Ethical DB

· Patient Self-Determination Act (1990)

· Health Insurance Portability and Accountability Act of 1996 (HIPAA)

· confidentiality and access to medical records

· advance directives for health care

· end-of-life; do not resuscitate (DNR)

· Emergency Medical Treatment and Active Labor Act (EMTALA) (1986)

· patient’s consent to care

· culturally and linguistically appropriate services (CLAS) standards in health and health care

Under a patchwork of laws, regulations, and ethical obligations, health service organizations have a responsibility to provide health services to patients. For example, the Joint Commission’s standards on patient rights and responsibilities address a provider’s obligation to keep patients informed and to effectively communicate with them. Patients have the right to participate in care decisions; the right to know care providers; and the right to informed consent. One federal law embraces these values: the Patient Self-Determination Act of 1990 (PSDA). The PSDA requires that health care organizations that receive Medicare and Medicaid funding provide information to patients about their right to accept or refuse life-sustaining treatments and their option to complete advance directives. Autonomy, or self-determination, is an underlying principle and obligation requiring that (1) patients participate in communications that allow for informational exchanges, with medical advice, and (2) patients are able to elect interventions. Patient-informed consent to care is a doctrine whereby the risks of the treatment, benefits of the treatment, and treatment alternatives must be disclosed to and acknowledged by the patient. This doctrine is based in case law, which is the legislative branch’s interpretation of codified laws. The body of rulings from key court cases produces useful information on legal expectation and the enforcement mechanisms in the law.

Patients also determine their own end-of-life decisions based on their values and belief systems and not necessarily the provider’s code of ethics. As set forth in the PSDA, a patient’s wishes can be communicated through advanced directives, a durable power of attorney for health care, or a living will, as well as a do not resuscitate (DNR) order. These directives can be reduced to writing or can be an oral statement; both are legally binding in most jurisdictions. Providers are generally obligated to respect the patient’s wishes even when those wishes are counter to the provider’s personal values, the standard of care, and, at times, hospital procedure. It is critical that managers be aware of and provide operating guidance for health care organizations and providers about patient’s rights and preferences, especially at life’s end.

Managers may be called in to mediate cultural, ethnic, and religious influences on patient and provider decision making. Health organizations and providers who recognize individuals’ cultural beliefs, values, attitudes, traditions, and language preferences create a more inclusive environment, a factor which may influence a patient’s perceptions and access to care. Further, a patient’s degree of literacy can be a barrier when stating his or her preferences for care. Managers must be knowledgeable of rules, regulations, and services to meet cultural and linguistic needs. The federal culturally and linguistically appropriate services (CLAS) standards in health and health care are intended to address barriers to optimal care for patients with language needs. CLAS is intended to help eliminate health care disparities by establishing clear expectations for health care organizations. Patient diversity in language, ethnicity, and literacy levels all point to the importance of responsive health systems where people understand their care.

The Health Insurance Portability and Accountability Act of 1989 (HIPAA) establishes a standard for a patient’s confidential medical information and access to medical records, as well as employee rights for health insurance. All students in this course are required to take HIPAA certification training. Proof of successful completion is required to pass this course. The training acquaints all direct and indirect care employees in health care provider facilities with their obligations to preserve the confidential health information of all patients. Waivers to HIPAA are common and a patient’s right to privacy remains an ethical issue in many facilities (large and small). Those who care for patients are legally obligated to protect health information. Here are two examples where HIPAA protections would come into play:

· Employers cannot receive notes regarding an employee’s visits with a psychiatrist without the patient’s/employee’s consent.

· A pharmacy cannot “sell” the names of patients who purchase a certain drug for epilepsy to the manufacturer of that drug or a competing pharmaceutical manufacturer.

Patient data at the psychiatrist’s office and in the pharmacy is confidential and HIPAA protected.

Perhaps one of the most wide-reaching health care laws is the 1986 Emergency Medical Treatment and Labor Act (EMTALA), which requires hospitals to provide medical treatment for any and all patients presenting with emergent health issues or in active child birth. Case law supports EMTALA and demonstrates that failure to comply can result in civil judgments as well as penalties for violation. Patients cannot be transferred or refused treatment if they present in an emergent medical condition or are in active labor and the facility has an emergency room. Organizations must ensure that employees are informed of this responsibility and that policies and procedures are in place to reinforce the responsibility.