Jones and Bartlett Publishers Answer Questions 13

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April 20th, 2022

Table of Contents

Jones and Bartlett Publishers

here are 13 questions

6 questions from chapter 13 which is in the first powerpoint

and 7 questions form chapter 15 in the second powerpoint

each question must be answered with example and support from 250 to 400 words each answer

Chapter 13

Patient Consent

LEARNING OBJECTIVES – I

Explain the concept of informed consent.
Discuss the difference between verbal, written, and implied consent.
Describe the role of the patient, physician, nurse, and hospital in informed consent.

LEARNING OBJECTIVES – II

Explain how consent differs between competent patients, minors, guardians, and incompetent patients.
Discuss under what circumstances a patient might refuse treatment.
Explain the available defenses for defendants as it relates to informed consent.

Consent

Voluntary agreement by a person who possesses sufficient mental capacity to make an intelligent choice to allow something proposed by another to be performed on himself or herself.

Forms of Consent

Express consent
Verbal
Written
Implied consent
Act or silence raising presumption consent has been authorized
e.g., treatment of accident victim

Informed Consent

Legal doctrine where a patient has right to know potential risks, benefits, & alternatives of a proposed procedure.
Patient has absolute right to know about & select from available treatment options.

Physicians
Informed Consent

Informed consent is predicated on the duty of the physician to disclose sufficient info to enable the patient to evaluate proposed medical or surgical procedures before submitting to them.
Physicians expected disclose risks, benefits, & alternatives of recommended procedures.
Disclosure: what a reasonable person would consider material to a decision of whether to or not to undergo treatment.

Nurses
Informed Consent

Nurses most cases have no duty to
advise a patient as to a surgical procedure to be employed
may confirm physician has explained the procedure
witness patient’s signature on consent form

Hospitals
Informed Consent

Not generally responsible for informing patients as to the risks, beneﬁts and alternatives.
Some cases in which hospitals have a duty
CT Scans
MRI Imaging

Patients
Informed Consent

Patient’s ability to:
understand risks, benefits, & alternatives
evaluate info provided by the physician
express his or her treatment preferences
voluntarily make decisions regarding his or her treatment plan

Course of Treatment
Patient’s Decision – I

Elderly woman living alone fell & fractured her hip. An orthopedic surgeon reviewed the patient’s condition & decided that rather than utilizing a pinning procedure for her hip, it would be better to adopt a conservative course of treatment, bed rest.

Course of Treatment
Patient’s Decision – II

Prior to her injury, plaintiff maintained an independent style of living.
Expert testimony at trial indicated that bed rest was an inappropriate treatment.
Was the patient successful for not being informed as to alternatives courses of treatment?

Yes!
Court’s Decision

Court held that it is necessary to advise a patient when considering alternative courses of treatment. The physician should have explained medically reasonable invasive & noninvasive alternatives, including risks & likely outcomes of those alternatives, even when the chosen course is noninvasive.

−Matthies v. Mastromonaco

Lack of Consent – I

Patient had multiple medical diagnoses. Her physician, Dr. Sottiurai, ordered bilateral arteriograms to determine cause of the patient’s impaired circulation. De La Ronde Hospital could not accommodate Sottiurai’s request & patient was transferred to Dr. Lang, a radiologist at St. Jude Hospital.

Lack of Consent – II

Lang performed a femoral arteriogram, not the bilateral brachial arteriogram ordered by Sottiurai. The patient was prepared for transfer back to De La Ronde Hospital. Shortly after the ambulance departed, patient suffered a seizure in the ambulance & was returned to St. Jude. Riser’s condition deteriorated & died 11 days later.

What did the trial court determine?

Trial Court Decision

The district court ruled for the plaintiffs, awarding damages in the amount of $50,000 for Riser’s pain and suffering and $100,000 to each child. Lang appealed.

On appeal, what did the appeals court determine?

Appeals Court’s Decision

The Court of Appeal held that Lang breached the standard of care by subjecting the patient to a procedure that would have no practical benefit to the patient, that Lang failed to obtain informed consent from the patient.

