1. Legal and Ethical Responsibilities

2. Legal Responsibilities
Legal Responsibilities - those that are authorized or based on law.
Civil Law – focuses on legal relationships between people & the protection of a person’s rights
Criminal Law – focuses on wrongs against a person, property, or society
Torts – wrongful acts that do not involve contracts

3. Torts
A tort occurs when a person is harmed or injured because a health care provider does not meet the established or expected standards of care.
There are many types of torts

4. Torts
Malpractice - the failure of a professional to use the degree of skill & learning commonly expected in that person’s profession. Results in injury, loss or damage to person being cared for.
Negligence - failure to give care that is normally expected of a person in that position, results in injury.
Assault - a threat or attempt to injure.
Battery - unlawful touching of another person without consent.

5. Torts
Invasion of Privacy - unnecessarily exposing an individual or revealing personal info without consent
False Imprisonment - restraining an individual or restricting an individual’s freedom
Abuse - any care that results in physical harm, pain, or mental anguish.
False imprisonment - such as, keeping a pt hospitalized against their will, or applying physical restraints without proper authorization or with no justification. You can keep a pt against their will if they present a threat to themselves or toward others. Documentation must be maintained. Physician’s orders must be given every 24 hours to continue restraint procedures. Good documentation is a must.
Abuse - e.g. (see next slide)

6. Abuse
Physical Abuse – hitting, forcing people against their will, restraining movement, depriving food or water, not providing physical care.
Verbal Abuse – speaking harshly, swearing, shouting, threats, abusive stmts
Psychological Abuse – threatening harm, denying rights, belittling, intimidating, ridiculing, threatening to reveal confidential info
Sexual Abuse – unwanted sexual touching or act, using sexual gestures or behaviors

7. Abuse
Domestic Abuse – when intimate partners use threats, aggressive, or violent behaviors to maintain power & control over the other
Child Abuse – abuse directed toward a child
Elder Abuse – abuse directed toward an older person

8. Torts
Defamation – when false statements either cause a person to be ridiculed or damage the person’s reputation (even in error)
Slander – when the defamation is spoken
Libel – when the defamation is written

9. Informed Consent Scenario
What would it feel like if someone in scrubs came into the room and just grabbed your arm and started drawing blood?

10. Informed Consent
Informed Consent - permission granted voluntarily by a person of sound mind after informed
The patient understands the methods of tx.
What necessitates the tx.
The potential risks of tx.
The alternative methods of tx.
The projected outcome of the tx.

11. Informed Consent Indviduals who cannot give consent.
Minors (with the exception of those who are emancipated, married, are self supporting)
People who are mentally disabled
A power of attorney may come into play here
People who speak a foreign language and do not understand English fully.

12. What is Syphillis
Primary Stage The primary stage of syphilis is usually marked by the appearance of a single sore (called a chancre), but there may be multiple sores.
Secondary Stage Skin rash and mucous membrane lesions characterize the secondary stage. This stage typically starts with the development of a rash on one or more areas of the body.
Late and Latent Stages
In the late stages of syphilis, the disease may subsequently damage the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. Signs and symptoms of the late stage of syphilis include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. This damage may be serious enough to cause death.

13. Tuskegee Syphilis Study
Was the study unethical in 1932? Should it ever have been started? Did the subjects provide informed consent?
Was it ethical at first, but then unethical after penicillin was discovered?
Could this study have been done differently? Should it have been done differently?

14. Contracts Contract An agreement between 2 or more parties.
Most contracts have 3 parts:
Offer – competent person enters into relationship with HCP and offers to be a patient
Acceptance – HCP gives an appt or exam or treatment to the pt
Consideration – payment made by the pt for services provided

15. Contracts
Implied Contracts – obligations that are understood without verbally expressed terms.
Expressed Contracts – stated in distinct & clear language, either orally or in writing.
Legal Disability – minors, mental incompetent persons, under the influence of alcohol or drugs that alter mental status, semiconscious or unconscious.
Agent – when a person works under the direct control of another person
Contracts in HC are implied or expressed.
All parties entering into a contract must be free of legal disability. A person who has a legal disability does not have the legal capacity to form a contract.
Implied contract – e.g. when a qualified HC worker prepares a med and a pt takes the med it is implied that the pt accepts the tx.
Expressed Contract – e.g. surgical permit. Promises of care must be kept, therefore, all risks must be explained completely to the patient.
All parties entering into a contract must be free of legal disability.

16. Confidentiality and HIPAA scenario
Imagine that you are taking care of a patient and a person claiming to be his daughter calls on the phone to see how the patient is and what is going on w/ him. That patient is asleep.
What do you say?
Do you answer her questions?
Would it go against HIPAA if you do?

17. Privileged Communications
Privileged Communications – comprise all info given to HC personnel by a pt; by law, this info must be confidential and shared ONLY with other member of the pt’s health care team.
Health Care Records – contain info about the care provided to the pt.
Privileged communications are another important aspect of legal responsibility.
HC Records are also considered privileged communication.

