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

Patient–Physician Relationship

• Foundational principle: BOTH parties must cooperate for safe, effective care.
  • Physician cannot make sound clinical decisions without full, accurate patient disclosure.
  • Failure to disclose ⇢ possible misdiagnosis, contraindicated prescriptions, delayed care, malpractice suits.
• Legal doctrine: Physician not liable for adverse outcomes that stem from facts the patient knowingly withheld.
  • Example: A patient hides OTC‐herbal use; drug–herb interaction causes injury ⇒ physician usually shielded.

Physician Rights

• May select or refuse patients except where discrimination statutes forbid (EMTALA, ADA, Title VII).
• May declare:
  • Scope of services (e.g., “no obstetrics”).
  • Office location & business hours.
• Entitled to payment commensurate with services rendered.
• May schedule personal leave (vacation, CME, family, medical).

Patient Rights

• Autonomy: give or withhold consent for any procedure.
• Reasonable standard of care based on prevailing professional norms.
• Confidentiality under HIPAA, state privacy acts, professional ethics.

Patient Obligations

• Adherence: follow physician instructions; non-compliance can void malpractice claims.
• Financial duty: pay for agreed services (contract law).

The Patient Care Partnership (formerly AHA Bill of Rights)

• Guarantees during hospitalization:
  • \text{High-quality\ care}
  • Clean, safe environment.
  • Participation in decisions.
  • Privacy protection.
  • Discharge planning support.
  • Billing clarification & aid with claims.
• Medical assistants (MAs) must be prepared to explain & provide this document in understandable language.

Informed Consent

• Doctrine: Valid consent = disclosure + understanding + voluntariness + competence.
• Required elements (mnemonic “NARBO”):
  • Nature of treatment.
  • Alternatives (including no treatment).
  • Risks (quantify when possible, e.g., 5\% bleeding).
  • Benefits/outcomes.
  • Opportunity for questions.
• Must be conveyed in plain language; translators or adapted forms provided for LEP, visually/hearing-impaired.
• Review textbook form (pp. 51-53) to ensure all five criteria met.

Shared Decision-Making Continuum

1. Informed Consent (baseline).
2. Informed Choice = consent + verification of understanding + explicit selection.
3. Shared Decision-Making = informed choice + exploration of values, goals, cost, provider experience; true two-way dialogue.

Good vs. Bad Consent

• Good: individualized, interactive, documented; patient can paraphrase risks.
• Bad: generic, rushed, technical jargon, No documentation of Q&A.

Barriers & Special Considerations

• Language: LEP needs interpreter; forms in native language.
• Sensory deficits: large-print, Braille, ASL interpreter.
• Religion/Culture: e.g., Jehovah’s Witness & blood products.
• False expectations: media-driven hype → clarify realistic outcomes.
  • Link: University of Texas El Paso ethical issues resource.

Medical Assistant’s Responsibility in Consent

• Verify signed consent before procedure; file in chart.
• Secure parent/guardian signature for minors, unless emergent.
• Document interpreter’s name/ID when used.

Rights of Minors

• Minor: person < 18 (varies by state).
• General rule: cannot consent EXCEPT for:
  • Pregnancy-related care.
  • Contraception.
  • STI testing/treatment.
  • Substance-abuse services.
  • Mental health services.

Emancipated Minor Criteria (any subset):

• Lives independently.
• Married.
• Financially self-supporting.
• Active-duty military.

Patient Self-Determination Act (PSDA)

• Hospitals, SNFs, HMOs must inform adults of advance directives rights.
• Motto: “My Voice – My Choice”.

Advance Directive Types

• Living Will: Declines life-sustaining measures (ventilator, PEG feeding).
• Durable Power of Attorney (DPOA) for healthcare: appoints agent.
• Combined Advance Directive usually merges both.

DPOA Implications (Critical Thinking)

• Without DPOA: guardianship hearings, treatment delays, judicial costs.
• Disadvantages: competency challenges, institutional form refusals, expiration doubts, potential agent abuse; bonding/accounting provisions mitigate.

