Legal and Ethical Responsibilities

Objective 64.01:Analyze legal roles and ethical behaviors

Legal Legal responsibilities: those that are

based on law

Law: a rule that must be followed

Health care workers must know and follow the state laws that regulate their licenses or registrations or set standards for their profession

Criminal Law:

Commonly known as a crimeFocuses on wrongs against person, property, or

societyExamples:

practicing without a licenseMisuse of narcoticsTheftMurder

Civil Law:

Focuses on legal relationships between people and protection of a person’s rights

Deals with torts and contracts

Tort:

Wrongful act that does not involve a contract

Called a civil wrong not a crimeMany types of tortsHappens when a person is injured

because a health care provider does not meet the established or expected standards of care

Malpractice

“Bad practice” or “professional negligenceDefined as the failure of a professional to use

the degree of skill and learning commonly expected in that individual’s profession

Causes injury, loss, damage to the person receiving care

Examples: physician not giving tetanus injection when a patient has a puncture wound or nurse performing minor surgery without having any training

Negligence

Failure to give care that is normally expected of a person in that particular profession

Results in injury to another personExamples: falls and injuries that occur when

side rails are left down; using or not reporting defective equipment, infections caused by the use of nonsterile instruments and/or supplies and burns caused by improper heat or radiation treatments

Assault and BatteryThreat or attempt to injureIncludes unlawful touching of another without

consentWritten consent required for some procedures

such as surgery, diagnostic tests, experimental procedures, treatment of minors, and side rail releases

Verbal consent is permitted for only some procedures but must be informed consent

Patients must five consent for care and have right to refuse

Informed ConsentPermission granted voluntarily by a person that

is of sound mind after the procedure and all risks involved have been explained in terms the person can understand

Person has right to withdraw consent at any timeAll procedures must be explained to patient and

none performed without consentExamples of assault and battery include

performing a procedure after a patient has refused to give permission and improper handling or rough treatment of a patient while providing care

Invasion of PrivacyMay involve unnecessarily exposing an

individualMay also be caused by revealing personal

information without consentExamples: improperly draping or covering a

patient during a procedure so that other patients or personnel can see the patient exposed sending information regarding a patient to an insurance company without patient's written permission or informing media without permission

False Imprisonment

Restraining an individual or restricting an individual’s freedom

Examples: keeping patients hospitalized against their will or applying physical restraints without proper authorization or with no justification

Abuse

Care that results in physical harm, pain, or mental anguish

Physical abuse: hitting forcing people against their will; restraining movement; depriving people of food or water; not providing physical care

Verbal abuse; speaking harshly, swearing or shouting, using inappropriate words to describe a person’s race or nationality or writing threats or abusive statements

Abuse

Psychological abuse: threatening harm; denying rights; belittling; intimidating or ridiculing the person; threatening to reveal information about the person

Sexual abuse: any unwanted sexual touching or act using sexual gestures and/or suggesting sexual behaviors

Signs of abuseUnexplained bruises, fractures, burns or injuries

\Signs of neglect such as poor personal hygiene

Irrational fears or a change in personality

Aggressive or withdrawn behavior

Patient statements that indicate abuse or neglect

Reportable Incidents

Laws required all forms of abuse be reported to the proper authorities

Presence of a sign or symptom of abuse indicated need for more investigation

Health care workers are required to report any signs or symptoms of abuse to their immediate supervisor

Defamation

Occurs when false statements cause a person to be ridiculed or damage the person’s reputation

Incorrect information given out in error can result in defamation

2 types: slander and libel

Slander

Occurs when the information is spoken

Libel: Occurs when the information is written

Examples: reporting that a patient has an infectious disease to a government agency when laboratory results are inaccurate or telling others that a person has a drug problem when another medical condition actually exists

Objective 6.02

Analyze contracts, privileged communication and HIPAA .Understand the elements of a contractPrivileged communicationPrivacy Act

Contracts

An agreement between two or more partiesHas three parts

Offer: competent individual enters into a relationship with a health care provider and offers to be a patient

Acceptance: the health care provider gives an appointment or examines or treats the patient

Consideration: the payment made by the patient for the services provided

Contracts

May be implied or expressedImplied: those obligations that are understood

without verbally expressed terms. Example: qualified health worker prepares med and patient takes med. This makes it implied that patient accepts treatment

Expressed: stated in distinct and clear language either orally or in writing. Example: Surgery permit where all promises of care must be kept and all risks associated with treatment bust be explained completely to the patient

Contracts

All parties entering into a contract must be FREE from LEGAL DISABILITY.

