Code of Conduct

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HELPFUL ADVICE FOR CAREGIVERS Helpful advice for caregivers includes the following:

Break down the barriers between departments and work as a team. Abide by the ethical code of one’s profession. Do not criticize the professional skills of others. Maintain complete medical records. Provide each patient with medical care comparable with national standards. Seek the aid of professional medical consultants when indicated. Obtain informed consent for diagnostic and therapeutic procedures. Inform the patient of the risks, benefits, and alternatives to proposed procedures. Practice the specialty in which you have been trained. Participate in continuing education programs. Keep patient information confidential. Check patient equipment regularly and monitor it for safe use. When terminating a professional relationship, give adequate written notice to the patient. Authenticate all telephone orders. Obtain a qualified substitute when you will be absent from your practice. Be a good listener and allow each patient sufficient time to express fears and anxieties. Develop and implement an interdisciplinary plan of care for each patient. Safely administer patient medications. Closely monitor each patient’s response to treatment. Provide education and teaching to patients. Foster a sense of trust and feeling of significance. Communicate with the patient and other caregivers. Provide cost-effective care without sacrificing quality.

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CHAPTER REVIEW 1. The contents of codes of ethics vary depending on the

risks associated with a particular profession.

Ethical codes for psychologists, for example, define relationships with clients in greater depth because of the personal one-to-one relationship they have with their clients.

Practicing outside one’s scope of practice has both ethical and legal concerns.

2. Legislation in many states imposes a duty on hospitals to provide emergency care. If the public is aware that a hospital furnishes emergency services and relies on that knowledge, the hospital has a duty to provide those services to the public.

3. Hospitals are expected to notify specialty on-call physicians when their particular skills are required in the emergency department. A physician who is on call and fails to respond to a request to attend a patient can be liable for injuries suffered by the patient because of his or her failure to respond.

4. There can be both ethical and legal repercussions if a professional incorrectly interprets a physician’s orders.

5. A defense that sexual improprieties with clients did not take place during treatment sessions is unacceptable conduct.

6. Scope of practice refers to the permissible boundaries of practice for healthcare professionals, as is often defined in state statutes, which define the actions, duties, and limits of professionals in their particular roles.

7. A professional who exceeds his or her scope of practice as defined by state practice acts can be found to have violated licensure provisions or to have performed tasks that are reserved by statute for another healthcare professional.

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8. The power and authority to regulate drugs and their products, packaging, and distribution rest primarily with federal and state governments.

9. Certification of healthcare professionals is the recognition by a governmental or professional association that an individual’s expertise meets the standards of that group.

10. Licensure can be defined as the process by which some competent authority grants permission to a qualified individual or entity to perform certain specified activities that would be illegal without a license.

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TEST YOUR UNDERSTANDING

Terminology advanced practice nurse certification chiropractor clinical nurse specialist dentist dietitian float nurse laboratory medical technologist licensure medical assistant nonmaleficence nurse anesthetist nurse midwife nurse practitioner nursing assistant paramedic patient care teams pharmacist physical therapy physician assistant psychologist radiology technologist registered nurse respiratory therapist social worker special duty nurse

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REVIEW QUESTIONS 1. Describe how ethics and the law have an impact on the

various healthcare professions discussed in this chapter.

2. Discuss the ethical and legal implications of practicing outside one’s scope of practice.

3. Discuss the circumstances under which a hospital has a duty to provide emergency services to the public.

4. Are sexual encounters acceptable with clients as long as they do not take place during treatment? Explain your answer.

5. Consider under what circumstances a professional’s legal responsibilities may overlap with his or her ethical duties.

6. Describe how and why the scope of practice for various professionals (e.g., nurses and pharmacists) is changing.

7. Discuss what action a caregiver should take, if any, if a physician’s written orders appear questionable.

8. Describe a professional’s responsibilities when a patient’s condition takes a turn for the worse.

9. Describe the difference between the certification and licensing of a healthcare professional.

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NOTES 1. Walter F. Roche, Jr., “City Hospital’s HIV Testing Manipulated,”

The Baltimore Sun (March 11, 2004). http://www.baltimoresun.com/news/maryland/bal- lab0311-story.html (accessed July 27, 2018).

