Transcript ethics

Basic Surgical Skills
Ethical And Legal Issues
By
Dr. Hazem El-Mehairy
Prof. Otorhinolaryngology and Head &Neck Surgery
Ain-Shams University
Introduction
Ethical issues are everywhere in medicine, and a
professional ethic built on trust has always been the
very cornerstone of the doctor-patient relationship.
Physicians at the bedside are beginning to encounter
ethical dilemmas which until recently were hypothetical
situations posed only for the philosophic discussion.
Clinical Ethics
In practice, ethical and legal issues can be central to
the delivery of patient care because patient and society
expect physicians to practice with technical proficiency
and at the same time to identify and respond to
important ethical issues.
Key questions in ethical dilemmas:
•Must physicians always prolong life?
•Does cutting costs mean cutting corners?
•Who controls patient care?
•How much should physicians tell patients?
•When should physicians break confidentiality?
•Is legal equivalent to ethical?
Principles of Medical Ethics
1. A physician shall be dedicated to providing competent medical
service with compassion and respect for human dignity.
2. A physician shall deal honestly with patients and colleagues,
and strive to expose those physicians deficient in character or
competence ,or who engage in fraud or deception.
3. A physician shall respect the law and recognize a responsibility
to seek changes in those requirements which are contrary to the
best interests of the patient.
4. A physician shall respect the rights of patients, of colleagues,
and other health professionals, and safeguard patient confidences
within the constraints of law.
5. A physician shall continue to study, apply and advance
scientific knowledge, make relevant information available to
patients, colleagues, and the public , obtain consultation , and
use the talent of other health professionals when indicated.
6. A physician shall, except in emergencies, be free to choose
whom to serve, with whom to associate, and the environment in
which to provide medical services.
7. A physician shall recognize a responsibility to participate in activities
contributing to an improved community.
Doctor- Patient Communication
1. Patient satisfaction. Communication skills are the single
most important determinant of patient satisfaction with
care and patient satisfaction with care is the primary
determinant of patients’ decisions about which doctor,
which hospitals and which health care plans they will
use.
2. Good communication skills have positive effect on the
overall outcome of patient care.
3. Good communication skills have shown to correlate with
increased compliance with physician recommendation and
adherence to proposed plans of therapy.
4. Good communication skills can help doctors cope with
increased patient volume and subsequent decrease in
the amount of time available to spend per patient.
5. Good communication skill correlates with decrease
probability of medical / legal consequences.
Learn To Listen
Some doctors believe that the art of medical communication
consists of their training themselves to speak clearly and
professionally so that they cannot be misunderstood by their
patients. While that is a good start, it is equally important
to learn how to listen.
a. Every patient comes to you with an agenda, sometimes
short, other times lengthy. So listen to what they are
saying and listen to what they are not saying as you take
a careful history.
b. Remember that patients seldom return to doctors who
don’t take the time to listen to what they have to say.
c. Remember that you don’t really know if the patient is
hearing what you have to say, unless you listen to the
questions they are asking and the comments they are
making.
Barriers To Optimal Medical Communication
A- Patient Barrier
a. Patients and their families frequently tend to steer
conversations away from difficult or emotionally-laden
topics.
b. Shyness, confusion, and fear of death or disability.
c. Inability to accept bad news.
d. Over estimation of the ability of cure in difficult situations.
e. Information obtained from media may confuse patients
and cause them to have difficulty hearing your message.
Physicians Barrier
a. Physicians frequently fear causing pain with the bad
news they have to convey.
b. Lack of good communication skills.
c. Some physicians view death as an enemy to be defeated
when death or disability cannot be prevented they take it
personally and feel they have failed as physicians.
d. Some physicians tend to anticipate a disagreeable
response from patients or their family and in order to
avoid this they present a misleading picture of the patient
condition and prognosis for full recovery.
e. Some physicians fear the medical/legal consequences
of the strong negative reactions that some patients have
to bad news.
Special Medical Communication
Situations
1. End of life communication:
a- There should be a sincere and heart –felt expression
of sympathy.
b- Patients and family members sometimes need to be
reminded that the patient had a good life.
c- In almost all situations, the patient was realistic and
knew that things would come to an end at some point.
d- Usually, the patient was not happy with their preterminal condition and probably didn’t want to live in
that state.
e- Emphasize that everyone involved did everything
possible tp keep the patient comfortable to the end.
