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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
Glossary - Terminology
Terminology
Accepted Standard Of Medical Practice
Medical practice and treatment options that are based on evidence-based medicine, objectively determined by measurable peered reviewed data and research, and practiced in the community.
Advance Directive
1. It is best if advance directives are initiated during outpatient visit with the primary provider.
2. Advance directives should be readdressed during each hospital admission.
3. Advance directives takes precedence over family wishes.
Alternative Therapy
If a patient is interested in an alternative therapy, then the practitioner should first inquire as to why.
Bad News (Difficult News)
Bad news is a poor choice of words, as the term “bad” has moral implications and/or judgment. A much better term is difficult news. When disclosing difficult news, it is important to provide the appropriate details and to be empathetic, supportive and be observant of the patient’s perception and reactions to the situation. Difficult news should be delivered in person when possible with the use of open-ended questions to assess the patient’s current level of understanding.
Best Interests
Patient’s best interests are fundamental.
Checklists
Checklists are very important in the prevention of undesired outcomes that result from communication failures during the patient handoff process.
Child Abuse
Clinicians have a legal and ethical obligation to report child abuse, neglect, and exploitation. The patient should be interviewed alone in order to avoid intimidation by possible abusers. Abuse should be approached with empathic interviewing techniques. Contact Child Protective Services immediately if child abuse is suspected.
Competent patients
Competent patients, with decisional capacity, have the right to refuse any medical treatment.
Confidentiality & Family
Medical providers cannot disclose information to family members if the patient objects.
Confidentiality
Patient confidentiality should be vigilantly protected. Exceptions are when keeping confidentiality would endanger the health and welfare of others. However, patients should be encouraged to discuss their health and medical conditions with loved ones or those potentially affected by their disease (i.e., STD contacts).
Conflict of Beliefs I
Living in a pluralistic, multicultural society means by definition that practitioners will regularly be exposed to a variety of differences in beliefs between the patient and medical-provider. Patient best interests must always be a top priority. When conflict of beliefs does occur, professional public responsibility can override a medical-provider’s personal beliefs and convictions. Under such conditions, treatment should be provided in a professional and non-judgmental way.
Conflict of Beliefs II
In non-emergency settings, medical providers are not required to provide medical services that are against their personal beliefs. In such cases, the practitioner should provide a referral to providers who will perform the requested procedure, in a professional and non-judgmental way.
Consent of Minors
Without being emancipated, and without parental consent or notification, minors can consent to:
1. prenatal care,
2. contraception,
3. diagnosis or treatment of sexually transmitted disease, and
4. drug or alcohol rehabilitation.
Consent, Parental
If parent(s) refuse to provide consent for their child to receive treatment for a non-emergency, but potentially fatal condition, then the health care provider should seek a court order.
Consent
Consent of spouse or significant other is not needed in order for a patient to consent to undergo any type of procedure, including sterilization.
Difficult & Non-Compliant patients
It is no longer acceptable to refer to patients as being “difficult” or “non-compliant”, as that is a moral or character claim and assumes the decision-making authority of the practitioner, and/or medical team rather than the patient. Medical providers must always keep a professional demeanor when addressing the medical and psychological needs of patients.
Disability Benefits
Medical providers frequently evaluate patients for disability benefits. With demanding patients, it may be necessary to explain that the practitioner has a responsibility to perform a thorough assessment prior to making the determination and report honestly the findings.
Doctor Access
Patients of all ages should have the opportunity to speak with the medical-provider alone.
Donor Bodies
All interactions and contact with a donated body must be done with dignity and respect.
Elder Abuse
Clinicians have a legal and ethical obligation to report elder abuse, neglect, and exploitation. Patient should be interviewed alone in order to avoid intimidation by possible abusers. Abuse should be approached with empathic interviewing techniques.
Emergency, Adult
In an emergency, if an adult patient does not have capacity, then consent is not required before providing lifesaving treatment.
Emergency Medical Treatment and Labor Act (EMTALA)
EMTALA was enacted by Congress to prevent hospitals from inappropriately transferring, discharging, or refusing to treat indigent patients. All patients who come to the emergency department need to be provided screening, medical examination and stabilization regardless of their ability to pay.
Emergency Minor
In an emergency, minors must always be provided lifesaving therapy.
Gifts
Accepting expensive gifts can influence or appear to influence medical care. These gifts should be declined after expressing appreciation for the gesture.
Health Insurance Portability Accountability Act (HIPAA) Records - Access
HIPAA gives patients the legal right to obtain copies of their medical records information within a specified timeframe. Health Insurance Portability and Accountability Act (HIPAA) is a federal statute with punishable fines of up to $250,000 and jail term up to 5 years for noncompliance.
Health Insurance Portability Accountability Act (HIPAA) Records
HIPAA protects health information by requiring verbal or written authorization from the patient before there is a release of information even to family members. Disclosure of protected health information (PHI) to friends and family members can only occur if the patient gives explicit permission or does not object when given a reasonable opportunity. Hospitals and practitioners’ offices may have additional policies and procedures. If the medical provider is obligated to disclose information, then they should only disclose necessary information.
Hospice
Hospice is a palliative, interprofessional model of care for patients who have a prognosis of less than six months.
Impaired Colleagues
Medical providers are ethically and legally required to report on the job or on call impaired colleagues in a timely manner. Reporting promotes patient safety and can assist the colleague in receiving appropriate evaluation and treatment.
Informal Treatment
Except for emergency situations, it is generally considered problematic to informally treat family and friends. Full understanding and other risks factors may not be available or disclosed.
Information Withholding
Patients have the right not to be informed of their medical condition if they so choose.