Uniform Anatomical Gift Act (UAGA)

• Adults \ge 18 years & sound mind may donate organs/tissues.
• Safeguards:
  • Surgeon who removes organ ≠ physician who pronounced death.
  • No monetary exchange.
  • Documentation: donor card, driver’s license, state registry; family may consent posthumously if no documented choice.

Organ Donation Controversies (Critical Thinking)

• Myth: “Doctors won’t try as hard if I’m a donor.” Fact: transplant team separate from resuscitation team; professional ethics require maximal care for all.

Documentation Standards

• Record everything: calls, visits, vitals, meds, missed appts, refills, treatments.
• Axiom: “If it isn’t written, it didn’t happen.”
• Must include date, time, credentials; physician co-signature for diagnostics.

SOAP Notes

• S (Subjective): patient’s verbal narrative.
• O (Objective): measurable findings, vitals, lab results.
• A (Assessment): provider’s diagnosis/differential.
• P (Plan): tests, meds, referrals, follow-up.
• MA scope: may enter S & O; never A or P.
• Example (Mr. Dregg) shows correct format.

Tampering vs. Legitimate Amendments

• Tampering includes:
  • Back-dating, rewriting, destroying, inserting false data, adding to another’s note.
• Proper amendment: late entry labeled “Late Entry” with current date/time & initials.

Certification & Scope for MAs

• Know limits: no diagnosing, no prescribing, no “nurse” title.
• Maintain CEUs; follow state “standard of care” for credential (CCMA, CMA, RMA).

Legal Processes

• Litigation: lawsuit adjudicated in court.
• Subpoena: legal demand for records ⇒ release only requested items.
• Court Testimony Guidelines:
  • Professional demeanor, calm, truthful.
  • Do not guess; request clarification; avoid memorized scripts.

Public Duties of Physicians (Mandatory Reporting)

• Births, stillbirths, deaths.
• Communicable diseases.
• Drug abuse.
• Injuries: rape, child/elder abuse, IPV, GSW/knife wounds, animal bites.

Drug Regulations

• FDA: research & approval for public use.
• DEA: schedules, registration numbers, audits.
  • Controlled substances stored double-locked.
• MA Responsibilities:
  • Administer meds only under direct supervision per state law.
  • Secure prescription pads.
  • 3-Check Rule before administering: shelf → preparing → before replacing.

Office Management & Patient Relations

• Courtesy and dignity: prompt calls, delay explanations.
• Never promise cures.
• Transparent fees; identify on-call coverage.
• Document physician withdrawal from care via certified letter + chart note.

Case Study – Digoxin Overdose (Baby D)

• Facts:
  • Post-op infant with dysrhythmia ordered 450\,\mu g digoxin (ampule 500\,\mu g).
  • Nurse charted 225 mg by mistake; unused drug destroyed; no destruction record required ⇒ evidentiary gap.
  • Hyper-kalemia followed → cardiac arrest → death.
• Issues:
  • High-risk drug (double check required).
  • Documentation error vs. overdose? Lack of audit trail favored plaintiff.
• Verdict: \$2{,}000{,}000 for negligence (monitoring & dosing). Appeal filed.
• Lessons:
  • Double check, maintain wastage logs even if not mandated, meticulous documentation saves lives & lawsuits.

Practice Question Recaps

• Informed consent true items: 1–5; #6 false (must be in language understood by patient).
• Tampering: items 2–7. #1 (late entry w/ date, time, initials) is not tampering—it’s correct amendment.

Key Equations / Statutes in Brief

• Age of majority: \text{Minor} = \text{Age} < 18\, \text{years} (state variation noted).
• Double-locked rule: \text{Lock}1 + \text{Lock}2 ⇒ \text{DEA compliance}.

Ethical & Practical Take-Home Messages

• Autonomy, Beneficence, Non-maleficence, Justice underpin every topic (consent, minors, documentation).
• Transparency & communication reduce litigation risk and enhance patient trust.
• Good documentation is both clinical best practice and legal armor.