2. Federal Interagency Committee on Emergency Medical Services. 2011 National EMS Assessment. Washington, D.C.: U.S. Department of Transportation, National Highway Traffic Safety Administration, DOT HS 811 723. https://www.ems.gov/pdf/811723-National-EMS- Assessment-2011.pdf (accessed July 27, 2018).

3. U.S. Department of Transportation, National Highway Traffic Safety Administration (NHTSA), National EMS Scope of Practice Model. https://www.ems.gov/education/EMSScope.pdf (accessed July 27, 2018).

4. Federal Interagency Committee on Emergency Medical Services. 2011 National EMS Assessment. Washington, D.C.: U.S. Department of Transportation, National Highway Traffic Safety Administration, DOT HS 811 723. https://www.ems.gov/pdf/811723-National-EMS- Assessment-2011.pdf (accessed July 27, 2018).

5. NHTSA, National EMS Scope of Practice Model at 9. 6. Ibid. at 10. 7. U.S. Drug Enforcement Administration, “Officer Safety Alert:

Carfenatil: A Dangerous New Factor in the U.S. Opioid Crisis.” https://www.dea.gov/divisions/hq/2016/hq092216_attach .pdf (accessed July 27, 2018).

8. NHTSA, National EMS Scope of Practice Model at 23. 9. Ibid. at 26.

10. Ibid. at 26.

11. Ibid. at 27-28.

12. Morena v. South Hills Health Systems, 462 A.2d 680 (Pa. 1983).

13. Riffe v. Vereb Ambulance Service, Inc., 650 A.2d 1076 (Pa. Super. 1994).

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14. Fraijo v. Hartland Hosp., 160 Cal. Rptr. 252 (Ct. App. 1979).

15. Institute of Medicine, Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, D.C.: The National Academies Press, at 2. Available at http://www.nap.edu/openbook.php?isbn=0309090679 (accessed July 28, 2018).

16. HHS.gov, “HHS Awards $55.5 Million to Bolster America’s Health Care Workforce.” http://wayback.archive- it.org/3926/20150618190916/http://www.hhs.gov/news/p ress/2013pres/12/20131205a.html (accessed July 28, 2018).

17. Parija Kavilanz, “Nursing Schools Are Rejecting Thousands of Applicants—in the Middle of a Nursing Shortage,” CNN Money (April 30, 2018). https://money.cnn.com/2018/04/30/news/economy/nurs ing-school-rejections/index.html (accessed July 28, 2018).

18. Ibid.

19. Jilian Mincer, “Short on Staff: Nursing Crisis Strains U.S. Hospitals,” Reuters (October 20, 2017). https://www.reuters.com/article/us-usa-healthcare- nursing/short-on-staff-nursing-crisis-strains-u-s- hospitals-idUSKBN1CP0BD (accessed July 28, 2018).

20. Code of Federal Regulations, 42 CFR Ch IV, Subpart C, § 482.23 (b). https://www.gpo.gov/fdsys/granule/CFR-2011- title42-vol5/CFR-2011-title42-vol5-part482/content- detail.html (accessed July 28, 2018).

21. Teresa Serratt, Suzanne Meyer, and Susan A. Chapman, “Enforcement of Hospital Nurse Staffing Regulations Across the United States: Progress or Stalemate?” Policy, Politics, & Nursing Practice 15 (2014): 21–29. http://journals.sagepub.com/doi/pdf/10.1177/152715441 4532502 (accessed July 28, 2018).

22. Department of Health, Education and Welfare, Extending the Scope of Nursing Practice: A Report of the Secretary’s Committee to Study Roles for Nurses, Pub. No. (HSM) 73- 2037, 8 (1971).

23. Adams v. Krueger, 856 P.2d 864 (Idaho 1993).

24. Ibid. at 867.

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25. Carolyn Buppert, “Reducing Liability Risk When Collaborating with Nurse Practitioners,” Medscape (September 1, 2017). https://www.medscape.com/viewarticle/884582 (accessed July 28, 2018).

26. Debbie LaValley, “Boy Dies After Call to NP for Flu Symptoms.” CRICO (February 1, 2012). https://www.rmf.harvard.edu/Clinician-Resources/Case- Study/2012/Boy-9-Dies-After-Offhours-Call-to-NP-for-Flu- Symptoms (accessed July 28, 2018).

