MLI: Ch. 7 - Public Duties of the Physician and the Healthcare Professional

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Medical Law & Ethics, 4e Bonnie F. Fremgen Pearson

Addiction

p. 175

an acquired physical or psychological dependence on a drug.

Autopsy

p. 168

a postmortem examination of organs and tissues to determine the cause of death.

Bureau of Narcotics and Dangerous Drugs (BNDD)

p. 175

an agency of the federal government responsible for enforcing laws covering statutes of addictive drugs.

Compounding

p. 176

the combination and mixing of drugs and chemicals.

Controlled Substances Act of 1970

p. 175

a federal statute that regulates the manufacture and distribution of the drugs that are capable of causing dependency.

This act regulates the manufacture and distribution of the drugs that can cause dependence and places controlled drugs into five categories that are called schedules: I, II, III, IV, and V.

Coroner

p. 167

a public health officer who holds an investigation (inquest) if a person's death is from an unknown or violent cause.

Data

p. 165

statistics, figures, or information.

Dispensing

p. 176

distribution, delivery, disposing, or giving away a drug, medicine, prescription, or chemical.

Drug Enforcement Administration (DEA)

p. 175

a division of the Department of Justice that enforces the Controlled Substances Act of 1970.

Employee Assistance Program (EAP)

p. 177

a management-financed, confidential counseling and referral service designed to help employees and/or their family members assess and deal with a problem such as alcoholism. The goal is to help the employee maintain their work performace as well as improve their situation.

• It is estimated that personal problems cost the U.S. economy $70 billion annually; $30.1 billion is related to alcohol and/or drug abuse and resulting loss of productivity.
• DHHS estimates that 4.0 percent of employees use some form of illegal drugs daily.
• Also, DHHS estimates that 5% - 10% suffer from alcoholism. They are absent 16 times more, have 4 times more home accidents, use a third more sickness benefits, and have five times more compensation claims.
• EAP can help with substance abuse, stress-related family and marital, psychological, and job-related (interpersonal burnout).
• Only trained, objective professionals should counsel employees regarding their personal problems.

What happens with no way to deal with employee problems?
p. 178
By using EAP the supervisor . . .
p. 178
Warning signs that an employee needs EAP:
p. 178

Food and Drug Administration (FDA)

p. 174

an agency within the Department of Health and Human Services that ultimately enforces drug sales and distribution.

Forensic medicine

p. 174

branch of medicine concerned with the law, especially criminal law.

Habituation

p. 175

the development of an emotional dependence on a drug due to repeated use.

Inquest

p. 167

an investigation held by a public official, such as a coroner, to determine the cause of death.

Material Safety Data Sheet (MSDS)

p. 179

documentation of chemical wastes; also provides specific information on handling and disposing of chemicals safely.

Morbidity rate

p. 165

the rate of sick people or cases of disease in relationship to a specific population.

Mortality rate
or
death rate

p. 165

The ratio of the number of deaths to total population in a given location.

Postmortem

p. 168

after death.

Public duties

p. 165

responsibilities the physician owes to the public. They include reports on:
• births
• stillbirths
• deaths
• communicalbe illnesses or diseases
• drug abuse
• certain injuries (such as rape, gunshot, and knife wounds)
• animal bites
• abuse of children, spouses, and older adults

Restraining or protective order

P. 172

court order that prohibits an abuser from coming into contact with the victim.

Retailing

p. 176

the legal act of selling or trading a drug, medicine, prescription, or chemical.

Vital statistics

p. 165

major events or facts from a person's life, such as live births, deaths, induced termination of pregnancy, and marriages.

The reporting agencies and services include the:
• Department of Health and Human Services
• Centers for Disease Control and Prevention (CDC)
• National Center for Disease Statistics
• Public Health Services

Describe the public duties of a physician.

Public duties of the physician include collecting patients' vital statistics such as birth, death, illness, and abuse cases.

