Accounting assignments
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lesson5cont.pptxChapter 14
Patient Consent,
Rights, and Responsibilities
Learning Objectives (1 of 2)
Discuss the differences among verbal, written, and implied consent.
Describe the role of the patient, physician, nurse, and hospital in informed consent.
Describe the theories under which the validity of consent might be proven.
Explain how consent differs among competent patients, minors, guardians, and incompetent patients.
Learning Objectives (2 of 2)
Discuss the importance of understanding patient rights.
Discuss the importance of understanding patient responsibilities.
Patient Consent
[N]o right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person.
—Union Pacific Ry. Co. v. Botsford
Consent
Voluntary agreement by a person who possesses sufficient mental capacity to make an intelligent choice to allow something proposed by another to be performed on himself or herself
Forms of Consent
Express consent can take the form of:
Verbal agreement
Written document authorizing medical care
Implied consent
Determined by some act or silence, which raises a presumption consent has been authorized
Generally applicable to emergency situations
Informed Consent (1 of 2)
Legal doctrine where a patient has a right to know potential risks, benefits, and alternatives of a proposed procedure
Patient has absolute right to know about and select from available treatment options.
Predicated on duty of physician to disclose sufficient information to enable a patient to evaluate proposed medical or surgical procedures before submitting to them
Informed Consent (2 of 2)
Verbal consent
Binding as written consent
More difficult to prove
Written consent
Visible proof of a patient’s wishes
Elements of Informed Consent (1 of 2)
Nature of patient’s illness or injury
Procedure or treatment consented to
Purpose of proposed treatment
Risks and probable consequences of the proposed treatment
Probability proposed treatment will be successful
Elements of Informed Consent (2 of 2)
6. Alternative methods of treatment, plus their risks and benefits
7. Risks and prognosis if no treatment is rendered
8. Patient understands nature of proposed treatment, alternatives, risks, and probable consequences of treatment
9. Signatures of patient, physician, and witnesses
10. Date the consent is signed
Implied Consent
Unconscious patients are presumed under law to approve treatment
Generally presumed when immediate action is required to prevent death or permanent impairment
Unconscious patients presumed to approve treatment
Emergency from auto accident
Statutory Consent
Legislation allows emergency care
Eliminating need for written consent
Presumption:
A reasonable person would consent to lifesaving medical intervention.
Document need for immediate care
Attempt to contact family
Consider court order if necessary
Second opinion when in doubt
Judicial Consent
May be necessary in those instances where there is concern as to the absence or legality of consent.
Judge should be contacted only after alternative methods have been exhausted.
Some courts may require an attorney to initiate the call.
Written protocol should be available in ED.
Ensure staff education and training.
Physicians: Informed Consent
Physicians are expected to disclose to patients risks, benefits, and alternatives of recommended procedures.
Disclosure should include what a reasonable person would consider material to his or her decision of whether or not to undergo treatment.
Doctrine of informed consent is firmly rooted in the notions of liberty and individual autonomy.
Informed consent is not merely a tool to avoid lawsuits.
Physicians: Informed Consent Cases
Physicians Must Disclose Alternatives
Paternalism Fails
Physicians Duty to Advise: Delicate Medical Judgment
Adequacy of Consent
Lack of Consent
Course of Treatment Case: Patient’s Decision (1 of 2)
Elderly woman living alone fell and fractured her hip
Orthopedic surgeon ordered bed rest
Plaintiff maintained independent style of living
Expert testimony
Bed rest inappropriate treatment
Patient successful in proving that she was not informed of alternative treatment
Course of Treatment Case: Patient’s Decision (2 of 2)
Court held “necessary to advise a patient when considering alternative courses of treatment”
Physician should have explained alternatives
Risks & likely outcomes of alternatives
Matthies v. Mastromonaco
Lack of Consent: Riser v. American Medical Intern, Inc. (1 of 3)
Patient had multiple medical diagnoses.
Physician ordered bilateral arteriograms to determine cause of patient’s impaired circulation.
Hospital could not accommodate physician’s request & patient was transferred to a radiologist at St. Jude Hospital.
He performed a femoral arteriogram, not the bilateral brachial arteriogram ordered by the ordering physician.
Patient was prepared for transfer back to De La Ronde Hospital.
Shortly after ambulance departed, the patient suffered a seizure in the ambulance and was returned to St. Jude.
Lack of Consent: Riser v. American Medical Intern, Inc. (2 of 3)
Patient’s condition deteriorated, and the patient died 11 days later
Plaintiffs claimed patient was a poor risk for procedure
District court ruled for plaintiffs.
The defendant appealed.
What did the appeals court determine?
Lack of Consent: Riser v. American Medical Intern, Inc. (3 of 3)
The Court of Appeals held that there was a breach in the standard of care by subjecting the patient to a procedure that would have no practical benefit to the patient.
The physician had failed to obtain informed consent from the patient.
Information to Be Disclosed (1 of 2)
Physicians should provide as much information about treatment options as is necessary.
Based on a patient’s personal understanding of the physician’s explanation of risks and the probable consequences of treatment.
Needs of each patient can vary depending on age, maturity, and mental status.