27. Buppert, “Reducing Liability Risk When Collaborating with Nurse Practitioners”

28. New York State Nurses Association, “Position on Statement on Floating.” https://www.nysna.org/position-statement- floating#.W1zdmS2ZPIE.

29. The Joint Commission, 2014 Hospital Accreditation Standards, LD.03.06.04 at LD–20.

30. Cignetti v. Camel, 692 S.W.2d 329 (Mo. Ct. App. 1985).

31. Norton v. Argonaut Insurance Co., 144 So. 2d 249 (La. Ct. App. 1962).

32. Tami Dennis, “More Heparin Overdoses, This Time in Texas,” Los Angeles Times, July 9, 2008; http://latimesblogs.latimes.com/booster_shots/2008/07/ more-heparin-ov.html.

33. Harrison v. Axelrod, 599 N.Y.S.2d 96 (N.Y. App. Div. 1993).

34. Larrimore v. Homeopathic Hospital Association, 181 A.2d 573 (Del. 1962).

35. Cafiero v. North Carolina Board of Nursing, 403 S.E.2d 582 (N.C. Ct. App. 1991).

36. Ibid. at 584–585.

37. Goff v. Doctors General Hospital, 333 P.2d 29 (Cal. Ct. App. 1958).

38. Koeniguer v. Eckrich, 422 N.W.2d 600 (S.D. 1988).

39. Eyoma v. Falco, 589 A.2d 653 (N.J. Super. App. Div. 1991).

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40. Ibid. at 655.

41. Poor Sisters of St. Francis v. Catron, 435 N.E.2d 305 (Ind. Ct. App. 1982).

42. American Chiropractic Association, “Code of Ethics.” http://ccodc.org/ethics.html (accessed July 28, 2018).

43. Susan Berger, “How Safe Are the Vigorous Neck Manipulations Done by Chiropractors?” The Washington Post. http://www.washingtonpost.com/national/health- science/how-safe-are-the-vigorous-neck-manipulations- done-by-chiropractors/2014/01/06/26870726-5cf7-11e3- bc56-c6ca94801fac_story.html (accessed January 6, 2014).

44. Ibid.

45. Ibid.

46. Poor v. State, No.S-02-472, 266 Neb. 183 (Neb. 2003).

47. Brown v. Belinfante, 557 S.E.2d 339 (2001).

48. Melone v. State Education Department, 495 N.Y.S.2d 808 (N.Y. App. Div. 1985).

49. Lowenberg v. Sobol, 594 N.Y.S.2d 874 (N.Y. App. Div. 1993).

50. Hickman v. Sexton Dental Clinic, 367 S.E.2d 453 (S.C. 1988).

51. Ibid. at 455–456.

52. University Hospitals, “Nutrition Services.” http://www.uhhospitals.org/services/nutrition-services (accessed July 28, 2018).

53. Massachusetts General Hospital, “Nutrition.” http://www.massgeneral.org/nutrition/ (accessed July 28, 2018).

54. New York-Presbyterian, “Food and Nutrition.” http://www.nyp.org/nutrition (accessed July 28, 2018).

55. The Joint Commission, 2017 Hospital Accreditation Standards, PC.02.02.03 (element 7).

56. Lambert v. Beverly Enterprises, Inc., 753 F. Supp. 267 (W.D. Ark. 1990).

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57. J. P. McWhirter and C. R. Pennington, “Incidence and Recognition of Malnutrition in Hospital,” British Medical Journal 308 (1994): 945–948. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539799/ (accessed July 28, 2018).

58. Fjerstad v. Knutson, 271 N.W.2d 8 (S.D. 1978).

59. Thomas v. Corso, 288 A.2d 379 (Md. 1972).

60. Marks v. Mandel, 477 So. 2d 1036 (Fla. Dist. Ct. App. 1985).

61. Baptist Mem’l Hosp. Sys. v. Sampson, 969 S.W.2d 945, 947 (Tex. 1998).

62. Martin C. McWilliams, Jr., and Hamilton E. Russell III, Hospital Liability for Torts of Independent Contractor Physicians, 47 S.C. L. reV. 431, 473 (1996).