−Riser v. American Medican Intern, Inc.

Information to be Disclosed – I

Physician should provide as much information about treatment options as necessary based on a patient’s personal understanding of physician’s explanation of risks of treatment & probable consequences of treatment.
Needs of each patient can vary depending on age, maturity, & mental status.

Information to be Disclosed – II

Individual responsible for obtaining consent must weigh importance of giving full disclosure to the patient against likelihood such disclosure will adversely affect the patient’s decision.

Information to be Disclosed – III

Courts generally utilize an “objective” or “subjective” test
to determine if a patient would have refused treatment if the physician had provided adequate information
as to the risks, benefits, & alternatives of the procedure.

Objective Test

Take into account characteristics of the plaintiff
idiosyncrasies, fears, age, medical condition, and religious belief
Must show that a “reasonable person” would not have undergone a procedure if properly informed.

Subjective test

Relies on credibility of the patient’s testimony
Patients must testify & prove they would not have consented to the procedure(s) had they been advised of the risks.

Adequacy of Consent

Patient understand risks, beneﬁts, & alternatives
Evaluate the information provided
Express treatment preferences
voluntarily make decisions regarding treatment plan

Written Consent Describes – I

Nature of the patient’s illness
Procedure consented to
Risks & probable consequences of the procedure
Probability that the proposed procedure will be successful

Written Consent Describes – II

Alternative methods of treatment
Associated risks & benefits of each
Indication the patient understands nature of proposed treatment
Signatures dated & signed
patient
physician
witnesses

Special Forms of Consent

Consent for Routine Procedures
Consent for Specific Procedures
Implied Consent
Statutory Consent
Judicial Consent

Statutory Consent

Consent generally assumed
Ambulance Care
Good Samaritan Statutes
Emergency Departments
When patient clinically unable to give consent

Judicial Consent

May be periodically necessary
When alternatives exhausted
2nd opinions by consulting physicians helpful
On-call legal advice should be sought

Who May Consent

Competent patients
Guardianship
Consent for minors
Incompetent patients
Limited Power of Attorney

Right to Refuse Treatment

For any or no reason
Mere whim
Religious Beliefs
Blood or blood products
Impatience
Text Case: Good People Bad Decisions

Release Form

Completed release provides documented evidence of a patient’s refusal to consent to a recommended treatment.
Patient’s refusal to consent to treatment, for any reason, religious or otherwise, should be noted in the medical record.
A release form should be executed.

Informed Consent Defenses

Risk not disclosed is commonly known.
Patient assured practitioner he would undergo treatment regardless of the risk.
Consent not reasonably possible.
Patent did not want to know about the risks.
Physician disclosed what he considerable reasonable

Ethics
Informed Consent

Individual Autonomy
Informed consent protects the basic right of the patient to make the ultimate informed decision regarding the course of treatment to which he or she knowledgeably consents.

REVIEW QUESTIONS – I

1. Who should be responsible for reviewing with the patient the risks, benefits, and alternatives of a proposed diagnostic test or treatment?

2. Describe what information a patient should be provided prior to undergoing a risky procedure in order for consent to be informed.

3. Why is it important to obtain consent from a patient prior to proceeding with a risky procedure?

REVIEW QUESTIONS – II

4. Can a patient consent to a procedure and then withdraw it?

5. Can a parent refuse to consent to a lifesaving procedure for his or her child? Discuss your answer.

6. Discuss how much information is sufficient in order for informed consent to be effective (e.g., consider your answer here from both the objective and subjective forms of consent).

REVIEW QUESTIONS – III

7. Discuss the implications of the following statement: “Patients are generally persons unlearned in the medical sciences and, therefore, except in rare instances, the knowledge of patient and physician is not in parity.”

1. Who should be responsible for reviewing with the patient the risks, benefits, and alternatives of a proposed diagnostic test or treatment?

2. Describe what information a patient should be provided prior to undergoing a risky procedure in order for consent to be informed.