18. SDMC Workforce HIPAA Training
HIPAA PRIVACY
Health Insurance Portability and Accountability Act of 1996, It’s a federal law
HIPAA is mandatory, penalties for failure to comply
Establishes federal regulations regarding the privacy of patient information
Patient Privacy is EVERYONE’s responsibility
Government fines imposed for privacy violations
03/08/03
SDMC Workforce HIPAA Training

19. Confidentiality
Confidentiality – info about the pt must remain private and can be shared ONLY with other members of the pt’s HC team.
Refrain from talking about (even w/ minors)
Diagnosis
Medical Hx
Lifestyle
Patient records should not be discussed in elevators, gift shops, cafeteria’s, hallways, and/or parking lots.

20. Ways to guard confidentiality
Never disclose info to 3rd parties
Never reveal patient financial info.
When on the telephone do not use the patients name if others in the room can hear.
When leaving a message for a patient ask them to call back. (Don’t leave a message about a condition)
Do not leave medical charts or insurance reports where patients or office visitors can see.

21. Warm Up
Ethical scenario worksheet

22. Ethics
Ethics – set of principles relating to what is morally right or wrong.
Ethical Dilemmas – a necessary choice between equally undesirable ethical alternatives
It’s important to remember: legal responsibilities are determined by law.
Ethics provide a standard of conduct or code of behavior. This allows a HCP to analyze info and make decisions based on what people believe is right and good conduct.

23. Ethical Dilemmas Euthanasia (assisted death) AIDS
Aborted fetuses for research
Discontinue life support
Religious rights
Financial issues
Transplant recipients
Discuss the following dilemmas:
Is euthanasia (assisted death) justified in certain patients?
Should a patient be told that a health care provider had AIDS?
Should aborted fetuses be used for research?
When should life support be discontinued?
Do parents have a religious right to refuse a life-saving blood transfusion for their child?
Can a HC facility refuse to provide expensive treatment such as a bone marrow transplant if a pt cannot pay for the treatment?
Who decides whether a 75 y/o pt or a 56 y/o pt gets a single kidney available for transplant?

24. Ethical Dilemmas Selling organs Use of illegal substances
Animals in research
Cloning
stem cell research
Continue the discussion:
8. Should people be allowed to sell organs for use in transplants?
9. If a person can benefit from marijuana, should a physician be allowed to prescribe it as a treatment?
10. Should animals be used in medical research even if it results in the death of the animal?
11. Should genetic researchers be allowed to transplant specific genes to create the “perfect” human being?
12. Should human beings be cloned?
13. Should aborted embryos be used to obtain stem cells for research, especially since scientists may be able to use the stem cells to cure diseases such as diabetes, osteoporosis, and Parkinson’s?
Many hospitals and LTCF have ethical committees that will address each ethical dilemma as a group. They include medical and laymen, along with family members.

25. Ethical Code Guidelines
National Organizations vary
All have the same basic principles:
Put saving of life and the promotion of health above all else.
Keep patient as comfortable as possible & preserve life.
Respect patient’s choice to die peacefully & with dignity.
National organizations affiliated with the different HC occupations have established ethical codes for personnel in their respective occupations. Although some codes differ slightly, most contain the same basic principles.

26. Ethical Code Guidelines
Treat all patients equally regardless of race, religion, social or economic status, sex, or nationality.
Provide care for all individuals to the best of your ability.
Maintain competency.
Stay informed and continue education.
Refrain from immoral, unethical, and illegal practices.

27. 5 steps to principled reasoning
Clarify- what is to be decided
Evaluate- fact from beliefs
Decide- what is or isn’t true and the consequences to come
Implement- Develop a plan when a decision is made
Monitor and Modify- revise when necessary.

28. Client Rights Dilemma CASE 1
A 54-year-old woman with diabetes and schizophrenia has been hospitalized with unstable angina, bilateral heel ulcers, urinary retention caused by an acute urinary tract infection and anemia caused by a combination of gastritis and chronic renal failure. One year ago, she was hospitalized with diabetic ketoacidosis after reporting that “voices” told her to stop taking her insulin. Currently, she is improving but requires a urinary catheter and must keep her legs elevated at rest. She says she is now able to take care of herself and wants to return home. Does this patient have the capacity to make this decision?

29. Patient’s Rights
Federal & state legislation requires health care agencies to have a written policy concerning PATIENT’S RIGHTS.
The AHA has affirmed a “PATIENT’S BILL OF RIGHTS” that is recognized and honored by most health care facilities.

30. PATIENT’S BILL OF RIGHTS
Considerate & respectful care
Obtain complete, current info concerning diagnosis (dx), treatment (tx), & prognosis
Receive info necessary to give informed consent
Have advance directives for HC and/or refuse tx to the extent permitted under law
These rights must be posted.