63. Marks v. Mandel.

64. Ibid. at 1039.

65. U.S. Food and Drug Administration, “Tests Used in Clinical Care.” https://www.fda.gov/MedicalDevices/ProductsandMedic alProcedures/InVitroDiagnostics/LabTest/default.htm (accessed July 28, 2018).

66. Mike J. Hallworth, “The ‘70%’ Claim: What Is the Evidence Base?” Annals of Clinical Biochemistry: International Journal of Laboratory Medicine 48 (2011). http://journals.sagepub.com/doi/full/10.1258/acb.2011.0 11177 (accessed July 28, 2018).

67. American Society for Clinical Laboratory Science (ASCLS), “Code of Ethics.” http://www.ascls.org/about-us/code-of- ethics (accessed July 28, 2018).

68. Walter F. Roche, Jr., “City Hospital’s HIV Testing Manipulated,” The Baltimore Sun, March 11, 2004, http://www.baltimoresun.com/news/maryland/bal- lab0311,0,3643424.story.

69. American Society for Clinical Pathology, State Licensure of Laboratory Personnel (Policy Number 05-02). http://www.pathologylearning.org/docs/default-

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source/pdf/706df311-5dd9-49de-85bb-8fec4b1149b4.pdf (accessed July 28, 2018).

70. KOMONEWS.com/Associated Press, “Spokane Woman Suing over False HIV Diagnosis,” (December 26, 2013). http://www.komonews.com/news/local/Spokane- woman-suing-over-false-HIV-diagnosis-237318161.html.

71. Stepp v. Review Board of the Indiana Employment Security Division, 521 N.E.2d 350 (Ind. Ct. App. 1988).

72. Ibid. at 352.

73. Whirlpool Corp. v. Marshall, 445 U.S. 1 (1980).

74. Stepp v. Review Board of the Indiana Employment Security Division at 353.

75. Healthcare Careers Guide, “Medical Assistant Scope of Practice Varies in Every State.” http://www.healthcarecareersguide.com/medical- assistant-scope-of-practice/ (accessed July 28, 2018).

76. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook: Medical Assistants [online]. https://www.bls.gov/ooh/healthcare/medical- assistants.htm (visited July 23, 2018).

77. Ibid.

78. Follett v. Davis, 636 N.E.2d 1282 (Ind. Ct. App. 1994).

79. Institute of Medicine, To Err Is Human: Building a Safer Health System, supra note 1, at 194.

80. Katie Moisse, “Hospital Errors Common and Underreported,” ABC News, April 7, 2011. http://abcnews.go.com/Health/hospital-errors-common- underreported-study/story?id=13310733.

81. Jesse C. Vivian, “Generic-Substitution Laws,” U.S. Pharmacist (June 19, 2008). https://www.uspharmacist.com/article/generic- substitution-laws (accessed July 28, 2018).

82. Baker v. Arbor Drugs, Inc., 544 N.W.2d 727 (Mich. Ct. App. 1996).

83. Riff v. Morgan Pharmacy, 508 A.2d 1247 (Pa. Super. Ct. 1986).

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84. Hooks v. McLaughlin, 642 N.E.2d 514 (Ind. 1994).

85. Ind. Code A4 25-26-13-16(b)(3) (1993).

86. National Coordinating Council for Medication Error Reporting and Prevention, “About Medication Errors.” http://www.nccmerp.org/about-medication-errors (accessed July 28, 2018).

87. David M. Benjamin, “Reducing Medication Errors and Increasing Patient Safety: Case Studies in Clinical Pharmacology,” Journal of Clinical Pharmacology 43 (July 2013): 768–783. https://accp1.onlinelibrary.wiley.com/doi/full/10.1177/0 091270003254794.

88. Russell W. Steele, “Medical Error Reduction in Daily Practice,” Medscape. https://www.medscape.org/viewarticle/447139 (accessed July 28, 2018).

89. Ibid.

90. Pontiff v. Pecot & Assoc., 780 So. 2d 478 (2001).

91. American Physical Therapy Association, “Code of Ethics for the Physical Therapist.” https://www.apta.org/uploadedFiles/APTAorg/About_Us/ Policies/Ethics/CodeofEthics.pdf (accessed July 28, 2018).

