Discussion 10

HSA 515 Week 10 Lecture: End-of-Life Issues and Professional Liability Insurance

Slide #

Scene/Interaction

Narration

Slide 1

Scene 1

Professor Charles enters classroom and introduces the topics for today’s lesson and begins the lecture.

Prof Charles: Hello everyone. Welcome back to our final day of class. Today, we are going to discuss end-of-life issues and professional liability insurance.

Advances in medical technology have resulted in the power to prolong a productive life as well as delay inevitable death. A longer survival involves considerable cost and can therefore be a financial burden to the family and the government. Is it worth it? As long as we are alive we have value.

We will discuss the patient’s autonomy and one’s right to choose when to proceed with treatment or discontinue it.

Let’s first discuss end-of-life issues. Does medical ethics require a patient’s life be preserved at all costs and in all circumstances?

Casey: No. The ethical integrity of the medical profession allows for competent patients to decide for themselves whether a particular treatment is in their best interest.

Donald: I’d like to add that competent patients have the right to determine what shall be done with their body and a surgeon who performs surgery on a conscious competent patient must practice informed consent. Most cases dealing with euthanasia speak of the necessity that a physician diagnose a patient as being either in a persistent vegetative state or terminally ill.

Casey: In addition to what has already been noted, I would say that court involvement would be mandated only to appoint a guardian in one of the following cases:

Family members disagree as to the incompetent’s wishes;

Physicians disagree on the prognosis; or

The patient’s wishes cannot be known because he or she always has been incompetent.

Prof. Charles: Absolutely….Traditionally, what is the definition of death?

Casey: The courts used Black’s Law Dictionary definition: cessation of respiration, heartbeat, and certain indications of central nervous system activity, such as respiration and pulse.

Now, with modern technology sustaining these systems, the present definition of death is the irreversible cessation of brain function.

Prof. Charles: Excellent. What rights does an incompetent person have regarding end-of-life issues?

Donald: There was a case, Belchertown State School v. Saikewicz, which held that such different factors as the patient’s mental impairment and his or her medical prognosis with or without treatment must be considered before judicial approval is necessary to withdraw or withhold treatment from an incompetent patient.

Saikewicz was a mentally retarded sixty-seven year old man with leukemia and a grim prognosis. The court appointed a guardian recommended to the court after the court allowed the chemotherapy to end and spare him the suffering.

Prof. Charles: Great job Donald! In another case a female stroke patient could not speak or communicate or feed herself. It was determined that withholding nutrition would result in her death and prolonged suffering. The court would not allow terminating her life unless unequivocal proof of her wishes to not live as a vegetable was demonstrated. Factors outlined by the court in determining the existence of clear and convincing evidence of a patient’s intention to reject the prolongation of life by artificial means were the following:

The persistence of statements regarding an individual’s beliefs;

The desirability of the commitment to those beliefs;

The seriousness with which such statements were made; and

The inferences that may be drawn from the surrounding circumstances.

Slide 2

Check Your Understanding

Which of the following is not a constitutional right to refuse care?

A. The Thirteenth Amendment

B. Clear and convincing evidence that the patient did not want to live in a vegetative state

C. Wishes demonstrated by the patient when she or he was competent.

Correct Feedback:

A. The Thirteenth Amendment

Incorrect Feedback:

B. Clear and convincing evidence that the patient did not want to live in a vegetative state

C. Wishes demonstrated by the patient when she or he was competent.

Slide 3

Scene 2

Discussion between Prof Charles and students.

Prof. Charles: The Patient Self-Determination Act of 1990 (PSDA) was enacted to that patients are informed of their rights to execute advance directives and accept or refuse medical care.

What are the states required to do in enforcing PSDA?

Casey: Each state is required to provide a description of the law in the state regarding advance directives to providers, whether such directives are based on state statutes or judicial decisions. Providers such as hospitals must ensure that written policies and procedures with respect to all adult individuals regarding advance directives are established.

Prof. Charles: Absolutely! Providers are not entitled to reimbursement under the Medicare programs if they fail to meet PSDA requirements.

Donald (interrupts): What about euthanasia and its place in the modern world?

Prof. Charles: Good question Donald. Euthanasia originated from the Greek word euthanatos, meaning “good death” or “easy death”. There seems to an absence of controversy only when a patient who is kept alive by modern technology is still able to appreciate and maintain control over his or her life.

The legal system must ensure that the constitutional rights of the patient are maintained while protecting society’s interests in preserving life, preventing suicide, and maintaining the integrity of the medical profession. Currently, there is a strong movement advocating death with dignity, which excludes machines, monitors, and tubes.

Who can explain the two types of euthanasia?

Casey: I think I can. Active euthanasia is usually understood to be the intentional commission of an act, such as giving a lethal drug that results in death. Passive euthanasia occurs when life-saving treatment (such as a respirator) is withdrawn, allowing the patient diagnosed as terminal to die a natural death.

Prof. Charles: Excellent….Physicians are obligated to use reasonable care to preserve health and to save lives, so unless fully protected by the law, they will be reluctant to abide by patient or family wishes to terminate life support devices.

.