3. Why is it important to obtain consent from a patient prior to proceeding with a risky procedure?

4. Can a patient consent to a procedure and then withdraw it?

5. Can a parent refuse to consent to a lifesaving procedure for his or her child? Discuss your answer.

6. Discuss how much information is sufficient in order for informed consent to be effective (e.g., consider your answer here from both the objective and subjective forms of consent).

Chapter 15

End-of-Life Issues

LEARNING OBJECTIVES

Discuss the human struggle to survive and the right to autonomous decision-making.
Describe how patient autonomy has been impacted by case law and legislative enactments.
Discuss the following concepts: preservation of life with limits, euthanasia, advance directives, futility of treatment, withholding and withdrawal of treatment, and do-not-resuscitate orders.

LEARNING OBJECTIVES – II

Discuss the purpose of an ethics committee and its consultative role in the delivery of patient care.
Explain end-of-life issues as they relate to autopsy, organ donations, research experimentation, and clinical trials.
Describe how human genetics and stem cell research can have an impact on end-of-life issues.

Dreams of Immortality

Human struggle to survive
Desire to prevent & cure illness
Advances in medicine & power to prolong life
Process of dying can be prolonged
Ethical & legal issues have increased
involving entire life span, from right to be born to right to die

Scope of Ethical Issues

Entire Life Span
The Right to be Born
The Right to Die, &
Everything in between, e.g.,
to choose treatment
to refuse treatment for oneself
to refuse treatment for another
to limit the suffering one would endure

Ethical Dilemmas Arise

When values,

rights,

duties

& loyalties conflict.

Autonomy

Right of a person to make one’s own decisions.
Patient has right to accept or refuse care even if it is beneficial to saving his or her life.
Autonomy may be inapplicable in certain cases
affected by one’s disabilities, mental status, maturity, or capacity to make decisions.

Quinlan court
Relying on: Roe v. Wade

Announced the constitutional right to privacy protects a patient’s right to self-determination.
State’s interest did not justify interference with her right to refuse treatment.
Quinlan’s father was appointed her legal guardian

Cruzan Case

Supreme Court held that right-to-die should be decided pursuant to state law, subject to a due-process liberty interest, and in keeping with state constitutional law.
Cruzans returned to Missouri probate court:
Judge Charles Teel authorized physicians to remove the feeding tubes from Nancy.
testimony presented demonstrated clear & convincing evidence Nancy would not have wanted to live in a persistent vegetative state.

Legislative Response: Patient Self-Determination Act of 1990

Requires healthcare organizations to explain to patients their legal right to direct their own care
Right to refuse medical treatment
Right to formulate advance directives
Right to appoint surrogate decision-maker
Federal reimbursement requires compliance with Act

Preservation of Life

Medical ethics does not require patient’s life be preserved at all cost under all circumstances.
Ethical integrity
of a profession is not compromised by a patient’s decision to forego medical care.
Right to body integrity.

Euthanasia

Mercy killing of hopelessly ill, injured or incapacitated
Active
intentional commission of an act, such as giving patient lethal drug
Passive
occurs when life-saving treatment (such as a respirator) is withdrawn or withheld

Physician-Assisted Suicide

Oregon’s Death with Dignity Act of 1994
physician-assisted suicide became a legal medical option for the terminally ill residents
U.S. Supreme Court, in two unanimous & separate decisions, ruled
laws in Washington & New York prohibiting assisted suicide are constitutional
yet U.S. Supreme Court also ruled that states can allow doctors to assist in suicide of their terminally ill patients.

Advance Directives – I

Making Preferences Known
Obligation to make medical preferences known to treating physician.
Any glimmer of uncertainty as to a patient’s desires in an emergency situation should be resolved in favor of preserving life.

Advance Directives – II

Living Will
Health Care Proxy
Determining Incapacity
Agent’s Rights
Durable Power of Attorney
Guardianship
Substituted Judgment

Futility of Treatment

Physician recognizes effect of treatment will be of no benefit to the patient.
Morally, a physician has a duty to inform patient when there is little likelihood of success.
Determination as to futility of medical care is a scientific decision.

Withholding & Withdrawing Treatment – I

Withholding of treatment
decision not to initiate treatment or medical intervention for the patient.
Withdrawal of treatment
decision to discontinue treatment or medical interventions for the patient.

Withholding & Withdrawing
Treatment – II

When
Patient in a terminal condition & there is reasonable expectation of imminent death.
Patient a non-cognitive state with no reasonable possibility of regaining cognitive function.
Restoration of cardiac function will last but for a brief period.

DNR Orders

DNR orders written by a physician, indicate that in event of cardiac or respiratory arrest, no resuscitative measures should be used to revive patient.

Ethics Committee

Committee offering objective counsel when facing difficult health care issues & decisions resource to patients, families, & staff.
Includes wide range of community leaders.
Analyzes ethical dilemmas, advise & educate health care providers, patients, & families.
Assists patients & family in coming to consensus with options that best meet patient’s care needs.

Ethics Committee Function

Policy & procedure development
Educational role
Consultative role
Political Advocacy

Autopsy

Postmortem examinations to determine cause of death.
Add to medical knowledge.
Necessary for criminal activity or suspicious deaths.
Deaths during surgery are reportable.
Consent required.

Organ Donations – I

Federal regulations
hospitals to have, & implement, written protocols regarding organ procurement.
notification duties concerning informing families of potential donors.
Discretion & sensitivity in dealing with families.

Organ Donations – II

Education
facilitate timely donation & transplantation
Uniform Anatomical Gift Act
allows a person to make a decision to donate organs at the time of death and allows potential donors.

Organ Donations – III

Millions of people suffer from kidney disease, but in 2007 there were just 64,606 kidney-transplant operations in the entire world. In the U.S. alone, 83,000 people wait on the official kidney-transplant list. But just 16,500 people received a kidney transplant in 2008, while almost 5,000 died waiting for one.

—Alex Tabarrok, The Wall Street Journal, January 8, 2010

Research, Experimentation
& Clinical Trials

Combination of federal & state regulations
Office of Research Integrity
Institutional Review Board
Informed Consent
Duty to Warn
Risks, benefits, alternatives
Food & Drug Administration

Organ Human Genetics – I

Study of inheritance as it occurs in human beings, includes stem cell research, clinical genetics (e.g., genetic disease markers) & molecular genetics.
Genetic markers are genes or DNA sequences with a known location on a chromosome that can be used to
identify specific cells & diseases
individuals & species

Organ Human Genetics – II

Genetic Information Nondiscrimination Act of 2008 prohibits
discrimination on the basis of genetic information with respect to the availability of health insurance & employment
employers from using an individual’s genetic information when making hiring, firing, job placement, or promotion decisions

STEM CELL RESEARCH

Use of embryonic stem cells to create organs and various body tissues.
highly controversial, involving religious beliefs and fears as to how far scientists might go in their attempt to create, e.g., another human being.

When We Finally Know

REVIEW QUESTIONS – I

Discuss how one caregiver’s beliefs can be in conflict with another when making end-of-life decisions. Consider topics discussed on morality, virtues, situational ethics, autonomy, and medical paternalism when framing your answer.

Discuss the ever-expanding role of ethics committees, including internal operational issues & external influences that affect internal operations.

What are the differences between allowing a patient to die and physician-assisted suicide?

REVIEW QUESTIONS – II

Examine the statement: “The inherent risk is that society’s faith in doctors as healers would become subverted if doctors participate in physician-assisted suicide.“

Constitutionally, what gives patients the right to self-determination?

Explain why you think the Schiavo case is an example of legislating morality.

1. Discuss how one caregiver’s beliefs can be in conflict with another when making end-of-life decisions. Consider topics discussed on morality, virtues, situational ethics, autonomy, and medical paternalism when framing your answer.

2. Discuss the ever-expanding role of ethics committees, including internal operational issues & external influences that affect internal operations.

3. What are the differences between allowing a patient to die and physician-assisted suicide?

4. Examine the statement: “The inherent risk is that society’s faith in doctors as healers would become subverted if doctors participate in physician-assisted suicide.“

5. Constitutionally, what gives patients the right to self-determination?

6. Explain why you think the Schiavo case is an example of legislating morality.

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