Examples: minors, mentally incompetent, one that is under the influence of drugs that alter mental state, semiconscious or unconscious persons. Parents or legal guardians permitted by law must form the contract for these persons.

Contracts

Care given must be performed per the agreement. Failure to do so will breach the contract

Failure to pay will be a breach of contract

A translator must be used when a contract is explained to non-English-speaking person or the deaf

Contract

Agent – a person that works under the direction of another person – the employee

Principal – the employerThe Principal is responsible for the

actions of the agent.

Privileged Communications

Include all information given to health care personnel by a patient.

This information must be kept confidential and shared only with other members of the patient’s health care team

Must have written consent of the patient to tell anyone else that states:What information is to be releasedTo whom the information is to be givenAny time limits

Privileged Communications

Certain information is exempt by law from privacy act and MUST be REPORTED:Births and deathsInjuries due to violence (assault and battery,Abuse, stabbingsDrug abuseCommunicable diseasesSexually Transmitted diseases

Health Care Records

Also privileged communicationsContain information about care given to

patientBelong to the providerPatient still has right to get a copy Used as legal records in court of law

Health Care RecordsErasures are not allowed. Errors should be crossed out with a single line so

material is still readableCorrect information should be inserted, initialed,

and datedHealth care records must be properly maintained,

stored in a locked or secure area, kept confidential, and retained for the amount of time required by state law

After correct amount of time, records may be destroyed only by shredding or burning

Health Care Records

Many employers are creating safeguards to protect confidential records and informationLimiting those that have access to recordsUsing codes to prevent accessRequiring passwords in order to access

specific information on recordsConstantly monitor and evaluate computer

use

Privacy Act

Federal Government passed the HIPAA or Health Insurance Portability and Accountability Act in 1996

Requires the US DHHS to set standards to protect health information

These Standards are called Standards for Privacy of Individually Identifiable Health Information of Privacy Rule

Privacy ActAble to see and obtain copies of their medical

recordsGiven info by providers on how they use

medical infoAllowed to set limits on personal info usedAble to request that providers take reasonable

care to keep communications confidentialAble to state who has access to info and to limit

giving info to familyGiven info on how to file a complaint against

provider

Objective 4.02

Evaluate ethical behavior in a health care setting

Ethics

A set of principles relating to what is morally right or wrong.

Give a standard of conduct or code of behavior

Ethical Dilemmas

Is euthanasia ever justified?Should a patient be told that a health

care provider has AIDS?Do parents have a religious right to

refuse a life saving blood transfusion?Should a physician be allowed to

prescribe marijuana for treatment if a patient would benefit?

Latest Ethical Dilemma

Should aborted embryos be used to obtain stem cells for research since they can be used to cure diabetes, osteoporosis and Parkinson’s diseases?

Ethical CodesPut the saving of life and promotion of health

above all elseMake patient as comfortable as possible and

preserve life when possibleRespect patient’s choice to die with dignityTreat all patient’s equallyGive care for all individuals to best of your

abilityMaintain competent skill levelStay informed and up to date

Confidentiality

Information about a patient must remain private and can be shared only with other members of patient’s health care team. To ignore this means a legal violation. Gossiping about patient’s is legally wrong

Refrain from immoral, unethical, and illegal practices

Ethics and Confidentiality

Show loyalty to patients, co-workers, and employers. If you observe others you must report such actions to the proper authorities

Be sincere, honest, and caring. Treat others as you would want to be treated. Show respect and concern for feelings, dignity, and rights of others

Patient’s Rights

Federal and state legislation requires health care agencies to have written policies concerning patient’s rights. These are the factors of care that a patient can expect to receive.

AMA has adopted a “Patient’s Bill of Rights” that is recognized and honored by many health care facilities.

Resident’s Bill of Rights

OBRA or Omnibus Budget Reconciliation Act of 1987 guaranteed residents of long term care facilities certain rights. Every LTF is required to inform their residents of their rights and a copy must be posted in every facility.

