FIDUCIARY LAW  STATUS RELATIONSHIP  DISPARITY POWER & NEED  DISPARITY OF POWER & NEED  VOLUNTARY UNDERTAKING  TRUST GIVEN BY ONE  CARE PROMISED BY OTHER

 Formation  Duration  Termination ELEMENTS

DUTIES OWED Utmost Good Faith Utmost Good Faith Loyalty Loyalty Confidentiality Confidentiality Abstinence Abstinence Neutrality Neutrality Professional competence Professional competence Respect boundaries Respect boundaries No abandonment No abandonment

COMPETENCE PROFESSIONAL STANDARD OF CARE ACT AS ORDINARY AND REASONABLE PRUDENT PSYCHIATRIST UNDER SAME OR SIMILAR CIRCUMSTANCES ACT AS ORDINARY AND REASONABLE PRUDENT PSYCHIATRIST UNDER SAME OR SIMILAR CIRCUMSTANCES

BOUNDARIES Interact verbally Interact verbally Avoid personal relations & physical contact Avoid personal relations & physical contact Maintain stable fee policy Maintain stable fee policy Use appropriate setting & defined session length Use appropriate setting & defined session length Respect autonomy of patient decision-making Respect autonomy of patient decision-making Accept no material reward other than hourly fee Accept no material reward other than hourly fee Avoid double agency - if present, fully disclose Avoid double agency - if present, fully disclose

MALPRACTICE TORT OF ABANDONMENT DUTY DUTY BREACH BREACH STANDARD OF CARE STANDARD OF CARE UNREASONABLE RISK OF FORESEEABLE HARM UNREASONABLE RISK OF FORESEEABLE HARM DAMAGES DAMAGES CAUSATION CAUSATION BUT FOR (SCIENTIFIC) BUT FOR (SCIENTIFIC) PROXIMATE (WITHIN THE RISK) PROXIMATE (WITHIN THE RISK) ABSENCE OF DEFENSES ABSENCE OF DEFENSES STATUTE OF LIMITATIONS STATUTE OF LIMITATIONS OTHER OTHER

CHARTING 6-O’CLOCK NEWS RULE 6-O’CLOCK NEWS RULE CHART LESSER INTERVENTION MORE THAN GREATER ONE CHART LESSER INTERVENTION MORE THAN GREATER ONE NOT CHARTED MEANS NOT DONE NOT CHARTED MEANS NOT DONE COMMENT ON COMPETENCY/UNDERSTANDING COMMENT ON COMPETENCY/UNDERSTANDING DATE/TIME YOUR NOTE DATE/TIME YOUR NOTE

EMERGENCY PSYCHIATRY

ALWAYS THE SAME STANDARD OF CARE ALWAYS THE SAME STANDARD OF CARE LAW RECOGNIZES URGENCY TO ACT LAW RECOGNIZES URGENCY TO ACT DIAGNOSTIC PRECISION NOT EXPECTED DIAGNOSTIC PRECISION NOT EXPECTED ONLY REASONABLE EFFORTS REQUIRED ONLY REASONABLE EFFORTS REQUIRED NEED TO ACT BEFORE ALL FACTS IN NEED TO ACT BEFORE ALL FACTS IN A RISK ASSESSED REQUIRES A PLAN A RISK ASSESSED REQUIRES A PLAN A PLAN REQUIRES ACTION A PLAN REQUIRES ACTION STANDARD OF CARE

WHAT DO YOU NEED TO KNOW? WHAT DO YOU NEED TO KNOW? WHO KNOWS IT? WHO KNOWS IT? DOES PATIENT NEED HOSPITALIZATION? DOES PATIENT NEED HOSPITALIZATION? IS INVOLUNTARY HOSPITALIZATION POSSIBLE? IS INVOLUNTARY HOSPITALIZATION POSSIBLE? IF NOT, IS PATIENT SAFE UNTIL FOLLOW-UP? IF NOT, IS PATIENT SAFE UNTIL FOLLOW-UP? IS THERE A REPORTING DUTY? IS THERE A REPORTING DUTY? DECISIONS

INVOLUNTARY MEDICATION In emergency a person detained may be treated over objection prior to capacity hearing with medication to treat the emergency. It is not necessary for harm to take place or become unavoidable prior to intervention. In emergency a person detained may be treated over objection prior to capacity hearing with medication to treat the emergency. It is not necessary for harm to take place or become unavoidable prior to intervention. Emergency exists when medication immediately necessary for preservation of life or prevention of serious bodily harm to patient or others, and it is impracticable to first gain consent. Emergency exists when medication immediately necessary for preservation of life or prevention of serious bodily harm to patient or others, and it is impracticable to first gain consent.