92. Zucker v. Axelrod, 527 N.Y.S.2d 937 (N.Y. App. Div. 1988).

93. National Commission on Certification of Physician Assistants (NCCPA), “Just Released Data Registers Mobility Trends of Certified PAs [Press Release],” (May 22, 2018). http://prodcmsstoragesa.blob.core.windows.net/upload s/files/PressRelease2017StatisticalReport.pdf (accessed July 28, 2018).

94. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook: Physician Assistants [online]. http://www.bls.gov/ooh/Healthcare/Physician- assistants.htm (visited July 23, 2018).

95. Cox v. MA Primary and Urgent Care Clinic, 313 SW 3d 240 - Tenn: Supreme Court 2010.

96. Ibid. at 262.

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97. American Psychological Association (APA), “Ethical Principles of Psychologists and Code of Conduct.” http://www.apa.org/ethics/code/index.aspx.

98. Loomis v. Board of Psychologist Exam’rs, 954 P.2d 839 (1998).

99. APA, “Ethical Principles of Psychologists and Code of Conduct.”

100. Gilmore v. Board of Psychologist Examiners, 725 P.2d 400 (Or. Ct. App. 1986).

101. Ibid. at 204.

102. Michaels v. Gordon, 439 S.E.2d 722 (Ga. Ct. App. 1993).

103. Lisa Tortorello, “XRay Technicians: Missing in Malpractice Cases,” X-Ray Schools (June 10, 2011). http://www.xrayschools.com/articles/xray-technicians- missing-in-malpractice-cases.html (accessed July 28, 2018).

104. Cockerton v. Mercy Hospital Medical Center 490 N.W.2d 856 (Iowa Ct. App. 1992).

105. American Association of Respiratory Care, AARC Statement of Ethics and Professional Conduct (Revised 04/2015). https://www.aarc.org/wp- content/uploads/2017/03/statement-of-ethics.pdf (accessed July 28, 2018).

106. State University v. Young, 566 N.Y.S.2d 79 (N.Y. App. Div. 1991).

107. National Association of Social Workers, “Code of Ethics.” https://www.socialworkers.org/about/ethics/code-of- ethics (accessed July 28, 2018).

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CHAPTER 10

Physicians’ Ethical and Legal Issues

Observation, Reason, Human Understanding, Courage; these make the physician.

— Martin H. Fischer (1879–1962)

LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to:

Apply the Hippocratic Oath to modern codes of medical ethics. Understand how the law and ethics intertwine in patient care. Describe common medical errors and ethical issues relative to physician practice. Describe important guidelines for developing positive physician–patient relations.

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INTRODUCTION Of all the Hippocratic writings the Oath, in spite of its shortness, is perhaps the most interesting to the general reader and also to the modern medical man. Whatever its

origin, it is a landmark in the ethics of medicine.

—W. H. S. Jones, Ed.

1

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The Hippocratic Oath I swear by Apollo the physician, and Asclepius, and Hygieia and Panacea and all the gods and goddesses as my witnesses, that, according to my ability and judgement, I will keep this Oath and this contract:

To hold him who taught me this art equally dear to me as my parents, to be a partner in life with him, and to fulfill his needs when required; to look upon his offspring as equals to my own siblings, and to teach them this art, if they shall wish to learn it, without fee or contract; and that by the set rules, lectures, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to students bound by this contract and having sworn this Oath to the law of medicine, but to no others.

I will use those dietary regimens which will benefit my patients according to my greatest ability and judgement, and I will do no harm or injustice to them.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly, I will not give a woman a pessary to cause an abortion.

In purity and according to divine law will I carry out my life and my art.

I will not use the knife, even upon those suffering from stones, but I will leave this to those who are trained in this craft.

Into whatever homes I go, I will enter them for the benefit of the sick, avoiding any voluntary act of impropriety or corruption, including the seduction of women or men, whether they are free men or slaves.

Whatever I see or hear in the lives of my patients, whether in connection with my professional practice or not, which ought not to be spoken of outside, I will keep secret, as considering all such things to be private.

So long as I maintain this Oath faithfully and without corruption, may it be granted to me to partake of life fully and the practice of my art, gaining the respect of all men for all time.

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