2. How to convey bad news (cancer or major illness):
a. Before the conversation, be sure that the patient brings a
family member to the meeting. The discussion should
always be face-to-face.
b. Allow enough time for all the patient’s questions to be
answered.
c. Always present the same information and give the same
thoughts about the prognosis to both the patient and his
family.
d. Present the whole truth, but it is all right to be optimistic.
e. “I’m afraid that I have some bad news for you” is a
reasonable way to begin the discussion.
f. Listen carefully to the response that the patients have to
the news.
g. Be empathetic.
h. Don’t take away the patient’s hope.
i. Understand that the patient may not comprehend much
of what you have said and they may not hear any of the
conversation that follows after the word “cancer”. This
is an extremely loaded word that has the ability to jam all
communications for some period to time after it enters
the conversation.
3. The angry patient
1. Appropriateness of anger : explore the cause, show
understanding without bring defensive, apologize if it is
your fault and do not apologize for others.
2. Escalating anger : if anger is not defusing or worsening:
position yourself near exit door, set limits.
If the patient cannot accept limits: pathological anger, stop
interview and leave immediately.
3. Depression : anger can be a feature.
4. Persisting anger: consider specialist help.
4. The withdrawn patient
1. Usual behavior: offer time to establish trust.
2. Refusing help : their right, acknowledge refusal and offer
help in future.
3. Confusion.
4. Fears, guilt or shame.
5. Clinical depression: persistent low mode, early morning
rise, diurnal variation and hopelessness. Medical treatmen
6. Organic cause: Parkinson’s ,severe fatigue or drugs
Informed Consent
•An informed consent is a consent that results from an
understanding by the patient of the risks and adverse effects
of the proposed treatment.
*Obtaining an unformed consent requires that the physician
make an effort to educate a patient capable of learning.
*The physician who makes this effort and obtains such
consent has met both the legal and ethical obligations
imposed upon him by law.
INFORMED consent
.Patients autonomy must be respected at all times.
.Patients can determine what treatment they are or are not
willing to receive.
.They have the right to decide not to undergo a treatment.
.This could not adversely affect outcome or result in their
death.
.Patients must be given sufficient information to make these
decisions.
.Obtaining informed consent is an isolated event.
.It involves a continuing dialogue between doctor and patient
Information Required For Valid Consent
Patients should be informed of:-Details of diagnosis and prognosis with and without
treatment.
-Uncertainties about diagnosis.
-Options available for treatment.
-The purpose of proposed investigation or treatment.
-The likely benefits and probability of success.
-A reminder that the patient can change his or her mind
at any stage.
-A reminder that the patient has the right to a second opinion
The responsibility for informed consent
1. The responsibility for informed consent remains with the
physician, even though physicians may delegate the duty
of educating patients to auxiliary staff.
2. The agreement comes before the decision is made to put
the agreement in writing.
3. Informed consent implies patient participation in medical
decision making.
4. Enough information must be provided to patients in
terms that they can understand to assure their right to
self-determination can be exercised effectively.
Informed Consent In Emergencies
In an emergency a life - saving procedure can be
performed without consent.
However, all actions must be justifiable.
Informed Refusal
1. In cases where consent is refused, the physician should
obtain an informed refusal from the patient.
2. Failure to inform the patient of the risks of declining
treat renders the physician liable to the same extent as
failing to disclose the risks of performing the treatment.
3. Unless the patient knows the risks of leaving the disease
or condition untreated, a truly informed decision in which
the patient can balance the risks and benefits within the
patient’s own psychological framework has not been
reached.
Medical Malpractice
More than 4000 years ago, the Babylonian King Hammurabi
promulgated a law that provided a physician whose patient
lost an eye as a consequence of surgery should himself
lose his hand.
Claim Of Negligence
1. A relationship must exist between physician and patient
such that a duty of due care was reached.
2. That duty must have breached.
3. The breach of the standard of care must have been the
proximate cause of a compensable injury to the pateint.
Existence of duty
reasonable expectations of treatment
Physicians of higher duty, which is to possess the knowledge
and to exert the care and diligence that would be expected
of another similarly trained physician in similar circumstances.
This requirement usually is abbreviated to “ duty to meet the
standard of care”. For this duty to apply, a physician–patient
relationship first must exist.
Generally, courts look to see if contact between the physician
and patient led the patient to have a reasonable expectation
of treatment.
Breach of duty by failure to meet
Standard of care
Expert witness report to testify both to the standard of care
and to departure from the standard of care in the case at
hand.
The major expectation is a situation where an error clearly
was made, the incident could not have occurred in the
absence of some person’s error, and the physician was the
person in control at the time the error was made.
Four Most Prevalent Suits
1. Improper performance.
2. Error in diagnosis.
3. Failure to supervise or monitor a case.
4. Performed when not indicated or contra-indicated.