The obligation to respect patients as individuals and to honor their preferences in medical care
What is beneficence?
The duty to act in the patient's best interest
Which value might beneficence conflict with, and how is this conflict resolved?
Autonomy; if the patient can make an informed decision, ultimately the patient has the right to decide
What is nonmaleficence?
"Do no harm" However, if the benefits of an intervention outweigh the risks, a patient may make an informed decision to proceed (most surgeries fall into this category)
What is justice?
Treating persons fairly
What three things are required for valid informed consent?
1. Discussion of pertinent information 2. Patient's agreement to the plan of care 3. Freedom from coercion
What three things must be explained to the patient in order for informed consent to be valid?
1. Risks 2. Benefits 3. Alternatives (includes no intervention)
What are the four exceptions to informed consent?
1. Patient lacks decision making capacity or is legally incompetent 2. Implied consent in an emergency 3. Therapeutic privilege-withholding information when disclosure would severely harm the patient or undermine decision-making capacity 4. Waiver-patient waives the right of informed consent
How is a minor defined?
Any person < 18 years of age that is not emancipated
What are four ways in which a minor can become emancipated?
1. Marriage 2. Self-supporting 3. Have children 4. In military
In which five situations is consent from parents NOT required to treat a minor?
1. Emergency situations 2. When prescribing contraceptives 3. Treatment involving STDs 4. Medical care during pregnancy 5. Management of drug addiction
What five things must occur for a patient to demonstrate "decision-making capacity"?
1. Patient makes and communicates a choice 2. Patient is informed 3. Decision remains stable over time 4. Decision is consistent with patient's values and goals 5. Decision is not a result of delusions or hallucinations
Can a patient's family require that a doctor withhold information from a patient?
What are advance directives?
Instructions given by a patient in anticipation of the need for a medical decision
What is an oral advance directive?
An incapacitated patient's prior oral statements used as a guide
Where can problems with oral directives arise from?
Variance in interpretation
What four things make an oral directive more valid?
1. The patient was informed 2. The directive is specific 3. The patient made a choice 4. The decision was repeated over time
What is a living will?
A written description of treatments the patient wishes to receive or not receive if he/she becomes incapacitated and cannot communicate about treatment decisions.
What does a living will usually direct?
A physician to withhold or withdraw life-sustaining treatment if the patient develops a terminal disease or enters a persistent vegetative state
What is a durable power of attorney?
A surrogate designated by a patient to make medical decisions in the event that he/she loses decision-making capacity
Which is more flexible, a power of attorney or a living will?
Power of attorney
A power of attorney retains power until ______?
Revoked by the patient
What does confidentiality respect?
Patient privacy and autonomy
What should disclosing information to family and friends be guided by?
What the patient would want
Can a patient waive the right to confidentiality? What is an example of this?
Yes, e.g., insurance companies
What are four instances in which a physician is allowed to breach confidentiality?
1. Potential to harm others is serious 2. Likelihood of harm to self is great 3. No alternative means exist to warn or to protect those at risk 4. Physicians can take steps to prevent harm
What are 5 examples of steps physicians can take to prevent harm?
1. Infectious diseases--physicians may have a duty to warn public officials and identifiable people at risk 2. The Tarasoff decision--law requiring physician to directly inform and protect potential victim from harm; may involve breach of confidentiality 3. Child/elder abuse 4. Impaired automobile drivers 5. Suicidal/homicidal patients
What must be proved for a malpractice suit to be upheld?
1. Physician had a duty to the patient (Duty) 2. Physician breached that duty (Dereliction) 3. Patient suffers harm (Damage) 4. The breach of the duty was what caused the harm (Direct) **The 4 D's**
What is the most common factor leading to litigation?
Poor communication between a physician and patient
What is the burden of proof in malpractice suit?
"More likely than not"
What should a physician do if a patient is noncompliant?
1. Attempt to identify the patient's reason for non-compliance 2. Determine patient's willingness to change harmful behavior or undergo a necessary procedure 3. Do not attempt to coerce the patient into complying or refer the patient to another physician
What should a physician do if a patient continues smoking, believing that cigarettes are good for him?
1. Ask how the patient feels about his/her smoking 2. Offer advice on cessation if the patient seems willing to make an effort to quit
What should a physician do if a patient desires an unnecessary procedure?
1. Attempt to understand why the patient wants the procedure 2. Do not refuse to see the patient or refer him/her to another physician 3. Address the underlying concern 4. Avoid performing unnecessary procedures
What should a physician do if a patient has difficulty taking medications?
1. Provide written instructions 2. Attempt to simplify treatment regimens
What should a physician do if a patient's family members ask for information about patient's prognosis?
Avoid discussing issues with relatives without the permission of the patient
What should a physician do if a child wishes to know more about his illness?
1. Ask what the parents have told the child about his/her illness 2. Parents of a child decide what information can be relayed about the illness
What should a physician do if a 17-year-old patient is pregnant and requests an abortion?
1. Many states require parental notification or consent for minors for an abortion 2. Unless she is at medical risk, do not advise a patient to have an abortion regardless of her age or the condition of the fetus
What should a physician do if a 15-year-old patient is pregnant and wants to keep the child, but her parents want you to tell her to give the child up for adoption?
1. The patient retains the right to make decisions regarding her child, even if her parents disagree 2. Provide information to the teenager about the practical issues of caring for a baby 3. Discuss the options, if requested 4. Encourage discussion between the teenager and her parents to reach the best decision
What should a physician do if a terminally ill patient requests physician assistance to end his/her life?
1. In the overwhelming majority of states, refuse involvement in any form of physician assisted suicide 2. Physicians may, however, prescribe medically appropriate analgesics that coincidentally shorten the patient's life
What should a physician do if a patient is suicidal?
1. Assess the seriousness of the threat 2. If it is serious, suggest that the patient remain in the hospital voluntarily 3. Patient can be hospitalized involuntarily if he/she refuses
What should a physician do if a patient states that he finds you attractive?
1. Ask direct, closed ended questions, with a chaperone if necessary 2. Romantic relationships with a patient are NEVER appropriate 3. Never say, "there can be no relationship while you are a patient," because it implies that a relationship may be possible if the individual is no longer a patient
What should a physician do if a patient who had a mastectomy says she feels "ugly" when she undresses at night?
1. Find out why the patient feels this way 2. Do not offer falsely reassuring statements (e.g., "You still look good.").
What should a physician do if a patient is angry at the time spent in the waiting room?
1. Acknowledge the patient's anger, but do not take a patient's anger personally 2. Apologize for any inconvenience 3. Avoid efforts to explain the delay
What should a physician do if a patient is upset by the way he was treated by another doctor?
1. Suggest that the patient speak directly to that physician regarding his concerns 2. If the problem is with a member of the office staff, tell the patient you will speak to that individual
What should a physician do if a drug company offers a "referral fee" for every patient a doctor enrolls in a study?
Eligible patients who may benefit from the study may be enrolled, but it is NEVER acceptable for a physician to receive compensation from a drug company