31. PATIENT’S BILL OF RIGHTS
Privacy concerning a medical care program
Confidential tx of all communications and records
Reasonable response to a request for services
Obtain info regarding any relationship of the hospital to other HC & educational institutions

32. PATIENT’S BILL OF RIGHTS
Be advised of & have the right to refuse to participate in any research project
Expect reasonable continuity of care
Review medical records & examine bills & receive an explanation of all care/charges
Be informed of hospital rules, regulations, and/or policies & resources available to resolve disputes or grievances

33. Client Rights Dilemma http://www.aafp.org/afp/20010715/299.html Case 2
A 78-year-old man has a recent diagnosis of metastatic cancer of unknown primary. He returned to the office today after having a computed tomography (CT) scan showing a pancreatic lesion that may be the primary cancer and is the only lesion accessible for biopsy. He requires large doses of narcotics for pain control and his level of consciousness fluctuates greatly. It is not clear if he understands his prognosis or that a tissue diagnosis will probably not affect treatment or outcome. When he is more lucid, he wants “the test”—a CT-guided pancreas biopsy. Does this patient have the capacity to consent to this procedure?

34. RESIDENT’S BILL OF RIGHTS
Residents in LTCF are guaranteed certain rights under the Omnibus Budget Reconciliation Act (OBRA) of 1987.
These rights known as the ‘Resident’s Bill of Rights’
These rights must be posted in the LTCF facility.

35. RESIDENT’S BILL OF RIGHTS
Free choice regarding Dr, tx, care & participation in research
Freedom from abuse & chemical or physical restraints
Privacy & confidentiality of records
Accommodation of needs & choice regarding activities, schedules, & HC

36. RESIDENT’S BILL OF RIGHTS
Voice grievances without fear of retaliation or discrimination
Organize & participate in groups, social, religious, and community activities
Info on medical benefits, records, & advocacy groups
Manage personal funds & use personal possessions

37. RESIDENT’S BILL OF RIGHTS
Unlimited access to immediate family or relatives & to share a room with his/her spouse (if both are residents)
Remain in the facility & not be transferred or discharged except for medical reasons; the welfare of the resident or others; failure to pay; or if the facility either cannot meet the resident’s needs or ceases to operate.
All states have adopted these rights, and some have added additional rights. Health care workers can face job loss, fines, and even imprisonment if they do not follow these rights.
By observing these rights, the health care workers helps ensure the patient’s safety, privacy, and well being, and provides quality care at all times.

38. Advance Directives
Advance Directives - legal documents that allow individuals to state what medical tx they want or do not want in the even they become incapacitated and are unable to express their wishes regarding medical care.
Living Wills - documents that allow individuals to state what measures can & cannot be taken to prolong life.
Durable Power of Attorney (POA) - for HC it is a document that permits an individual (principal) to appoint another person (agent) to make any medical decisions regarding HC if the principal should become incapacitated.
Advance directives for HC are also known as legal directives.
Advance directives have 2 main directives: Living Wills & POA
Living wills are signed when the individual is competent & witnessed by 2 adults who cannot benefit from the death. A living will frequently results in a DNR (do not resuscitate) order for a terminally ill patient. DNR means that cardiopulmonary resuscitation (CPR) is not performed when the pt stops breathing. The pt is allowed to die with peace & dignity.
POA - this includes providing or withholding specific medical or surgical procedures, hiring or dismissing HC providers, spending or withholding funds for HC & having access to medical records.

39. Advance Directives Patient Self-Determination Act (PSDA)
Inform every adult, both orally & written, of their rights
Provide info & assistance in preparing advance directives
Document any advance directives on the pt’s record

40. Professional Standards
Legal responsibilities
Ethical responsibilities
Patients/Residents Rights
Advance Directives
There are certain standards of behavior/care required by health care providers to carry out their duties
By following certain standards at all times, you can protect yourself, your employer, and the patient. There are some basic standards to follow (next slide)

41. Professional Standards
Perform only those procedures for which you have been trained & are legally permitted to do
Use approved, correct methods while performing any procedure
Obtain proper authorization before performing any procedure
Identify the pt & obtain the pt’s consent before performing any procedure

42. Professional Standards
Observe all safety precautions
Keep all info confidential
Think before you speak & carefully consider everything you say
Treat all pts equally regardless of race, religion, social or economic status, sex, or nationality
Think – do not reveal information, such as lab results or a blood pressure reading, to the pt unless you are specifically instructed to do so. Be aware of others in the room (family, visitors, other pts).

43. Professional Standards
Accept no tips or bribes for the care you provide
If any error occurs or you make a mistake report it immediately to your supervisor
Behave professionally in dress, language, manners, and actions

44. REMEMBER!!!
It is your responsibility to understand the legal and ethical implications of your particular health care field.
Ethical responsibilities are based not on law, but rather, on what is morally right or wrong.
HC workers must respect the patient’s rights.