Discuss the guidelines that should be used when completing a legal record or certificate.

p. 166

a. Request information from the state registrar for specific requirements oncompleting certificates.
b. Type all documents when possible. If the record is completed manually, then print using black ink.
c. Make sure that all blank spaces are completed.
d. Verify correct spelling of all names.
e. Use full original signature, not a rubber stamp.
f. File original certificates or reports with the appropriate registrar.
g. Avoid abbreviations.
h. Do not alter the certificate or make erasures.
i. Keep a copy in the patient's file.

List the information that must be included in a death certificate.

a. The date and time of death.
b. The cause of death.
c. How long the deceased person was treated for the disease or injury before dying.
d. The presence or absence of pregnancy (for female decedent).
e. If an autopsy took place.

Describe the cases in which a coroner or health official would have to sign a death certificate.

p. 167

a. No physician present at the time of death.
b. A violent death, including homicide, suicide, or accident.
c. Death as a result of a criminal action.
d. An unlawful death, such as assisted suicide.
e. Death from an undetermined cause.
f. Death resulting from chemical, electrical, thermal, or radiation injury.
g. Death caused by criminal abortion, including self-induced.
h. Death occurring less than 24 hours after hospital admission.
i. No physician attending the patient within 36 hours preceding death.
j. Death occurring outside a hospital or licensed care facility.
k. Suspicious death.
l. Death of a person whose body is not claimed by friends or relatives.
m. Death of a person whose identity is unknown.
n. Death of a child under the age of 2 years if the death is from an unknown cause or if it appears the death is from Sudden Infant Death Syndrome (SIDS).
o. Death of a person in jail or prison.

List the 10 reportable communicable diseases.

a. Tuberculosis
b. Rubeola
c. Rubella
d. Tetanus
e. Diphtheria
f. Cholera
g. Poliomelitis
h. AIDS
i. Meningococcal meningitis
j. Rheumatic fever
k. STDs

Discuss the Child Abuse Prevention and Treatment Act of 1974.

This act requires reporting of all child abuse cases. All states have statutes that define child abuse and require that all abuse must be reported.

Describe eight signs that indicate a child, spouse, or elderly person may be abused.

p. 172

a. Repeated injuries
b. Bruises such as blackened eyes and unexplained swelling
c. Unexplained fractures
d. Bite marks
e. Unusual marks such as those occurring from a cigarette burn
f. Bruising, swelling, or pain in the genital area
g. Signs of inadequate nutrition such as sunken eyes and weight loss
h. Venereal disease

Discuss the federal legislation of controlled substances.

The Food and Drug Administration (FDA), an agency within the Department of Health and Human Services, ultimately enforces drug (prescription and over-thecounter) sales and distribution. Drugs that have a potential for addiction, habituation, or abuse are regulated and controlled by the Drug Enforcement Administration (DEA) of the Department of Justice.

List and explain the five schedules of drugs.

• Schedule I: Has the highest potential for addiction and abuse. These drugs cannot be prescribed and are not accepted for medical use. They may be used for research purposes. Examples are marijuana, heroin, and LSD.
• Schedule II: Has a high potential for addiction and abuse. They are accepted for medical use in the United States and can be prescribed by a DEA-licensed physician. Examples are codeine, cocaine, morphine, opium, and secobarbital.
• Schedule III: Has a moderate-to-low potential for addiction and abuse. A DEA number is not required to prescribe these drugs, but the physician must handwrite the order. Examples are butabarbital, anabolic steroids, and APC with codeine.
• Schedule IV: Has a lower potential for addiction and abuse than Schedule III drugs. The physician must sign the prescription. Examples include chloral hydrate, phenobarbital, and diazepam.
• Schedule V: Has a low potential for addiction and abuse.

Explain how an Employee Assistance Program (EAP) can help troubled employees.

This management-financed, confidential counseling and referral service is designed to help employees and/or their family members assess a problem such as alcoholism. The EAP is aimed at helping employees to maintain their job performance and keep their job while finding assistance with an emotional or abuse problem.

Introduction

p. 165

• Each state has passed public health statutes that require certain information be reported to state and federal authorities.
• These statutes help protect the public from unsanitary conditions in public facilities and require examination f water supplies.
• Physicians must inform the government when a situation may affect public health.