MEDICAL COMPETENCY

CONSENT PRESUMED IN EMERGENCY CONSENT PRESUMED IN EMERGENCY ONLY IF NO READILY AVAILABLE SURROGATE ONLY IF NO READILY AVAILABLE SURROGATE PRESUMPTION ENDS WHEN EMERGENCY ENDS. PRESUMPTION ENDS WHEN EMERGENCY ENDS. LPS DOES NOT AUTHORIZE MEDICAL RX LPS DOES NOT AUTHORIZE MEDICAL RX A REFUSAL IS INCOMPETENT IF: A REFUSAL IS INCOMPETENT IF: UNABLE TO RESPOND KNOWINGLY AND INTELLIGENTLY TO QUESTIONS ABOUT TREATMENT UNABLE TO RESPOND KNOWINGLY AND INTELLIGENTLY TO QUESTIONS ABOUT TREATMENT UNABLE TO PARTICIPATE IN TREATMENT DECISIONS USING RATIONAL PROCESSES UNABLE TO PARTICIPATE IN TREATMENT DECISIONS USING RATIONAL PROCESSES UNABLE TO UNDERSTAND INFORMATION ABOUT THE RECOMMENDED TREATMENT UNABLE TO UNDERSTAND INFORMATION ABOUT THE RECOMMENDED TREATMENT

THE PSYCHIATRIC CONSULTATION REFUSING PATIENT MUST BE TOLD ALL RISKS. REFUSING PATIENT MUST BE TOLD ALL RISKS. DO GOOD MSE. (SEE PROBATE SEC 811) DO GOOD MSE. (SEE PROBATE SEC 811) DETERMINE FOLLOWING: DETERMINE FOLLOWING: DID PATIENT COMMUNICATE DECISION? DID PATIENT COMMUNICATE DECISION? WAS DECISION BASED ON CONSENT INFORMATION? WAS DECISION BASED ON CONSENT INFORMATION? IS THERE AN 811 MENTAL STATUS DEFECT? IS THERE AN 811 MENTAL STATUS DEFECT? DOES THE DEFECT EXPLAIN THE REFUSAL? DOES THE DEFECT EXPLAIN THE REFUSAL? WRITE A NOTE SUFFICIENT FOR A PETITIION. WRITE A NOTE SUFFICIENT FOR A PETITIION. IF INCOMPETENT, BURDEN ON PCP TO ACT. IF INCOMPETENT, BURDEN ON PCP TO ACT.

CLINICAL ETHICS What are the possible treatments? What are the possible treatments? What are the pros & cons of each? What are the pros & cons of each? Is there preponderance supporting one decision? Is there preponderance supporting one decision? If not, is there conflict over facts or ethical principles? If not, is there conflict over facts or ethical principles? Substituted Judgment > Best Interests Substituted Judgment > Best Interests Substituted Judgment Substituted Judgment Power of attorney, probate conservator, surrogate Power of attorney, probate conservator, surrogate Best Interests Best Interests Reasonable patient standard Reasonable patient standard If still unclear, If still unclear, Ask family. Ask family. If family in unclear, ask jusge. If family in unclear, ask jusge.

SHC ETHICS POLICY GUIDELINES PATIENT HAS APPOINTED DECISION MAKER PATIENT HAS APPOINTED DECISION MAKER DPHC DPHC CONSERVATOR CONSERVATOR PATIENT HAS NO APPOINTED DEICSION MAKER PATIENT HAS NO APPOINTED DEICSION MAKER LAST COMPETENT WISHES KNOWN LAST COMPETENT WISHES KNOWN SURROGATE AVAILABLE SURROGATE AVAILABLE NO CONFLICT OF INTEREST NO CONFLICT OF INTEREST BEST INTERESTS STANDARD BEST INTERESTS STANDARD PATIENT CAN DISQUALIFY PATIENT CAN DISQUALIFY IF PATIENT DISAGREES WITH TREATMENT, REFER TO ETHICS COMMITTEE IF PATIENT DISAGREES WITH TREATMENT, REFER TO ETHICS COMMITTEE IF PATIENT PROTESTS COMMITTEE DECISION, REFER TO RISK MANAGEMENT IF PATIENT PROTESTS COMMITTEE DECISION, REFER TO RISK MANAGEMENT PATIENT LACKS CAPACITY