Medical Law & Ethics – Week 2: Patient/Physician Relationship

Patient / Physician Relationship

• Effective care requires the patient to disclose ALL relevant facts.
  • Withholding information → possible serious clinical consequences.
  • If a patient conceals critical information, the physician is not legally liable for resulting harm.

Physician Rights

• May select which patients to accept.
• May refuse service when ethically / legally permissible.
• May define:
  • Scope of services offered.
  • Office location & business hours.
• Entitled to payment for services rendered.
• May take vacation / time-off.

Patient Rights

• Give or withhold consent for treatment.
• Receive care that meets the appropriate standard.
• Expect confidentiality of all health information.

Patient Obligations

• Follow the physician’s instructions / treatment plan.
• Pay for medical services in a timely manner.

The Patient Care Partnership ("Patient’s Bill of Rights")

• Outlines hospital expectations; patients should receive:
  • High-quality hospital care.
  • A clean & safe environment.
  • Involvement in their own care decisions.
  • Privacy protections.
  • Help with discharge / leaving the hospital.
  • Help with billing & insurance claims.
• Medical assistants (MAs) must be prepared to review these rights with patients before hospitalization.

Informed Consent – Core Elements

• Provide information in plain, understandable language covering:
  • Nature of the treatment / procedure.
  • Benefits expected.
  • Risks / complications.
  • Reasonable alternatives (including no treatment).
  • What may occur without the proposed treatment.
  • Opportunity for questions & confirmation of comprehension.
• MA Study Check: Textbook consent form (pp. 51-53) should meet all above criteria.

Shared Decision-Making Continuum

• Informed Consent ⟶ Informed Choice ⟶ Shared Decision-Making
  • Informed Consent = basics (nature, risks, benefits, alternatives, Q&A).
  • Informed Choice = basics + verify understanding; discuss all risks/benefits of each alternative; patient/family makes explicit choice.
  • Shared Decision-Making = informed choice + explore patient values, goals, cost concerns, provider experience, uncertainties through a two-way conversation.

Potential Barriers to Valid Consent

• Language, hearing, or visual impairments.
• Religious or cultural influences.
• False expectations / misconceptions about outcomes.
• MAs should consult resources (e.g., UTEP ethical issues link) to overcome barriers.

MA Responsibilities with Consent

• Verify that a signed consent form is on file before procedure.
• Obtain parent / guardian signature for minors (exception: true emergencies).

Rights of Minors

• A "minor" = under the age of majority (usually 18 yrs; state laws vary).
• Minors generally cannot consent EXCEPT for:
  • Pregnancy-related care.
  • Contraception / birth-control information.
  • STD testing & treatment.
  • Substance-abuse services.
  • Psychiatric care.

Emancipated Minors

• May consent independently if they:
  • Live on their own.
  • Are married.
  • Are self-supporting.
  • Are on active military duty.

Patient Self-Determination Act

• Encourages adults to state treatment preferences – "My Voice, My Choice".

Advance Directives

• Living Will – requests no life-sustaining treatment / artificial nutrition when terminal.
• Durable Power of Attorney (DPOA) – appoints an agent to make decisions when patient is incapacitated.
  • Implications of no DPOA: court guardianship, delays, loss of patient choice.
  • Possible disadvantages: challenges to competence at signing, restrictive bank forms, expiring recognition, overly broad powers, untrustworthy agent.
• Advance Directive – umbrella term; often combines Living Will + DPOA.

Uniform Anatomical Gift Act (Organ Donation)

• Any individual ≥ 18 yrs & of sound mind may donate organs/tissues.
• Physician who declares death cannot be the transplant surgeon.
• No monetary exchange allowed.
• Donor status noted on card / driver’s license; family may authorize donation if decedent left no directive.
• Controversy / myth: Donor designation does not diminish resuscitation efforts; transplant team is separate from treating team.