Public Health Records and Vital Statistics

p. 165

• The Mortality and Morbidity Weekly Report is published every week by the CDC.

Med Tips

p. 165

Births

• Physicians issue the certificate that becomes a person's proof of age.
• A physician must sign the certificate for a hospital birth; the hospital files it with the county clerk's office. For a home birth the person in attendance must file the birth certificate at the county public health department.
• Some states impose a criminal penalty if a birth certificate is not completed and handled properly.
• Physicians and midwives re required to report certain diseases in newborns. Ex. ophthalmia neonatorium (must be reported within 12 hours) and PKU.

Death

p. 166

• Physicians must also sign a certificate indicating the cause of a natural death (diseases, injuries, or complications), date, time, how long the deceased was treated for the condition before dying, the presence or absence of pregnant (for female decedent) and if an autopsy took place. The state's DPH sets the requirements.
• In most states a death certificate must be signed within 24 to 72 hours.
• After signing the certificate is given to the mortician who files it with the state or county clerk's office.
• Funeral arrangements and burial cannot take place until the death certificate is signed, so it is important for the physician to sign as soon as possible.
• The certificate is required to confirm information concerning veteran's benefits, IRS information, insurance benefits, and other financial information when settling an estate.
• In some cases, a coroner or health official must sign the certificate. One case is when the deceased was not under the care of a physician.

Medical examiner

p. 167

a physician, usually a pathologist, who can investigate an unexplained death and perform autopsies to determine cause.

Unless the death results from a suspicious cause, such as homicide, an autopsy can not be performed on a body without the consent of the surviving person who has the "first right" to the body.

Communicable Diseases

p. 168

Physicians must report all diseases that can be transmitted from one person to another and are considered a general threat to the public. The report can be made by phone or mail. It should include:
- Name, address, age, and occupation of the patient
- Name of the disease or suspected disease
- Date of onset of the disease
- Name of the person issuing the report
• What needs to be reported varies by state but some diseases must always be reported.Employees in food service, day care, and healthcare occupations are carefully monitored.
• The National Childhood Vaccine Injury Act requires physicians and healthcare administrators to report all vaccine administrations and adverse reactions to vaccines and toxoids with the manufacturer and lot number.
• Required vaccines are:
- Diphtheria, pertussis (whooping cough) tetanus toxoid (DPT)
- Measles, mumps, and rubella (MMR)
- Poliovirus vaccine, live
- Polio vaccine, inactivated
- Tuberculosis test
• Recommended vaccines are:
- H. influenzae type b (Hib)
- hepatitis A vaccine
- varicella (chicken pox)
- pneumococcal vaccine (PCV7)
• In most states, newborns also receive erythromycin applied to both eyes and a Vitamin K injections to prevent hemorrhagic disease.
• The name and address of there person administering the vaccine and the date of administration should be documented in the patient's record.

Duty to Report AIDS, HIV, and ARC Cases

p. 169

• All states require healthcare providers report cases of AIDS to the local or state department of health. Most also require the reporting of HIV and ARC (AIDS Related Complex) too.
• Who makes the report varies by state.
• Minnesota is the only state were healthcare workers must self-report, within 30 days, if they are diagnosed with HIV. They must also report, within 10 days, other healthcare workers who are infected.
• Many states have confidentiality statutes that allow notification of an HIV patient's spouse, needle-sharing partner, or other contact person who is at risk. The physician should first discuss this with the patient along with informing them that in some states knowingly putting someone at risk of contracting HIV is a criminal offense.

Disclosure to Patients of Health Worker's HIV Status

p. 169

• Many people believe that healthcare workers have a moral obligation to disclose their own HIV-positive status to their patients. However there is little evidence that HIV is transmitted from healthcare providers to patients.
• A law mandates the testing of all blood and tissue donors.
• Some people believe that healthcare workers who practice invasive procedures should be required to take an HIV test. The alternative is for healthcare workers to be tested a needlestick incident.