Individual responsible for obtaining consent must weigh importance of giving full disclosure to the patient against the likelihood that such disclosure will adversely affect the patient’s decision.
Information to Be Disclosed (2 of 2)
Courts generally utilize an “objective” or “subjective” test to determine whether a patient would have refused treatment if the physician had provided adequate information as to the risks, benefits, and alternatives of the procedure.
Hospitals: Informed Consent (1 of 2)
Hospitals generally do not have an independent duty to obtain informed consent.
Caveat: Cases where hospitals have been found to owe a duty to provide patients with informed consent
For example: CT scan involves injection of a contrast dye. Keel was given no information concerning risks attendant to the procedure. The dye was injected and the plaintiff developed a thrombophlebitis at the site of the injection.
Hospitals: Informed Consent (2 of 2)
The Kentucky Supreme Court held that expert testimony was not required to establish lack of informed consent and that the hospital had a duty to inform the patient of the risks associated with the procedure.
Keel v. St. Elizabeth Medical Center, Ky.
Hospitals: Life or Death: Right to Choose
Jehovah’s Witness, in Stamford Hospital v. Nelly E. Vega, executed a release requesting that no blood or its derivatives be administered during her hospitalization.
Hospital filed a complaint requesting the court issue an injunction.
Connecticut Supreme Court determined hospital had no common law right or obligation to thrust unwanted medical care on a patient.
Nurses: Informed Consent
A nurse generally has no duty to:
Advise a patient as to a procedure to be employed
A nurse may confirm with the patient that the physician has explained the procedure.
Obtain a patient’s informed consent
Policy and procedures may provide that the nurse may witness that the risks, benefits, and alternatives have been explained.
Validity of Consent
Subjective test
Must determine if the individual patient would have chosen the procedure if fully informed
Objective test
Must show that a reasonable person would not have undergone a procedure if properly informed
Objective test preferred
Assessing Decision-Making Capacity
Includes patient’s ability to:
Understand risks, benefits, and alternatives of a proposed test or procedure
Evaluate information provided by the physician
Express his or her treatment preferences
Voluntarily make decisions regarding his or her treatment plan
Without undue influence by family, friends, or medical personnel
Admission Consent Forms
Signed at the time of admission
For routine services
Limited power of attorney
School officials when other options lacking
Consent for Specific Procedures
Variety of consent forms
Specifically describe the risks, benefits, and alternatives of particular procedures
Anesthesia
Cardiac catheterization
Surgery
Radiation & chemotherapy therapy
Blood and blood by-products, etc.
Limited Power of Attorney
Authorizes, for example, school officials, teachers, and camp counselors act on the parents’ or legal guardian’s behalf
When seeking emergency care
Limited protection
Active ongoing contact of family necessary
Who May Consent
Competent patients
Guardianship
Parental consent
Emancipated minor
Incompetent Patients
When there is doubt as to a patient’s capacity to consent, the consent of the legal guardian or next of kin should be obtained.
Ability to consent is a question of fact.
Physicians are in the best position to make that determination.
Spousal consent
Right to Refuse Treatment and Religious Beliefs
Patients have a right to refuse treatment.
Must be conscious and mentally competent
Hospitals must honor a patient’s decisions when treatment is refused.
Religious beliefs
Blood or blood products
Exculpatory Agreements
An agreement that relieves one from liability when he or she has acted in good faith
Exculpatory agreements in the medical setting are generally considered invalid.
Case: Cudnik v. William Beaumont Hospital
Release Form
A patient’s refusal to consent to treatment, for any reason, religious or otherwise, should be noted in the medical record, and a release form should be executed.
A completed release provides documented evidence of a patient’s refusal to consent to a recommended treatment.
Proving Lack of Consent
Reasonably prudent person in patient’s position would not have undergone treatment if fully informed
Lack of informed consent is proximate cause of injury for which recovery is sought
Informed Consent: Claims and Defenses
Risk not disclosed is commonly known.
Patient assured the practitioner that he or she would undergo treatment regardless of the risk.
For example: Patient did not want to know about the risks.
Consent was not reasonably possible.
Practitioner reasonably believed manner and extent of disclosure could reasonably be expected to adversely and substantially affect patient’s condition.
Patient Rights
Patient Rights (1 of 8)
Know one’s rights
Patient’s bill of rights
Explanation of rights
Know caregivers
Ask questions
Patient Rights (2 of 8)
Admission
Discrimination prohibited
Government facilities
Assessments and reassessments
Participate in care decisions
Informed consent
Patient Rights (3 of 8)
Right to treatment
Refuse treatment
Pain management
Quality care
Appoint a surrogate decision maker
Patient Rights (4 of 8)
Have special needs addressed
Execute advance directives
Compassionate care
Confidentiality
Patient Rights (5 of 8)
Privacy and HIPAA
Disclosures permitted without patient authorization
Limitations on disclosures
Patient advocate
Ethics consultation
Chaplaincy services
Patient Rights (6 of 8)
Discharge orders
News: don't leave the hospital until you know what comes next
Discharge or detainment
Release from hospital contraindicated transfer
Failure to override physician’s discharge order
Patient Rights (7 of 8)
Transfer
Access medical records
Know hospital’s adverse events
Know third-party relationships
Patient education
Patient Rights (8 of 8)
Transparency and hospital charges
Failure to disclose insurance applicants’ HIV status
Transparency not so transparent
Patient Responsibilities
Patient Responsibilities: Historical Perspective (1 of 4)
Cornwall General Hospital’s Rules for Patients (posted in 1897)
1. Patients on admission to the Hospital must have a bath, unless orders to the contrary are given by the Attending Medical Attendant . . .