Slide 4

Check Your Understanding

Typically a living will allows a person to----------------

A. Inform family, when competent, to inform caregivers in writing his or her wishes with regard to withholding and withdrawing life support treatment, including nutrition and hydration

B. Die when any illness occurs

Correct Feedback:

A. The living will is the instrument or legal document that describes those treatments an individual wishes or does not wish to receive should he or she become incapacitated and unable to communicate treatment decisions

Incorrect Feedback:

B. The living will is only effective when a patient is either in a terminal condition, permanently unconscious, or suffering irreversible brain damage

Slide 5

Check Your Understanding

Generally, the primary right to custody of a deceased person belongs to the surviving ----------------------

,

A. Children.

B. Spouse.

C. Attending physician

D. Mother inlaw

Correct Feedback:

B. Spouse

Incorrect Feedback:

A. Children.

C. Incorrect.

D. Incorrect. .

Slide 6

Scene 3

Discussion of organ donations

Prof. Charles: Now let’s discuss organ donations.

Can anyone explain the moral solution to the organ shortage?

Casey: I think I can. Tragically, many deaths could be prevented if more people signed their donor cards. The problem is exacerbated because medical technology increases the number of potential beneficiaries while fear and apathy keep the number of donors relatively constant. Federal regulations require hospital have and implement, written protocols regarding the organization’s organ procurement responsibilities.

Prof. Charles: Very good Casey! That is an excellent explanation.

Donald: Prof. Charles….what about the Uniform Anatomical Gift Act?

Prof. Charles: Donald that is a great question… This statute was adopted by all fifty states and has many detailed provisions that apply to the wide variety of issues raised in connection with the making, acceptance, and use of anatomic gifts. Donors usually carry a card or driver’s license indicating the decision to donate organs at the time of death. Individuals who are eighteen years of age or older are permitted to donate or dispose of their body parts. Those eligible to receive organs are hospitals, dental schools, physicians, tissue banks, and individuals who need the organ for transplantation.

Casey: Who decides who lives, who dies?

Prof. Charles: Casey, those questions are not easy to answer. If there is an unlimited supply of an organ, then there are no supply and demand issues. If there are supply and demand issues, there are a number of ethical issues. In the case of a seventy year old patient with multiple life-threatening health problems, the patient may not be considered a suitable candidate for transplantation, whereas a fifteen year-old patient with a few health issues would be considered a more appropriate candidate.

Donald: A donation by will becomes effective immediately on the death of the testator, without probate, and the gift is valid and effective to the extent that it has been acted on in good faith, This is true even if the will has not been probated or is declared invalid for testimonial purposes.

Prof. Charles: Well, next we are going to learn about professional liability insurance.

Slide 7

Scene 4

Discussion of the law and professional liability insurance.

Prof. Charles: The purpose of liability insurance is to spread the risk of economic loss among members of a group who share common risks. As risks increase, premiums increase to cover the associated risks.

Who can tell us the necessary elements of an insurance policy?

Casey: I can. They are as follows:

Identification of the risk covered;

The specific amount payable; and

The specified occurrence.

Prof. Charles: Exactly…Physicians protect themselves from their exposure to a legal loss by acquiring a professional liability policy.

All professionals holding a license to practice should carry liability insurance if they are not working in an employment capacity. Hospitals who employ physicians usually carry malpractice insurance for them. A private-duty nurse is not an employee of the hospital meaning the hospital does not carrying liability insurance on the nurse. Anyone employing a private-duty nurse should inquire if the nurse has personal coverage.

Donald: Professor, in our discussion, you have provided us with a lot of information about end-of-life issues and professional liability insurance.

Prof. Charles: Donald, a hospital patient injured by a physician may request a settlement from the hospital and a separate settlement from the physician prior to instituting legal action since each have liability coverage. If the attorney representing the patient fails to secure a settle prior to legal action, the cases can either be dropped or proceed to legal action commenced.

Casey: Are hospital trustees covered by professional liability coverage?

Prof. Charles: Yes. Trustees should be covered by liability coverage just as are physicians and other healthcare professionals. Such coverage is generally provided for by the organization. Insurance coverage for officers and directors should include indemnification, to the extent possible, by law, for all liabilities and expenses, including legal fees.

Slide 8

Scene 5

Summary

Picture of Casey and Donald as they speak.

Prof Charles: We are just about out of time. Let’s go over what we learned in this lesson.

We discussed end-of- life issues and professional liability insurance.

The right of self-determination was emphasized when the court announced that every human being of adult years and sound mind has the right to determine what shall be done with his or her body. When there exists an element of uncertainty regarding a patient’s wishes in an emergency situation, the situation should be resolved in a way that favors the preservation of life. Euthanasia is the mercy killing of the hopelessly ill, injured, or incapacitated. The legal debate over euthanasia is complex, and the legal system must maintain a balance between ensuring that the patient’s constitutional rights are protected and protecting society’s interests in preserving life, preventing suicide, and maintaining the integrity of the medical profession.

Before we adjourn, are there any questions?

Donald: I have no questions. I think that the information was clearly presented, Professor.

Casey: No questions for me…

Professor Charles: Well, if there are no further questions, thank you for your dedication to learning and good luck with your career.