Child Abuse

p. 170

• The Child Abuse Prevention and Treatment Act of 1974 requires reporting of all child abuse cases.
• Many states list personnel who are required by law to make an immediate report of any suspected child abuse; these include teachers, all health professionals, law-enforcement, daycare, and social service workers.
• Questionable injuries must be reported to local law-enforcement agencies.
• Signs of neglect such as malnutrition, poor growth, and lack of hygiene are reportable in some states.
• Physicians are liable if they do not report abuse
• Persons reporting child abuse are protected from civil and criminal liability (unless the reporter is also the abuser). Failure to report can result in a charge of misdemeanor.
• Most states require an oral report of suspected abuse be made immediately, followed by a written report. The written report should include:
- Name and address of the child
- Child's age
- Person(s) responsible for the care of the child
- Description of the type and extent of the child's injuries
- Identity of the abuser, if known
- Photographs, soiled clothing, or any other evidence that abuse has taken place
• Parents may be asked to leave during the child's exam
• Parental neglect occurs when a parent has a religious belief that does not allow medical treatment of their children. The state tried to stay out of these situations but will step in if the child's life is in danger.

Probable cause

p. 170

Reasonable belief that something improper has happened

Battered-child syndrome

p. 170

a non-legal term used to describe a series of injuries, including fractures, bruises, and burns done to children by parents or caregivers.

Elder Abuse

p. 171

• Elder abuse defined in the amendment to the Older Americans Act of 1987; it includes physical abuse, neglect, exploitation, and abandonment of adults 60 years and older. It is reportable in many states
• The person reporting the abuse is protected from civil and criminal liability in most states.
• Some states have made "resident abuse" (abuse at the hand of nursing home staff) a crime
• It is also a crime in many states to commit elder financial abuse.

Spousal Abuse

p. 172

• Laws about reporting spousal abuse vary from state to state
• Police may have to become involved
• A restraining order may have to be issued
• Questions frequently asked of a suspected abused spouse are on page 172
• All medical offices and hospital emergency rooms should have access to a 24-hour abuse hotline

Abuse

p. 173

• It is not possible to assure the victim that all information will be held in confidence, as abuse cases are reportable by law. This should be clearly explained.
• Healthcare workers must protect abuse victims, especially those that cannot protect themselves (e.g.,children, the elderly)

Substance Abuse

p. 173

• Abuse of prescription drugs is reportable immediately, according to the law.
• A violation of controlled substance laws is a criminal offense and can result in fines, imprisonment, or loss of license. All healthcare workers should be familiar with the laws relating to controlled substances.
• Prescription pads and blanks should always be kept locked up when not in use. Never leave them on in an exam room.

Gathering Evidence in Cause of Abuse

p. 173

• Precise documentation of all injuries, bruises, and suspicious fluid deposits in the genital area of children is critical.
• The court may subpoena these records at a later date.
• Evidence in abuse cases includes:
- Photo of bruises and other signs of abuse
- Female child's urine specimen (containing sperm) or laboratory report indicating the presence of sperm in the urine
- Clothing
- Body fluids, such as semen, vomitus, or gastric contents
- Samples like blood, semen, vaginal, or rectal smears
- Foreign objects such as bullets, hair, and nail clippings
• Evidence should be handled as little as possible and by only one employee
• All evidence should be labeled and protected by sealed plastic bags or covers.

Chain of Evidence

p. 174

• It is important to maintain a clear chain of custody for evidence to verify that the specimen has been handled correctly.
• All evidence, including photographs, should be labeled with the patient's name, date, time and the specimen was obtained.
• Evidence should be kept in a locked storage area until it is required.
• When turning evidence over to a third party, always request identification and authorization as well as a receipt to place in the medical record.

