HAS 4400

Session Ten

Chapter 11Relationship with the patient

• Physician-patient

• Hospital-patient

Physician-patient

• Beginning the relationship– Contract to care for a certain population– Express contract– Implied contract

• Nondiscrimination• Ending the relationship

– Patient withdrawal– Transfer– Physician withdrawal– Unable to provide care– Abandonment

Hospital-Patient• Nondiscrimination statutes

– Title VI CRA– ADA– The Rehabilitation Act of 1973– The age Discrimination Act of 1975– State Law– Attempts to require discrimination

• Patient recruiting• Nonemergency Patients

– Common law right to admission– Contractual right to admission– Hill-Burton Community service– Statutory Right to Admission

• Reasons for nonadmission

The Emergency Medical Treatment and Active Labor Act (EMTALA)

• Screening

• Stabilization

• Transfers

• Penalties– Loss of Medicare entitlement– Law Suit

Discharge

• False imprisonment• Habeas corpus• Discharge of patients needing additional care• Level of care• Disruptive patients• Recommended procedure (review)• Refusal to leave• Temporary releases• Escape

HAS 4400

Chapter Twelve

Treatment, Authorization and Refusal

Dr. Burton

InformedConsent

Required DisclosureRequired Disclosure•Reasonable PhysicianReasonable Physician•Reasonable PatientReasonable Patient

Elements of Disclosure

• Patient’s Medical Condition

• Nature and purpose of the proposed procedure

• Consequences and risks

• Feasible accepted alternatives, including consequences of no treatment

Exceptions to the disclosure requirement

• Emergencies

• Therapeutic privilege

• Patient waiver

• Prior patient knowledge

• Statutory exceptions

Responsibilityfor Obtaining Consent

PhysicianPhysician

Limited Hospital Role

BlanketBlanket

BatteryBattery

DetailedDetailed

ChallengesCapacity, Readability, Translation, Voluntariness, Withdrawal of consent

Right to Refuse(Bases)

• Common Law– Freedom from nonconsensual invasion

• Statutory rights– Living Wills, Durable powers of attorney, Hospice

laws

• Constitutional rights– Liberty interest protected by due process clause

– Freedom of religion

– Right to privacy

Involuntary Treatment• Threats to the Community• Impaired Capacity• Life of Others• Dependents• Criminal Law Enforcement• Civil Law Discovery• Other:

– Preservation of Life– Prevention of Irrational Self-destruction– Protection of the Ethical Integrity of Health Care

Providers– No Family Veto

Limits on Treatment

• Inappropriate treatment

• Medically unnecessary treatment

• “Futile treatment”

• Refusal to leave

Adults w/Decision Making capacity

• Age of majority (18)• Not declared incompetent• Capable of understanding consequences• Limits on Authority to consent

– Mayhem– Suicide– Illegal drugs or devices– Inappropriate treatment

Incapacitated Adults

• W/ prior directive

• W/O prior directive– Next of Kin– Guardian

• Substituted judgment and best interests

Minors

• Emergency care• Self-determination

– Statutes– Emancipated minors– Mature minors

• Limits on decisions (same rationale as adults)

• Infants

Patient Self-Determination Act (PSDA)• Genesis

Louis Kutner coined the term “living will” in 1969

California passed the Natural Death Act in the mid-seventies

• PSDA implemented through Medicare/Medicaid Providers• Written info at time of admission.

- the person’s rights under law to make health care decisions, including the right to accept or refuse treatment and right to complete state-allowed advanced directives, and

- the provider’s written policies concerning implementation of those rights;• document in the patient’s medical record whether or not the person has completed an

advance directive;• not discriminate or condition care based on whether or not the person has completed an

advance directive;• ensure compliance with state laws concerning advance directives• provide education for staff and the community on issues concerning advance directives.

Advance directives

Instructional – living will/terminal care document

Proxy – durable power of attorney

Assisted Suicide

Philosophy Statement Eval Form

Student Name: _____________________Course: ____________________• Worldview• Guiding principles and values• Application of ethical principles• Ethical Approach to decision making• Focus as a health care professional**Written Expression

ClaritySyntax/GrammarEditing