Which of the following is not a requirement for hospitals according to the Federal Patient Self-Determination Act?
The Patient Self-Determination Act (PSDA) took effect in 1991, and is intended to promote awareness and discussion to prepare for medical decisions at the end of life. It requires hospitals to inform patients upon admission of state laws concerning self-determination. Hospitals must inform patients about their rights to accept or refuse terminal care, and this information has to be documented in the patient’s chart. The patient has the option to make a clear assignment of who can make medical decisions if the patient is unable. Patients are not required to allow organ donation.
A 31-year-old G3P3 Jehovah’s Witness begins to bleed heavily 2 days after a cesarean delivery. She refuses blood transfusion, and says that she would rather die than receive any blood or blood products. You personally feel that you cannot do anything and watch her die.
Appropriate actions that you can take under these circumstances include which of the following?
Determination of ethical conduct in doctor-patient relationships can sometimes be very difficult for the physician who is confronted with a patient’s autonomy in making a decision that the physician finds incomprehensible. However, the autonomy of the patient who is oriented and alert must be respected even if it means that the patient is refusing potentially lifesaving therapy. Attempting to obtain a court order to transfuse an adult against his or her will is almost never an acceptable option, and leads to a tremendously slippery slope of the doctor’s control of the patient’s behavior. A patient’s spouse also does not have legal authority to make decisions for the patient if the patient is competent, awake, and alert. The situation is different when a child is involved, in which case societal interests can occasionally override parental autonomy. It would be inappropriate for a physician to abandon a patient without obtaining suitable coverage from another qualified physician. Transfusing forcibly is assault and battery; thus, in this case, the physician must adhere to the patient’s wishes and, if need be, let her die.
A physician is being sued for malpractice by the parents of a baby born with cerebral palsy.
Which of the following is not a prerequisite for finding the physician guilty of malpractice?
Negligence law governs conduct and embraces acts of both commission and omission (ie, what a person did or failed to do). In general, the law expects all persons to conduct themselves in a fashion that does not expose others to an unreasonable risk of harm. In a fiduciary relationship such as the physician-patient relationship, the physician is held to a higher standard of behavior because of the imbalance of knowledge. In general, the real gist of negligence is not carelessness or ineptitude, but rather, how unreasonable was the risk of harm to the patient caused by the physician’s action? Thus physicians are held accountable to a standard of care that asks the question, “What would the reasonable physician do under this specific set of circumstances?” The physician is not held accountable to the level of the leading experts in any given field, but rather to the prevailing standards among average practitioners. When a doctor-patient relationship is established, the defendant (doctor) owes a duty to the patient. If the defendant breaches that duty—that is, acts in a way that is inconsistent with the standard of care and that can be shown to have caused damage directly to the patient (proximate damage)—then the physician may be held liable for compensation.
A 27-year-old woman who has previously received no prenatal care presents at term. On ultrasound, she is shown to have a placenta previa, but refuses to have a cesarean delivery under any circumstances.
Important points to consider in her management include which of the following?
When confronted by a complex situation in which there are conflicting values and rights, getting the most qualified people involved is the best approach to reduce risk and to come up with the best, most defensible answer under the current circumstances. The obstetrician should employ whatever departmental or hospital resources are available. A standing ethics committee or an ad hoc committee to deal with such complex situations is often available, and will minimize the ultimate medicolegal problems that can ensue when bad outcomes seem likely. The obstetrician must further recognize that he or she has two patients, but that it is not clear, nor is it legislated, whose interests take priority. However, general ethical opinion is that the mother usually should come first. Most court-ordered cesarean deliveries have been performed on patients who were estranged from the medical system, and this sets a very bad precedent for further state intervention in doctor-patient relationships and maternal rights. Child abuse statutes do not, at this point, require a court order to force a cesarean delivery, even for a healthy fetus.
Your 36-year-old patient is admitted to the hospital for induction of labor at 42 weeks’ gestation. She provides the hospital with her living will at the time of her admission. She signed the will 5 years ago, but she says to her nurse that she still wants to abide by the will. She has also signed an organ donor card allowing the harvesting of her organs in the event of her death.
Why is her living will not valid for this hospitalization?
Living wills present the opportunity for patients to declare their wishes in advance of situations in which they become no longer competent to do so. They are revocable by the patient at any time, and are automatically invalid if the patient is pregnant, as another being is involved. Living wills can be set aside if a long period has elapsed since their drafting and the wishes are not known to be current. Also, there is the potential for conflict if the patient has signed a donor card and prolongation of life would be needed to carry out those wishes. Generally, such action would not be honored unless relatively expeditious arrangements were possible.
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