Resident’s Bill of Rights :Free choice regarding MD, treatment, care and

participation in researchFreedom from abuse, chemical or physical

restraintsPrivacy and confidentiality of personal and clinical

recordsVoice grievances without fear Organize and participate in group activities and be

accommodated for needs and choice of activitiesManage personal funds & Unlimited access to

familyRemain in facility and not be transferred without

medical reasons

Objective 4.03

Explore legal and ethical issues related to death and dying.

Advance Directives

Also called legal directivesAllows individual to state what medical

treatment they want or do not want in the vent that they become incapacitated and cannot state their wishes regarding medical care.

Advance Directives

Two Types:Living WillDurable Power of Attorney (POA) for

Health Care

Living Will

Documents that allow individuals to state what measures should or should not be taken to prolong life when their conditions are terminal.

Must be signed when the individual is competent and witnessed by two adults that cannot benefit from death

Frequently results in a DNR (Do Not Resuscitate) order for a terminally ill individual

Means that CPR is not performed when patient stops breathing

Durable Power of Attorney

Document that permits an individual to appoint another person to make any decisions regarding health care if the principal should become unable to make decision.

Includes giving or withholding specific medical or surgical procedures, hiring or dismissing health providers

Patient Self Determination ActStates that all health care facilities receiving any

type of federal aid comply with the following requirements

Inform every adult orally and in writing of their rights to make decisions about health care

Give info and assistance in preparing advance directives

Document any advance directive on the patient’s record

Written statements to implement the patient’s rights in the decision making process

Affirm that there will be no discriminationEducate the staff on the medical and legal issues

Professional Standards

Perform only those procedures that you have been trained and are legally allowed to do

Use approved, correct methods Obtain proper authorization before startingIdentify the patient and obtain the patient’s

consent before performing any procedureObserve all safety precautionsKeep all info confidential

Professional Standards

Think before you speak and consider everything you say

Treat all patient’s equally regardless of race, religion, or social or economic status

Accept no tips or bribesIf any error occurs report it immediatelyBehave professionally in dress, language,

manners,and action.

EuthanasiaCalled “mercy killing” and is the act of ending the

life of a person that suffers from a terminal illness or an incurable condition. Euthanasia carried out by lethal injection or by suspending extraordinary medical treatment. 4 types:Voluntary – when the patient requests itNon-voluntary – when patient gave no consentInvoluntary – When the patient made a specific request

to the contraryAssisted Suicide – When someone gives patient help and

means to take their own life with the intention of it being used for this purpose.

This is a controversial issue. Euthanasia is legal in Oregon.

Euthanasia

The administration of a lethal agent by another person to cause the patient's death and thereby relieve the patient’s intolerable and incurable suffering.

Healthcare workers should respond to the needs of patients at the end of life instead engaging in euthanasia. Patients should not be abandoned once it is determined that a cure is impossible.

Active versus Passive Euthanasia

Active euthanasia is the intentional killing of the terminally ill. Example: injecting a lethal dose of medication

Illegal in all states except Oregon, which allows physician-assisted suicide but not homicide. Some physicians engage patient-assisted suicide where the physician gives patient the knowledge and the perscription to take his/her own life.

Passive Euthanasia

Allows a patient to die naturally.

This is legal everywhere.

Includes withholding basic needs such as hydration and nutritional feedings.

Arguments in Favor

Respect for patient self-determination. Individuals should have the right to determine the outcome of their lives.

Gives a means for harvesting viable organs.

Gives relief for family of patientGives a means to end terminally ill

person’s suffering.

Arguments in OppositionNo certainty in regard to death. Many

terminally ill patients have been known to recover.

Modern technology may find a cure for a terminal disease.

Families may be examining euthanasia just to relieve burden of stress and financial problems

There is value and dignity in every human life.The involvement of health care workers in

euthanasia erodes the dignity of their profession.

Only God has domination over life.

Important Fact

Many patients will often ask for advice from health care workers on what course of action they should take for a dying loved one. Remember that only the physician can advise the patient on a course of treatment.

Stages of DyingDeath – the final stage of growthElizabeth Kubler-Ross performs extensive

research on process of death and dying and is the leading expert on that field.

In America, most healthcare personnel feel a patient should be told of their terminal diagnosis.

It is important that patients be left with some hope and the knowledge that they will not be left alone

You need to be aware of what information was given to the patient and their reaction to it.

Five Stages of Grieving

Stages may not occur in order, may overlap or be repeated several times. Patients may not go through all stages before death. Some stop or go back and forth between stages

Stage One: Denial = “No, not me!” Person is first told diagnosis and cannot accept truth or their loved ones cannot accept the truth. Patients will seek second opinions. Statements such as “It must be hard for you” or “You feel additional test will help” can help patients move on.

AngerHappens when the patient is no longer able to

deny death.Statements like “Why me” or “It’s your fault

are common.Patients may strike out at anyone who comes in

contact with them and become hostile and bitter. They may blame themselves, their loved ones, or health care personnel for their illness.

Health care workers need to remember that this is not personal, and give patience, support, listen, and respond to patient’s demands quickly and with kindness.

Bargaining

Occurs when patient accepts deathPatient turns to religion and spiritual beliefsPatients fight hard to achieve goals they have

set. Example wedding of a child etcPatients make promises with God to obtain

more time.Health care workers must be supportive and be

good listeners and help patients meet their goals.

Depression

Happens when patients realize death will come soon and they’ll no longer be with families or able to complete goals.

Will express regrets, withdraw, become quietExperience great sadness, despair.Offer quiet understanding, support, a simple

touch, allowing them to cry and express grief

Acceptance

Final stagePatients understand that they will dieComplete unfinished business, help those

around them deal with their coming deathThey separate themselves from others

and the worldOffer emotional support and your

presence even if only a hand touch

HospiceProvides supportive care to patients when they

need it mostOffers palliative care that gives support and

comfortNot limited to a specific time period in a

patient’s lifeOnly starts when a patient has 6 months or less

to liveFamilies are reluctant to begin hospice as it

recognizes end of life

Hospice

Their philosophy is to allow patient to die with dignity and comfort.

Uses palliative measures of care and death with dignity and comfort

Helps family find closureProvides hospital equipment, psychological,

spiritual, social and financial counseling and gives free or less expensive pain medication

Provides support, understanding, and allows patient to die with dignity and in peace

Senses

Vision will blur and then fail. Patient may be frightened of dark room. Keep room well lit. Good eye care essential as secretions will collect in corners. If eyes stay open apply ointment.

May people hear until moment of death, even when unconscious. Always assume patient can hear you. Offer comforting words

Speech will be difficult. Anticipate patient’s needs. Ask yes/no questions

Mouth, Nose, Skin

Oral hygiene essential. Give frequently as death approaches

Crusting in nostrils can occur due to oxygen, ng tube or nasal secretions. Apply a lubricant to nostrils.

Circulation fails and body temp rises. Skin is cool, pale and mottled (blotchy). Perspiration increases. Patient needs good skin care, bathing and pressure ulcer prevention. Change linens and gowns prn. Use only light bed coverings.

Elimination Comfort and Positioning

Expect urinary and fecal incontinence. Use bed protectors and briefs Pericare prn. Possible constipation and urinary retention. Dr may order enemas or foley catheters.

Good skin care, back massages, oral hygiene, personal hygiene. Give pain medications, frequent position changes, promote comfort. Care when turning. Patients usually prefer semi fowlers position

Signs of DeathMovement, muscle tone, sensation lost. Starts in

feet and legs and spreads to rest of body. Mouth muscles relax, jaw drops, mouth stays open.

Peristalsis and GI functions slow down. Abdominal distention, fecal incontinence, impaction, nausea and vomiting.

Circulation fails, body temp rises, Person feels cool, looks pale, perspires heavily. Pulse is fast, weak, irregular. BP falling.

Respiratory system fails, cheyne stokes respirations noted, mucus in throat called death rattle. Rigor mortis develops 2 to 4 hrs after death.

Organ Procurement and Donation

Organ donation – the removal of tissues from an individual who has died recently or a living donor.

Organ procurement – the obtaining of organs for donation; includes transporting, surgical removal and transplantation.

The following can be transplanted: heart, intestines, kidneys, lungs, liver, pancreas, bones, skin. These tissues can be procured: tendons, corneas, heart valves, bone marrow, veins.

Signs of DeathNo pulse, no respirations, no blood pressure.

Pupils fixed and dilated. A doctor determines that death has occurred and

pronounces person dead.Postmortem care is care of the body after death.

Starts as soon as death is pronounced. Use standard precautions. Done to maintain body’s appearance.

Includes gathering personal items and valuables. Patient has right to be treated with dignity,

privacy and respect.