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INR

P.O. Box 5757 ♦ Concord, CA 94524 ♦ (925) 609-2820 ♦ (925) 687-0860

Medical Ethics & Legal Issues:

A Course for Healthcare Professionals

Instructor: Dr. R.S. Hullon (M.D., J.D.)

Participants completing this program will be able to: 1) Define and distinguish between ethics, morals, and values. 2) Describe and discuss the 4 principles of medical ethics. 3) Identify the ethical obligations in a clinician-patient relationship. 4) Explain the issues surrounding patient consent and confidentiality with respect to patient

autonomy and HIPAA (Health Insurance Portability and Accountability Act). 5) Discuss the lack of capacity of the patient and healthcare proxies. 6) Examine the role of ethics in complex medical developments artificial intelligence and robotics.

Copyright 2020, INR (Institute for Natural Resources). All Rights Reserved. First Edition (07/2019)

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(Effective January 1, 2020)

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MEDICAL ETHICS & LEGAL ISSUES:A Course For Healthcare Professionals

Rajinder Hullon M.D., JD.Institute for Natural Resources © 2019

Procedures• To obtain the 6 hours of credit (0.6 CEU) associated with this

course, the health care professional will need to sign in, attend

the course, and complete program evaluation forms. At the end of

the program, the health care professional successfully completing

the course will receive a statement of credit

• Four sessions, three breaks, including a lunch break

• Special sign‐up sheets: If needed

• PLEASE TURN CELL PHONES OFF (vibration mode is OK)

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Additional Sign‐ins

The following health professionals have to sign in twice in the morning:

Pharmacists/Pharmacy Technicians ‐ For reporting credit to CPE Monitor, please verify NABP # and DOB (month and day only – Oct 31 would be 10/31). INR only has 60 days to report credit. ACPE charges $200 fee for reporting after the deadline.

Nursing Home Administrators ‐ To obtain credit for NAB (except for IL and CA where INR is a provider of NHA, no need to report credit to NAB).

Massage Therapists ‐ Complete special form and return to coordinator.

Social Workers who are members of NASW‐ Complete NASW info on sheet including signing your name when you arrive AND at the end of the day.

Dentists – MEMBERS of AGD ONLY

If you see “NONE” in the profession on the sign‐in sheets, please add your profession if you are a health professional.

Ethics and Morals

• Ethics ‐ derived from the Greek ethosmeaning character or conduct.

• Moral ‐ derived from the Latin word mores, meaning customs or habits.

• Ethics and morals refer to the conduct, character, and motivations involved in moral acts.

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Ethics and Morals

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Ethics and Morals

• Ethics describes a generally accepted set of moral principles.

• Morals are described as the individual ideals or principles of what is right or wrong.

• Values describe individual or personal standards of what is valuable or important.

• Medical ethics, on the other hand, is defined as the system of values and guidelines governing decisions in medical practice

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Ethical Theories

• There are many ethical theories and even more ethical philosophers.

• Three major strands can be simplified as:‐

– Concern for the right act (Deontological)

– Concern for the consequence (Teleological)

– Concern for the greater good (Utilitarian)

Ethical Theories

• A deontological (duty‐based) theory determines that the morality of an action should be based on whether that action itself is right or wrong under a series of rules, rather than based on the consequences of the action.

• A teleological (meaning goal or end) theory describes an ethical perspective that contends the rightness or wrongness of actions is based solely on the goodness or badness of their consequences. Actions are morally neutral when considered apart from their consequences.

• A utilitarian (greatest good) theory is based on one’s ability to predict the consequences of an action. To a utilitarian, the choice that yields the greatest benefit to the most people is the one that is ethically correct.

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The History of Medical Ethics

• Earliest evidence ‐ Hippocratic oath and early Christian teachings.

• First code of medical ethics “Formula Comitis Archiatorum” ‐ published in the 5th century, during the reign of the Ostrogothic king Theodoric the Great.

• Medieval period ‐

a. Ishaq ibn Ali al‐Ruhawi, author of “Practical Doctor's Ethics”

b. Avicenna (Ibn Sina), author of the “Canon of Medicine.”

c. Maimonides, Thomas Aquinas, and the case‐oriented analysis of Catholic moral theology.

Modern Medical Ethics

• 1794‐1803 ‐Thomas Percival devised the first modern code of medical ethics introducing the terms “medical ethics” and “medical jurisprudence.”

• 1847, the American Medical Association adopted its first code of ethics based upon Percival's work.

• 1960s and 1970s, influenced by social and legal changes, medical ethics began to reconfigure itself into bioethics.

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Principles of Medical Ethics

Moral Principles

• Specify that some type of action or conduct is either prohibited, required or permitted in certain circumstances

• Moral principles commonly used in medical practice are:‐

– Autonomy

– Non maleficence

– Beneficence

– Justice

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Four Basic Principles Of Medical Ethics

Developed by ethicists Beauchamp and Childress:

• Beneficence describes the concept of acting for the patient’s good.

• Non‐maleficence describes the concept of doing no harm.

• Autonomy conveys the idea that each patient has a right to voice his or her own values and choices about care.

• Justice expresses the idea that healthcare resources should be equitably distributed among patients and that patients should be treated fairly.

Four Basic Principles Of Medical Ethics

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Ethics in Medicine

• “Ethical issues are embedded in every clinical encounter between patients and caregivers because the care of patients always involves both technical and moral considerations.”

Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 7th ed. New York, NY: McGraw Hill; 2010:1.

Autonomy

• An individuals ability to make or exercise self‐determining choices

• A person should be free to choose and entitled to act on their preferences provided their decisions and actions do not violate or impinge on the significant moral interests of others.

• Respect for autonomy creates the following obligations – those of informed consent, confidentiality, truth‐telling and effective communication.

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Example

• In your opinion, a patient needs surgery.

• The patient however can refuse and their refusal has to be respected.

• This right to autonomy (self‐determination) underpins the medico legal understanding of INFORMED CONSENT.

Violating The Principle Of Autonomy

• Treating patients without their consent

• Treating patients without giving them all the relevant information necessary for making an informed and intelligent choice (informed consent)

• Telling patient “white lies”.

• Withholding information from patients when they have expressed a reflective choice to receive it.

• Forcing information on a patient when they have expressed a reflective choice not to receive it.

• Forcing anyone to act against their reasoned moral judgment or conscience.

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Non‐Maleficence

• Above all, do no harm.

• Stringent duty not to injure others

• Medical providers must consider whether other people or society could be harmed by a decision made, even if it is made for the benefit of an individual patient.

Example

• You have a terminal patient and you feel you can no longer offer him anything that could cure him.

• He heard that the taking of arsenic may cure him and asked you to give him arsenic

• Arsenic is a poison.

• You must refuse to give him the arsenic.

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Violating The Principle Of Non‐Maleficence

• Amputating the wrong extremity.

• Operating on someone before confirming appendicitis

• Puncturing the heart while performing a bone marrow aspiration

Beneficence

• Act done for the good of others

• Provision of benefits

• Preventing and removing harm

• If an act does not bestow benefit or fails to address an imbalance of harms over benefits, the act could rightly be condemned.

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Example

• A patient cuts his hand and suffers blood loss.

• You stopped the bleeding and suture the wounds on his hand.

• He is cross‐matched and typed for a blood transfusion

• Patient recovers.

Violating Beneficence

• Refusing to provide treatment

• Refusing to help an accident victim

• Refusing to help a prisoner or a suspect of crime

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Justice

• The principle of justice states that there should be an element of fairness in all medical decisions: those that burden and benefit

• Equal distribution of scarce resources and new treatments

• Requires medical practitioners to uphold applicable laws and legislation when making choices.

Violating Justice

• Favoring one patient over another

• Senior and experienced doctors treating private patients only.

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Informed Consent

• Informed consent is based on the moral and legal premise of patient autonomy.

• The patient has the right to make decisions about their own health and medical conditions.

Informed Consent

• Process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment.

• Originates from the legal and ethical right the patient has to direct what happens to her body and from the ethical duty of the physician to involve the patient in her health care.

• Appelbaum PS. Assessment of patient’s competence to consent to treatment. New England Journal of Medicine. 2007; 357: 1834‐1840.

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Elements of Informed Consent

• The nature of the decision/procedure

• Reasonable alternatives to the proposed intervention

• The relevant risks, benefits, and uncertainties related to each alternative

• Assessment of patient understanding

• The acceptance of the intervention by the patient

Informed Consent

• All health care interventions require some kind of consent by the patient, following a discussion of the procedure with a health care provider.

• Patients fill out a general consent form when they are admitted or receive treatment from a health care institution.

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Informed Consent

• Explicit written consent is not always required nor needed, but the patient must be given adequate information to help with decision making.

• For instance, a man contemplating having a prostate‐specific antigen screen for prostate cancer should know the relevant arguments for and against this screening test, discussed in lay terms.

Informed Consent

• Most states have legislation or legal cases that determine the required standard for informed consent. Most states use the "reasonable patient standard.” ‐ what would the average patient need to know in order to be an informed participant in the decision?

• Focuses on considering what a typical patient would need to know in order to understand the decision at hand.

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Exceptions to Informed Consent• Emergencies ‐ when medical care is needed immediately to prevent serious or irreversible harm. The guiding principle is whether delay in treatment in order to obtain consent would result in harm to the patient. The procedure need not be lifesaving, as long as the potential harm to the patient is significant.

• Incompetence or lack of capacity ‐ someone is unable to give permission (or to refuse permission) for testing or treatment

Exceptions to Informed Consent

• Consent is waived ‐ the patient has waived consent.

• Advance directives ‐ When a competent patient designates a trusted loved‐one to make treatment decisions for him or her. In some cultures, family members make treatment decisions on behalf of their loved‐ones.

• Provided the patient consents to this arrangement and is assured that any questions about his/her medical care will be answered, the physician may seek consent from a family member in lieu of the patient.

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Clinical Case Scenario

• An unconscious man is brought to an emergency department in vascular collapse. He had been thrown off a motorcycle and ruptured his spleen. The surgeon recommended emergency surgery and blood transfusion, but no next of kin was readily available to give consent. An old wrinkled card in his wallet indicates the patient is a Jehovah's Witness and should never receive blood, but there is a diagonal line drawn across that part of the card. Which of the following is best?


• A. All interventions require informed consent, so in this case the surgeon should not operate.

• B. Because this is an emergency, no consent for operation or blood transfusion is necessary, as long as you get two supporting doctor signatures.

• C. If the man's spouse can be located and she gives consent for transfusion, then it's okay.

• D. Operate on the patient, but respect his disavowal of blood even if it means death.

• E. If the patient desperately needs a lifesaving blood transfusion, it should be given, because his wishes are not entirely clear.

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• Answer: E. This is because of the dire nature of the patient's condition, the critical and immediate need for blood, and most of all, the reasonable belief that the line across the wrinkled card represents a revocation of an earlier refusal of blood. Some may view D as the better option, and it is arguably the legally “safe” approach. However, a life hangs in the balance, and a doctor's first duty is to the patient.

• Beneficence:While the principle of respect for person obligates you to do your best to include the patient in the health care decisions that affect his life and body, the principle of beneficence may require you to act on the patient's behalf when his life is at stake. In emergencies where life or limb is at stake and where consent is unobtainable, consent is usually implied.

Confidentiality

• Confidentiality remains one of the most basic tenets of healthcare. Healthcare professionals maintain confidentiality on behalf of their patients and clients unless consent to release the information is provided.

• Patients routinely share personal information with healthcare professionals and if confidentiality of this information were not protected, trust in the clinician‐patient relationship would be diminished.

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Confidentiality

• Based on loyalty and trust

• Maintain the confidentiality of all personal, medical and treatment information

• Information to be revealed with consent and for the benefit of the patient except when ethically and legally required

• Disclosure should not be beyond what is required

Breaching Confidentiality

Confidentiality may be breached in the following circumstances:

• For other health care personnel for purposes of providing care or for health care operations; or

• For appropriate authorities when disclosure is required by law. State law requires the report of certain communicable/infectious diseases to the public health authorities. In these cases, the duty to protect public health outweighs the duty to maintain a patient's confidence.

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Breaching Confidentiality

• For other third parties to mitigate the threat when there is a reasonable probability that:

a) The patient will seriously harm him/herself.

b) The patient will inflict serious physical harm on an identifiable individual or individuals.

• For any other disclosures, healthcare professionals should obtain the consent of the patient (or authorized surrogate) before disclosing personal health information.

Duty to Warn

• The duty to warn arises when a patient has communicated an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim or victims

• The patient has the apparent intent and ability to carry out such a threat.

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Tarasoff v. Regents of the University of California

• In 1969, Prosenjit Poddar was a college student at the University of California, Berkley. He became enamored with fellow student Tatiana Tarasoff, but grew angry and depressed when Tarasoffrejected him. He sought emergency psychological treatment at the University hospital, where he was seen on seven occasions over the course of about 10 weeks.

• During Poddar's seventh appointment, he told his psychiatrist he intended to kill Tarasoff. Poddar was diagnosed as having an acute and severe 'paranoid schizophrenic reaction.' Doctors decided he should be committed to a psychiatric hospital and contacted University police. Campus police briefly detained Poddar, but released him after he agreed to stay away from Tarasoff.

• Neither the campus police nor the University doctors followed up with Poddar. Neither organization warned Tarasoff or her family. Two months later, Poddar accosted Tarasoff in her home. He shot her with a pellet gun, then chased her into the street and stabbed her to death with a kitchen knife.

Duty to Warn

• The duty to warn initially affected psychotherapists but its legal scope has extended to affect all healthcare professionals

• Courts have established that social workers have a legal obligation to warn the potential victim if they believe their client presents an imminent threat to that individual.

• Social workers may also have a legal obligation to seek hospitalization for the client, to inform law enforcement of the potential threat, or to take other steps to protect the potential victim from harm. This is called the “duty to protect.”

• Duty to warn and duty to protect are exceptions to ethical rules on client confidentiality, and failing to protect a potential victim could expose the social worker to legal action.

* Potentially dangerous patients: A review of the duty to warnHenderson E. (2015) Journal of Emergency Nursing, 41 (3) , pp. 193‐200.

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Rising Tide in Healthcare Fraud

• Definition: The intentional deception or misrepresentation made by an individual, knowing that the misrepresentation could result in some unauthorized benefit to them or to others.

• Commonly involves false statements or deliberate omission of information critical in the determination of authorization and payment for services.

• Can result in significant monetary liabilities and, in some cases, subject the perpetrator to criminal prosecution.

Rising Tide in Healthcare Fraud

• The National Heath Care Anti‐Fraud Association estimates conservatively that health care fraud costs the nation about $68 billion annually —about 3 percent of the nation's $2.26 trillion in health care spending.

• Other estimates range as high as 10 percent of annual health care expenditure, or $230 billion.

• Fraud or improper billing commonly occurs in Medicare, hospice care and nursing home or elder care.

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Examples Of Healthcare Fraud• Billing for services that were

never rendered—either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.

• Billing for more expensive services or procedures than were actually provided or performed, commonly known as “upcoding.”

• Performing medically unnecessary services solely for the purpose of generating insurance payments.

• Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary.

• Billing a patient more than the co‐payment amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.

• Accepting kickbacks for patient referrals.

• Waiving patient co‐payments or deductibles and over‐billing the insurance carrier or benefit plan.

Addressing Healthcare Fraud

• The False Claims Act (Lincoln Law) is an American federal law that imposes liability on persons and companies(typically federal contractors) who defraud governmental programs.

• Federal Government's primary litigation tool in combating fraud against the Government.

• Law includes a qui tam provision that allows people who are not affiliated with the government, called "relators" under the law, to file actions on behalf of the government (informally called "whistleblowing" especially when the relator is employed by the organization accused in the suit). Persons filing under the Act stand to receive a portion (usually about 15–25 percent) of any recovered damages.

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Addressing Healthcare Fraud

In 2018:

• More than 600 defendants in 58 federal districts charged

• Approximately $2 billion in losses to vital health care programs.

• Of those subjects charged, 165 are medicalprofessionals— including 32 doctors who were charged for their roles inprescribing and distributing opioids and other dangerous narcotics.

• For every $1 spent on health care related fraud and abuse investigations, more than $4 is recovered.

Medicare Fraud: Senior Abuse?Medicaid, Medicare, and private insurers who fund the care of nursing home residents are vulnerable to fraud and when it happens, residents are inevitably affected. In nursing homes, healthcare abuse and fraud include:

• Phantom billing, where a nursing home bills for services or care that is either unnecessary or not performed.

• Double billing, upcoding or upbilling, in which billing includes more procedures or supplies more expensive than those performed or used

• Billing for medically unnecessary goods or services

• Billing for non‐covered goods or services

• Providing kickbacks in exchange for unused drugs or medical records

• Managed Care Providers billing Managed Care Plans for medically unnecessary services

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Whistleblower Protection

• Several federal and state laws prohibit employers from retaliating against employees who report practices by employers that threaten public health and safety, or violate the law.

• Other laws prohibit retaliation against employees who file complaints about their own working conditions, including unsafe working conditions.

• State laws vary prohibiting adverse actions such as termination, layoff, demotion, suspension, denial of benefits, reduction in pay, and discipline, when the adverse action is taken in retaliation for employees’ reports of unsafe or unlawful practices.

Whistleblower Protection

Occupational Health and Safety Laws

• Federal law that protects workers from retaliation for complaining to their employer, OSHA, or other government agencies about unsafe conditions in the workplace.

• If you have reported unsafe or unhealthy working conditions, and your employer has retaliated against you for it, you can file an OSHA whistleblower complaint online.

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HEALTH INSURANCE PORTABILITY ANDACCOUNTABILITY ACT (HIPAA) (1996)

Health care providers (HCP) are required to control the ways in which they use and disclose patients’ health information.

• Requires HCPs to ensure that they are protecting the privacy and security of patients’ medical information.

• A standard format is required when submitting electronic transactions—to payers, for instance.

• Allows covered entities to transmit protected health information via email over an electronic open network, provided the information is adequately protected or encrypted.

Common HIPAA Violations• Impermissible disclosures of protected

health information (PHI)

• Unauthorized accessing of PHI

• Improper disposal of PHI

• Failure to conduct a risk analysis

• Failure to manage risks to the confidentiality, integrity, and availability of PHI

• Failure to implement safeguards to ensure the confidentiality, integrity, and availability of PHI

• Failure to maintain and monitor PHI access logs

• Failure to enter into a HIPAA‐compliant business associate agreement with vendors prior to giving access to PHI

• Failure to provide patients with copies of their PHI on request

• Failure to implement access controls to limit who can view PHI

• Failure to terminate access rights to PHI when no longer required

• The disclosure more PHI than is necessary for a particular task to be performed

• Failure to provide HIPAA training and security awareness training

• Theft of patient records

• Unauthorized release of PHI to individuals not authorized to receive the information

• Sharing of PHI online or via social media without permission

• Mishandling or mailing PHI

• Texting PHI

• Failure to encrypt PHI or use an alternative, equivalent measure to prevent unauthorized access/disclosure

• Failure to notify an individual (or the Office for Civil Rights) of a security incident involving PHI within 60 days of the discovery of a breach

• Failure to document compliance efforts

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Electronic Medical Records: Ethical Issues

• Allows for greater administrative ease in accessing, sharing and storing of the patient’s personal health information.

• While access to records is typically limited to authorized users, there have been cases of unauthorized access.

• The personal data though encrypted, can sometimes be breached by third parties

• This is made easier by the use of multiple formats and devices in accessing the information.

• When such unauthorized access occurs, this is a violation of all ethical principles.


• Autonomy: Patients never fully instructed about the risks and benefits of the endless data EMRs collect that often is not used at all to make treatment decisions on their care. Nor were they consulted on the attention it diverts away from their doctor‐patient interactions, time spent and the harm that can cause.

• Justice: Penalizes those physicians in mid or later career who did not grow up on technology. With EMRs a provider cannot go to the next page without answering certain questions that may or may not have anything to do with the patient’s care.

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• Beneficence: Transforming the physician into a data entry specialist by consuming their time erodes the doctor‐patient relationship, chips away at things like bedside manner and effective communication that all can impede care. It keeps physicians in the office longer, performing extraneous, routinely redundant tasks on EMRs diminishing the time dedicated to high‐quality care.

• Non‐Maleficence: EMRs do not speak between institutions causing delays in care since health professionals at one place cannot access the data from the other. This can further infringe on a person’s ability to choose their doctor given the undue pressure exerted upon them to remain within a hospital system for all of their care to their detriment.

HIPAA Violation Penalties

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Advance Directives

Living will

• A document designed to control certain future health

care decisions only when a person becomes unable

to make decisions and choices on their own.

• Much more limited than a health care power of

attorney. Both apply only when you are unable to

speak for yourself, but the living will takes effect only

if you are terminally ill or permanently unconscious.

Advance Directives

• The living will describes the type of medical treatment the patient would want or would not want in these situations. It can describe under what conditions an attempt to prolong life should be started or stopped.

• This applies to treatments such as dialysis, tube feedings, or artificial life support (such as the use of breathing machines).

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Advance Directives

• Most living wills do not designate an agent or proxy to make decisions or to ensure that the wishes of the patient are carried out.

• This is the reason why living wills usually include a health care power of attorney.

Advance Directives

Durable/Medical Power of Attorney (Designation of a Health care Surrogate)

• Also called a health care power of attorney, it is a legal document in which an individual is named to be a proxy (agent) to make health care decisions if you become unable to do so.

• The person named as your proxy or agent should be someone you trust to carry out your wishes. It is also a good idea to name a back‐up person in case your first choice becomes unable or unwilling to act on your behalf.

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Advance DirectivesDo Not Resuscitate (DNR)

• A “Do Not Resuscitate” or DNR order means that if you stop breathing or your heart stops, nothing will be done to try to keep you alive. A DNR order allows natural death and is sometimes called an “Allow Natural Death” order.

• Some states have an advance directive called a Do Not Attempt Resuscitation (DNAR) or special Do Not Resuscitate (DNR) order for use outside the hospital.

• The non‐hospital DNR or DNAR is intended for Emergency Medical Service (EMS) teams who answer 911 calls and are usually required to try to revive and prolong life in every way they can. When the patient dies, a moment of uncertainty sometimes results in a 911 call. This can mean unwanted measures are used to attempt resuscitation.


A 69‐year‐old woman with AML is hospitalized. The team feels she may need to be placed on a feeding tube soon to assure adequate nourishment. They ask the patient about this in the morning and she agrees.

However, in the evening (before the tube has been placed), the patient becomes disoriented and seems confused about her decision to have the feeding tube placed. She tells the team she doesn't want it in.

They revisit the question in the morning, when the patient is again lucid. Unable to recall her state of mind from the previous evening, the patient again agrees to the procedure.

Is this patient competent to decide?

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• Answer: There is a question about the patient’s capacity to make decisions due to her condition. If her wishes are consistent during her lucid periods, this choice may be considered her real preference and followed accordingly. However, as her decision‐making capacity is questionable, getting a surrogate decision maker involved can help determine what her real wishes are.

• Autonomy: The principle to be preserved here is the autonomy of the patient. She cannot make a rational decision for her continued care so autonomy can be maintained through the use of a surrogate decision maker.

Legal Issues In Medicine

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Malpractice

Under tort law, there are four elements that must be established for a ruling of malpractice

• Duty: The healthcare professional owed a duty to meet a particular standard of care.

• Breach of duty: The healthcare professional failed to perform the owed duty.

• Causation: There is a causal connection between the failure to perform the duty and the patient's injury.

• Damages: An injury occurred for which monetary compensation is adequate relief.

Nurses, Liability And Malpractice

• Since 2009, average payouts are up about 30%, from $186,000 to more than $240,000.

• In 2009 indemnity payments less than $100,000 accounted for more than half of all settlements.

• In 2016 they made up only 39%.

• Payments over $500,000 meanwhile, ballooned from 8% of all cases to 18%.

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• Neonatal, women's health, and emergency department nurses accounted for the highest average payouts, many in the mid‐ to high‐six‐figure range.

• Emergency medicine was also notable in that it grew as a proportion of settlements, from 3.5% in 2012 to 5.7% in 2016.

• Diagnosis, medication, and treatment came up as most often mentioned in the cases analyzed.

• Monitoring, however, was the biggest driver of large payments, with an average payment of $450,000.

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Six categories of nursing malpractice claims have been identified:

• Failure to follow standards of care

• Failure to use equipment in a responsible manner

• Failure to assess and monitor

• Failure to communicate

• Failure to document

• Failure to act as a patient advocate or follow the chain of command.

Professional Boundaries

• Zone of helpfulness ‐ constitutes the center of the continuum of recommended professional behaviors.

• Implementing the zone:a. Critical to treat all patients, at all times, with dignity and

respect.b. Inspire confidence in all patients by speaking, acting, and

dressing professionally.c. Through your example, motivate those you work with to

talk about and treat patients and their families respectfully.

d. Be fair and consistent with each patient to inspire trust, amplify your professionalism, and enhance your credibility.

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Professional Boundaries

Behaviors To Avoid :a. Discussing intimate or personal issues with a patientb. Keeping secrets with a patient or for a patientc. believing that you're a “supernurse” or the only one who

truly understands or can help a patientd. spending more time with a patient or revisiting that

patient when you're off duty or out of uniforme. engaging in any behavior that may be misinterpreted as

flirting (Nurses understand the difference between a sincere compliment that enhances the patient's self‐esteem and one that may be interpreted as flirtatious.)

f. taking a patient's side when there's a disagreement between the patient and his or her spouse or the patient and his or her family members.

Role of Risk Management in Hospitals• Enterprise Risk Management (ERM): Comprehensive risk management of

the organization from top down including financial and business viability.

• Patient care (Clinical)

• Medical staff (credentialing, privileging, job description, employee insurance, trainings, medical coverage)

• Non‐medical staff (job description, training, medical coverage)

• Financial (Budgeting, cost‐benefit and cost‐effectiveness analysis, insurance coverage)

• Managerial (organogram, Job descriptions, delegation of work)

• Project risk management (time, cost, human resources, operational, procedural, technical, natural and political)

• Facility Management and safety (building safety, security of the facility, hazardous materials and waste disposals (HAZMAT), emergencies internal and external, fire safety, medical equipment maintenance plan and maintenance plan for each of the utility system.

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Role of Risk Management in Hospitals

Five Basic Steps of Risk Management:

• Step 1: Establish the context

• Step 2: Identify risks

• Step 3: Analyze risks

• Step 4: Evaluate risks

• Step 5: Treat/Manage Risks

Current Ethical Issues In Medicine

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Ethical Issues: Healthcare Errors

• Johns Hopkins patient safety experts calculate that more than 250,000 deaths per year in the U.S. are due to medical error.

• This statistic surpasses the CDC’s third leading cause of death, respiratory disease which kills close to 150,000 people per year.

• According to the CDC, in 2013, 611,105 people died of heart disease, 584,881 died of cancer and 149,205 died of chronic respiratory disease — the top three causes of death in the U.S.


Common Hospital Errors:

• Misdiagnosis.

• Unnecessary treatment.

• Unnecessary tests and procedures

• Medication mistakes.

• Never events (events that should never happen like operating on the wrong extremity).

• Uncoordinated care.

• Hospital infections

• Hospital accidents

• Missed warning signs.

• Discharged too soon

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Case Scenario

• A 60‐year old female was transported to the floor post surgery. An epidural catheter with morphine was placed for post‐operative pain control. Upon arrival, the patient complained of nausea and a headache prompting the on‐call physician to prescribe, “Demerol 75mg every three hours for pain.”

• The preprinted medication orders from anesthesia stated “No narcotics, sedatives, or other respiratory depressants to be given during infusion of epidural medication and for 12 hours after epidural is discontinued except by order of anesthesia.” The nurse had not reviewed this order prior to obtaining and administering the new order for Demerol, a narcotic.


• Twenty minutes later, the patient was found unresponsive and aggressive resuscitation efforts were implemented, resulting in intubation and mechanical ventilation of the patient. When brain activity was not found, the family made the decision to take the patient off of life support and the patient died shortly thereafter.

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• Non‐maleficence, the obligation to avoid causing harm, is not restricted to deliberate harm.

• Harm committed with the intent of healing is no less prohibited by this principle than malicious harm, and every physician must assume the duty of preventing all harm

Ethical Issues: Artificial Intelligence

Medical Decision Making And Autonomy Algorithms

• Many patients do not have the capacity to make health care decisions creating a need for a reliable mechanism to predict patient preferences.

• Triple burden that incapacity creates:

a) Ethical burden upon health care systems to respect the wishes of these patients

b) Emotional burden upon surrogates to make difficult decisions; and

c) Economic burden upon society to fund investigations and treatments that the incapacitated patient would have

declined.

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• