confidentiality, they are NOT required to do so if (4):
1. Their patient is suspected of CHILD OR ELDER ABUSE.
2. Their patient has a significant RISK OF SUICIDE.
3. Their patient poses a seirous THREAT TO ANOTHER PERSON.
4. Their patient poses a RISK TO PUBLIC SAFETY (eg an impaired driver).
Confidentiality - Intervention by the physician if the patient poses a threat?
1. The physician must first ascertain the CREDIBILITY of the threat or danger.
2. If the threat or danger is CREDIBLE, the physician must NOTIFY the appropriate law enforcement officials or social service agency and WARN the intended victim (the TARASOFF decision).
Reportable illnesses - In most states:
1. Hep A/B.
STDs that are reportable in most states include ...?
1. AIDS - NOT HIV(+) status in ALL STATES.
2. Genital herpes --> NOT in MOST STATES.
Ethical issues involving HIV infection - HIV(+) Doctors:
Physicians are NOT REQUIRED TO INFORM either patients or the medical establishment about ANOTHER physician's HIV(+) status since, if the physician follows procedures for infection control, he or she does NOT POSE A RISK to patients.
Ethical issues involving HIV infection - HIV(+) patients:
1. Ethically + Legally, the physician CANNOT REFUSE to treat HIV(+) patients because of fear of infection.
2. A pregnant patient at high risk for HIV infection CANNOT BE TESTED OR TREATED for the viruse (eg with AZT +/- nevirapine) AGAINST HER WILL, even if the fetus could be adversely affected by such refusal. AFTER The child is born, however, the mother cannot refuse to allow the child to be tested and treated for the virus.
Ethical issues involving HIV infection - If a health care provider is exposed to the body fluids of a patient who may POTENTIALLY be HIV(+), ...?
It is ACCEPTABLE to test the patient for HIV infection, EVEN IF the patient REFUSES to consent to the test.
Should the physician maintain confidentiality when an HIV(+) patient habitually puts an identified person at risk by engaging in uprotected sex?
NO - Physicians are NOT required to maintain confidentiality in this case.
Involuntary and voluntary psychiatric hospitalization - Under certain circumstances, patients in psychiatric EMERGENCY SITUATIONS who will not or cannot agree to be hospitalized may be ...?
Hospitalized AGAINST their will or WITHOUT CONSENT (involuntary hospitalization) with certification by ONE or TWO physicians.
--> Such patients may be hospitalized for up to 90 days (depending on state law) before a court hearing.
Even if a psychiatric patient chooses VOLUNTARILY to be hospitalized, he or she ...?
May be required to wait 24-48hr before being permitted to sign out against medical advice.
Patients, who are confined to mental health facilities, whether voluntarily or involuntarily, have the right to ...?
Receive treatment + Refuse treatment (eg, medication, electroconvulsive therapy).
--> Patients who are ACTIVELY PSYCHOTIC or SUICIDAL, however, generally CANNOT REFUSE treatment aimed at stabilizing their condition.
Advances directives - What are these?
Instructions given by patients IN ANTICIPATION OF THE NEED FOR A MEDICAL DECISION.
Examples of advanced directives:
1. A durable power of attorney.
2. A living will.
A durable power of attorney is ...?
A directive in which a competent person DESIGNATES ANOTHER PERSON (eg spouse, friend) as his or her legal representative (ie health care proxy) to make decisions about his or her health care when he or she can no longer do so.
A living will is ...?
A written document or ORAL statement in which a competent person gives direction for his or her future health if he or she becomes incompetent to make decisions when he or she needs care.
Who is the most relevant advance directive?
The MOST RECENT INFORMATION about the patient's wishes.
Health care facilities that receive Medicare payments (most hospitals and nursing homes) are required to ...?
Ask patients whether they have advance directives and, if necessary, help patients to write them.
--> They must also inform patients of their right to refuse treatment or resuscitation.
Persistent vegetative state (PVS) - Whether to maintain a PVS patient on life support is dependent upon ...?
His or her advance directives or on the decisions of surrogates.
Surrogates - If an incompetent patient does NOT have an advance directive, people who know the patient, for example, family members (surrogates), must ...?
Determine WHAT THE PATIENT WOULD HAVE DONE IF HE OR SHE WERE COMPETENT (the substituted judgement standard).
--> The personal wishes of surrogates are IRRELEVANT TO THE MEDICAL DECISION.
Surrogates - The priority order in which family members make this determination is:
2. Adult children.
5. Other relatives.
If there is a conflict among family members at the same priority level and discussion among family members does NOT settle the issue, the ...?
ETHICS COMMITTE of the hospital may make the decision.
--> For intractable disagreement, LEGAL INTERVENTION (eg by a judge) may be necessary.
Even if a health care proxy or surrogate has been making decisions for an incompetent patient, if the patient regains function (competence) even briefly or intermittently, he or she ...?
REGAINS the right during those periods to make decisions about his or her health care.
Death and euthanasia - The legal standard of death (when a person's heart is beating) is ...?
Irreversible cessation of all functions of the entire brain, including the brain stem.
The legal standard of death differs among states but commonly involves ABSENCE of:
1. Response to external events or painful stimuli.
2. Spontaneous respiration.
3. Cephalic reflexes (eg pupillary, corneal, pharyngeal).
4. Electrical potentials of cerebral origin over 2mV from symmetrically placed electrodes more than 10cm apart.
5. Cerebral blood flow for more than 30min.
Physicians certify the ...?
CAUSE OF DEATH (Eg natural, suicide, accident) and sign the death certificate.
If the patient is dead according to the legal standard, the physician is AUTHORIZED to ...?
Remove life support.
--> A court order or relative's permissionis NOT necessary.
A patient's organs CANNOT be harvested after death unless the patient (or parent if the patient is a minor) has signed a document (eg an organ donor card) or informed surrogates of his or her wish to donate.
Organ donation - A minor (but NOT an adult) can be COMPELLED TO DONATE tissue (eg bone marrow, skin) to a close relative if he or she:
1. Is the ONLY appropriate source.
2. Will NOT be harmed seriously by the donation.
According to medical codes of ethics (eg those of AMA and medical specialty organizations), euthanasia (directly killing a patient for compassionate reasons) IS A CRIMINAL ACT and is NEVER APPROPRIATE.
Physician-assisted suicide (providing a means for a patient to commit suicide for compassionate reasons) is legal ...?
IN ONLY A FEW STATES, but is NOT generally an indictable offense in other states as long as the physician does NOT actually perform the killing (eg the patient injects himself).
There is NO ETHICAL DISTINCTION between ...?
WITHHOLDING + WITHDRAWING life-sustaining treatment.
If requested by a competent patient, food, water, and medical care can be ...?
WITHHELD from a patient who has NO REASONABLE PROSPECT OF RECOVERY.
If a competent patient REQUESTS REMOVAL OF ARTIFICIAL LIFE SUPPORT (eg ventilator support), it is ...?
BOTH LEGAL + ETHICAL for a physician to comply with this request. Such an action by the physician is NOT considered EUTHANASIA or ASSISTED SUICIDE.
Medical malpractice - Overview:
Medical malpractice occurs when harm comes to a patient as a result of the action or inaction of a physician.
The elements of malpractice (the 4 Ds) are:
1. Dereliction, or negligence (ie deviation from normal standards of care).
2. Duty (ie there is an established physician-patient relationship) that causes
3. Damage (ie injury).
4. Directly to the patient (ie the damages were caused by the negligence, not by another factor).
Who is most likely to be sued for malpractice?
Surgeons (including obstetricians) and anesthesiologists.
Who is the least likely to be sued?
Psychiatrists and family practitioners.
Malpractice is a ...?
Tort, or civil wrong, not a crime.
--> A finding for the plaintiff (the patient) results in a financial award to the patient from the defendant physician or his or her insurance carrier, NOT a jail term or loss of licence.
Recently, there has been an INCREASE in the number of malpractice claims. This increase is mainly a result of a BREAKDOWN of the traditional physician-patient relationship because of:
1. TECHNOLOGICAL ADVANCES in medicine, which reduce personal contact with the physician.
2. LIMITS ON TIME FOR PERSONAL INTERACTION and physician autonomy, partly as a result of the growth of managed care.
Damages - The patient may be awarded compensatory damages only, or BOTH compensatory and punitive damages - Compensatory damages:
Given to REIMBURSE the patient for medical bills or lost salary and to compensate the patient for pain and suffering.
Damages - The patient may be awarded compensatory damages only, or BOTH compensatory and punitive damages - Punitive damages:
Awarded to the patient to PUNISH THE PHYSICIAN and set an example for the medical community.
--> Punitive damages are RARE and awarded only in cases of wanton carelessness or gross negligence (eg a drunk surgeon who cuts a vital nerve).
Relationships with patients - Sexual relationships with current or former patients are ...?
INNAPPROPRIATE and are PROHIBITED by the ethical standards of most specialty boards.
Patients who claim that they had a sexual relationship with a physician may ...?
File an ethics complaint or a medical malpractice compalint, or both.
Physicians should avoid treating ...?
1. Family members.
2. Close friends.
--> Personal feelings can interfere with professional objectivity, and familiarity may limit questions or physical examinations of a sensitive nature.
Physicians should avoid ...?
ACCEPTING VALUABLE GIFTS (eg things that can be sold) from patients.
Impaired physicians - Causes:
1. Drugs or alcohol abuse.
2. Physical or mental illness.
3. Impairment in functioning associated with old age.
An impaired medical student should be reported to ...?
The DEAN of the medical school or the DEAN OF STUDENTS.
An impaired resident or attending physician should be reported to ...?
The person directly in charge of him or her (eg the residency training director or the chief of the medical staff, respectively).
Impaired physicians in private practice should be reported to the ...?
State licensing board or the impaired physicians program, usually run by physicians who are associated with the state medical society.