6. Patients must be quiet and exemplary in their behaviour and conform strictly to the rules and regulations of the Hospital, and carry out all orders and prescriptions of the various officers of the establishment . . .
Patient Responsibilities: Historical Perspective (2 of 4)
8. No male patient shall, under any pretense whatever, enter the apartments or wards for the females, nor shall a female patient enter the apartments or wards for males, without express orders from the Medical Attendant or Lady Superintendent . . .
10. Every patient shall retire to bed at 9 p.m. from First May to First November, and at 8 p.m. from November to May; and those who are able shall rise at 6 a.m. in the Summer and 7 a.m. in the Winter . . .
11. Such patients as are able, in the opinion of the physicians and surgeons, shall assist in nursing others, or in such services as the Lady Superintendent may require . . .
Patient Responsibilities: Historical Perspective (3 of 4)
13. Patients must not take away bottles, labels or appliances when leaving the Hospital.
14. No patients shall enter into the basement story, operating theater, or any of the officers’ or attendants’ rooms, except by permission of an officer of the Hospital . . .
Patient Responsibilities: Historical Perspective (4 of 4)
17. Any patient bringing spirituous liquors into the Hospital or the grounds, or found intoxicated, will be discharged.
18. Whenever patients misbehave or violate any of the standing rules of the Hospital, the Attending Physician may remove or discharge them, as provided by clauses 91 and 93 of Rules for Medical Staff.
Patient Responsibilities: Contemporary Perspective (1 of 4)
Practice a healthy lifestyle
Maintain current medical records
Keep appointments
Provide full disclosure of medical history
Accurately describe symptoms
Patient Responsibilities: Contemporary Perspective (2 of 4)
Responsibility to disclose information
Communicate care preferences
Stay informed
Report unexpected changes in health status
Adhere to agreed upon treatment plan
Patient Responsibilities: Contemporary Perspective (3 of 4)
Avoid self-administration of medications
Actively participate in care
Comply with hospital policy
Respect
Understand medicine has limits
Patient Responsibilities: Contemporary Perspective (4 of 4)
Ask questions
“What is this medication for?”
“What diet am I on?”
“Since you are going to change my dressing, did you wash your hands?”
Tips for Patients: Help Prevent Medical Errors (1 of 7)
Medications
Inform your doctors about medicine you are taking.
Bring your medicines and supplements to doctor visits.
Inform your doctor about any allergies and adverse reactions you have had to medicines.
Make sure you can read your doctor’s prescription order.
Tips for Patients: Help Prevent Medical Errors (2 of 7)
Ask for information about your medicines in terms you understand—both when your medicines are prescribed and when you pick them up.
When you pick up your medicine from the pharmacy, ask: “Is this the medicine that my doctor prescribed?”
Make queries about any questions and directions on your medicine labels; don’t be afraid to ask.
Tips for Patients: Help Prevent Medical Errors (3 of 7)
Ask your pharmacist for the best device to measure your liquid medicine.
Ask for written information about the side effects your medicine could cause.
Tips for Patients: Help Prevent Medical Errors (4 of 7)
Hospital stays
If you are in a hospital, consider asking all healthcare workers who will touch you whether they have washed their hands.
When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will follow at home.
Tips for Patients: Help Prevent Medical Errors (5 of 7)
Surgery
If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done.
If you have a choice, choose a hospital where many patients have had the procedure or surgery you need.
Tips for Patients: Help Prevent Medical Errors (6 of 7)
Other steps
Speak up if you have questions or concerns.
Make sure that someone, such as your primary care doctor, coordinates your care.
Make sure doctors have your health information.
Tips for Patients: Help Prevent Medical Errors (7 of 7)
Ask a family member or friend to go to appointments with you.
Know that “more” is not always better.
If you have a test, do not assume that no news is good news—be sure to follow up.
Learn about your condition and treatments by asking your doctor, nurses, and other reliable sources.
Review Questions (1 of 3)
Discuss the rights and responsibilities of patients as reviewed in this chapter.
Discuss the distinction among verbal, written, and implied consent.
Describe the role of the patient, physician, nurse, and hospital in obtaining informed consent.
Explain how consent differs among competent patients, minors, guardians, and incompetent patients.
Review Questions (2 of 3)
5. Explain the available defenses for defendants as it relates to informed consent.
Can a patient consent to a procedure and then withdraw it? Discuss your answer.
Discuss under what circumstances parental consent for a minor might not be necessary.
Review Questions (3 of 3)
8. Describe the rights and responsibilities of patients.
9. Why should caregivers should consider themselves patient advocates?
10. Describe what can patients can do to help prevent medical errors.