Information
Patients have the right to know their diagnosis if they so desire. If family members suggest otherwise, then the underlying reasons should be explored.
Informed Consent
The individual who gets the informed consent from a patient should have the ability to provide: 1. knowledge of the treatment, 2. an accurate description of the intervention, 3. risks and benefits of the treatment, 4. alternative treatments, and 5. address patient questions.
Intimate Partner Violence
Patients who experience intimate partner violence, should be assessed for safety in a supportive, nonjudgmental, and open-ended manner. Patients should have an emergency safety plan.
Jehovah Witness
If there is a life-threatening emergency with a Jehovah Witness, without the patient’s refusal and without documentary evidence such as an advance directive, it is advisable not to withhold blood, even if family and friends suggest otherwise.
Language
Trained medical foreign language interpreters should be used to ensure proper informed consent, and/or optimal medical care. Sign language is also included in this directive.
Literacy
Recognition of low literacy is very important for good medical care and adherence. Auditory and visual provisions are necessary to address this challenge.
Living Will
If patient loses capacity a living will communicates the patient’s wishes. The living will takes legal precedence over the wishes of the family.
Medical Errors
Medical providers should inform patients or their proxies of medical errors in a timely fashion regardless of whether or not harm occurred. This can be accompanied with an explanation of what happened, and a form of an apology.
Medical Interpreters
A trained medical interpreter should be used in order to promote patient understanding, and when getting informed consent for those who speak a different language or use sign language.
Name Addressing
Medical providers should ask patients of their preferred form of address. Formal address should be used unless indicated otherwise.
Parent, Minors
A parent who is a minor can give consent for the treatment of their child.
Patient Advances
Medical providers should politely but firmly respond to inappropriate patient requests. Professionalism should be maintained at all times.
Patient Confidentiality
Patient confidentiality is strongly protected because the patient must feel free to disclose details of their lives so that practitioners can provide the best care possible. Exceptions to confidentiality include: child or elder abuse, knife or gunshot wounds, diagnosis of a reportable communicable disease, and when patients are at risk of physically harming himself or others.
Patient-Provider Intimacy
Romantic and sexual relationships with current patients is unethical. A relationship with a former non-psychiatric patient might be accepted under very limited conditions. A relationship with a present or former psychiatric patient is unethical and illegal.
Patient Disclosure
Medical providers should neither confirm nor deny whether a person of interest is in fact their patient even to another healthcare provider if they are not involved in the patient’s care.
Patient Information
Confidential protected health information (PHI) should only be disclosed to fellow health care workers who are directly involved in the patient’s care. Avoid discussing a patient’s medical condition in public areas where comments might be overheard.
Patient Refusal
If a patient refuses a potentially life-saving treatment, then it is important that the medical-provider fully discusses the patient’s reasons for the decision and the consequences of the decision before honoring it.
Physical Abuse
Victims of suspected physical abuse should be approached with empathic interviewing techniques. Use open-ended questions and allow patients to describe their situation on their own terms. Priority is to obtain accurate and thorough information of the abuse and take any necessary action to ensure patient safety. Additional steps may be needed to address psychological symptoms and to satisfy legal reporting requirements.
Prayer
If a patient requests prayers in an acute setting, it is appropriate to offer personal support, without interjecting personal beliefs. The principle of nonmaleficence can be achieved by not disagreeing with the patient and not getting into a religious debate. The principle of beneficence would be achieved by responding “I will be keeping you in my thoughts.”
Pregnant Woman
A pregnant patient has the right to refuse treatment even if it places the unborn fetus at risk.
Protected Health Information (PHI)
Medical providers must be cautious about PHI in public places including public settings within the hospital.
Proxy
A proxy is a legally designated person for making medical decisions for a patient in the event that the patient loses medical decision-making capacity. This overrules the standard surrogate decision makers including family.
Psychiatric patients
Psychiatric patients have the right to give informed consent as long as they are competent to make such decisions.
Public Risk
Patients have the right to refuse treatment unless doing so would pose a serious threat to public health.
Root Cause Analysis
Root cause analysis is a quality improvement measure that identifies: what, how, and why a preventable adverse outcome occurred. The first step is usually the interviewing the individuals involved.
Sexual History:
When taking a sexual history, the medical provider should be neutral, open, and nonjudgmental. Sexual orientation should not be assumed and there should be an inquiry about all sexual partners.
Stages of Grief
Patients with terminal illness may experience stages of grief:
1. denial
2. anger
3. bargaining
4. depression
5. acceptance
The order and number of stages may vary. Experiences that do not impair relationships or interfere with patient care should not be confronted.
Surrogate
If patient does not have decisional capacity and has not designated a surrogate decision maker, then decision-making defaults to next of kin. For married individuals that is usually the spouse.
Unemancipated Minor
Unemancipated minors normally cannot consent to their own treatment. Parents or legal guardians usually need to provide consent. Informed consent from one parent or guardian is considered legally sufficient.
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Patient confidentiality is strongly protected because the patient must feel free to disclose details of their lives so that practitioners can provide the best care possible. Exceptions to confidentiality are: child or elder abuse, knife or gunshot wounds, diagnosis of a reportable communicable disease, and patients at risk of physically harming himself or others
Medical providers should neither confirm nor deny whether a person of interest is in fact their patient even to another healthcare provider if they are not involved in the patient’s care
Medical providers should neither confirm nor deny whether a person of interest is in fact their patient even to another healthcare provider if they are not involved in the patient’s care
Root cause analysis is a quality improvement measure that identifies: what, how, and why a preventable adverse outcome occurred. The first step is usually interviewing the individuals involved