Other Reportable Conditions

p. 174

• Many states require physicians to file reports of certain medical for use in maintaining accurate public health statistics. These include:
- cancer
- epilepsy
- congenital disorders (like PKU)
• Gunshot wound laws require reports when injuries are inflicted by lethal weapons or by unlawful acts.
- Every case of bullet wound, powder burn or other injury arising from the discharge of a gun or firearm must be reported to police of the city or town where the person reporting it is located
- The report must be made by the physician treating the patient or an administrative person in charge of the facility.
• Forensic Medicine
- A forensic pathologist is a physician who specializes in the examination of bodies when there is an unatural cause of death - The exam includes assessment of time of death and cause of death, along with examination of blood, hair, skin from the victim found on evidence
- They also examine victims of sexual child abuse and consult on cases of attempted poisoning and drug abuse. They may also be called upon to advise on blood grouping in cases of disputed paternity

Controlled Substance Act and Regulations

p. 174-175

• Physicians who administer narcotics must register with the DEA in Washington, DC and renew the registration every three years.
• A DEA registration number is assigned to each physician.
• When a physician leaves their practice, they must turn in registration and unused narcotics.
• Narcotics logs and records must be kept for two years.
• The date and name of the patient along with the signature of the person administering the drug recorded.
• A few states even require physicians who do not administer (put merely prescribe) narcotics to keep a log as well.
• Most states limit the administration of narcotics to physicians and nurses. States can have stricter regulations, but not less the the federal regulations.
• All narcotics must be kept under lock and key
• Narcotics should only be "wasted" or destroyed down a toilet or drain if the packages says to do that.
• Two people should be present when narcotics are destroyed.
• Non-narcotic drugs should be removed from their containers and disposed of with medical waste
• Medical office personnel can assist the physician in maintaining compliance with the law by:
- Alerting the physician to license renewal dates
- Maintaining accurate inventory records
- Keeping all controlled substances in a secure cabinet
- Keeping prescription blanks stored securely
• Violations of this act is a criminal offense. The penalties range from a fine to a long prison sentence.

Drug Enforcement Administration (DEA)

p. 175

is part of the Department of Justice and controls these drugs by enforcing the Comprehensive Drug Abuse Prevention and Control Act (Controlled Substances Act of 1970)

Prescriptions of Controlled Drugs

p. 175-177

• The DEA number must appear on all prescriptions for controlled substances
• Most state statutes authorize professionals (physician, nurse, nurse practitioners, physician assistants) to dispense drugs.

Drug

p 177

intended to affect he structure or function of the body of man or animals. This applies to OTC meds and supplements. This is why a nurse cannot give a patient an aspirin without a prescription from the doctor.

Medical Waste

p. 178

Hazardous waste from health care facilities weights 3.2 million tons a year. There are four major types of medical waste:
• Solid
• Chemical
• Radioactive
• Infectious

Physicians and healthcare personnel have an ethical responsibility to protect the public from harm caused by medical waste.

Solid Medical Waste

p. 179

generated in every area of the facility; it includes paper, bottles, cardboard etc. and is not considered hazardous but can pollute. Mandatory recycling programs have reduced this type of waste in the U.S.

Chemical Medical Waste

p. 179

• Includes germicides, cleaning solvents, and pharmaceuticals. It can cause a fire or explosion in the institution or community. It can also harm if ingested, inhaled, or absorbed though the skin or mucous membranes.
• Medical personnel have a duty to refrain from pouring toxic, flammable, or irritating chemicals down a drain. These chemicals should be placed in sturdy containers and removed by a licensed removal facility.
• Chemical wast must be documented on the MSDS by medical facility and clinical laboratories.
• Non-narcotics are considered chemical waste and should not be flushed won a toilet unless specifically instructed to do so. Drugs can kill bacteria in septic systems and pass though sewage treatment plants. In landfills, drugs can trickle into groundwater.

Radioactive waste

p. 179

• Any waste that contains or is contaminated with liquid or solid radioactive material
• This waste must be clearly labeled as radioactive and never placed into an incinerator, down the drain, or in public areas. It should be removed by a licensed removal facility.

Infectious waste

p. 179

• Any waste material that has the potential to carry disease.
• Between 10 and 15% of medical waste is infectious.
• This waste includes, lab cultures, blood and blood products.
• All needles and syringes must be placed in a specially designed medical waste container.
• The three most dangerous types of infectious pathogens found in medical waste are hepatitis B virus (HBV), hepatitis A virus (HAV), and HIV which causes AIDS.
• Infectious waste must be separated from other solid adn chemical waste at the point of origin. It must be labeled, decontaminated onsite, or removed by a licensed removal facility.

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