Documentation Essentials

• Record every interaction:
  • Calls, visits, treatments, meds, vitals, prescription refills, no-shows, cancellations, referrals.
• Legal maxim: "If it is not recorded, it did not happen."

Case Scenario – Digoxin Overdose Allegation

• Baby D post-operative cardiac dysrhythmias → ordered digoxin 450\,\text{mcg}.
• Nurse charted erroneously as 225\,\text{mg} (documentation error).
• Remaining medication destroyed (no destruction record required) → no proof of actual dose.
• Elevated potassium → arrest → death. Autopsy suggested digoxin overdose.
• Parents sued for negligent monitoring & overdose; jury awarded 2\,\text{million}. Appeal pending.
• Highlights importance of accurate documentation, dose double-checks, drug-destruction records.

Litigation Terms & Court Conduct

• Litigation = civil lawsuit tried in court.
• Subpoena – legal demand for records; provide only requested material.
• Testimony guidelines:
  • Be professional, calm, truthful.
  • Do not answer unclear questions.
  • Present facts only; avoid memorized statements.

Public Duties of Physicians (Mandatory Reporting)

• Report births, stillbirths, deaths.
• Report communicable diseases.
• Report drug abuse.
• Report certain injuries: rape, abuse, gunshot / knife wounds, animal bites.

Drug Regulation Framework

• FDA – tests & approves drugs for public use.
• DEA – enforces Controlled Substances Act:
  • Physicians obtain DEA registration number to handle controlled drugs.
  • Controlled substances stored in double-locked cabinet.

MA Medication Protocols

• Administer meds only under direct physician supervision (state laws apply).
• Secure prescription pads.
• Triple-check medication:
  1. Before removing from shelf.
  2. While preparing dose (verify name & dose).
  3. Before returning medication to storage.

Office Management & Patient Relations

• Treat patients with courtesy & dignity:
  • Prompt phone replies; explain delays.
• Never promise specific outcomes.
• Explain fees & financial responsibilities.
• Communicate dissatisfaction to supervisor.
• Provide after-hours contact info.
• If physician withdraws from care:
  • Send certified letter.
  • Document in chart.

Documentation Must-Do’s

• Sign / initial every entry.
• Note no-shows & follow-ups on referrals.
• Document all phone calls, tests, procedures, instructions.
• Physician reviews & initials all diagnostic reports.
• Provide written instructions to patients.
• Ensure SOAP notes are complete & accurate.

SOAP Note Structure

• S – Subjective: patient-reported symptoms, history, pain description.
• O – Objective: measurable data, vitals, physical findings, test results.
• A – Assessment: clinician’s diagnosis / differential (MA never writes).
• P – Plan: tests, medications, treatments, referrals, dispositions, follow-up.
• MA role: may record S & O, never A or P, but must understand them.

Example (abridged)

• S – "Pain in left hip x 3 months; worse with exercise."
• O – "Wt 195\,\text{lb}, Ht 5'5'', normal ROM, no swelling."
• A – "Possible osteoarthritis; R/O rheumatoid arthritis."
• P – "Sed-rate, rheumatoid factor, X-ray L hip; ibuprofen 600\,\text{mg} TID; re-check 2 months."

Tampering vs. Proper Amendment

• Tampering includes:
  • Inserting inaccurate info.
  • Omitting significant facts.
  • Back-dating entries.
  • Rewriting / altering existing notes.
  • Destroying records.
  • Adding to another person’s note.
• Proper amendment = add late entry with date/time/initials clearly marked.

MA Certification & Scope

• Know certification limits & standard of care.
• Do not diagnose or prescribe.
• Never refer to self as a nurse.
• Pursue continuing education & skills practice.

Practice Question Takeaways

• Valid informed consent requires items 1-5; forms should be available in the patient’s primary language (item 6 is false if English-only).
• Tampering scenarios 2-7 are improper; scenario 1 (late entry with proper notation) is acceptable amendment.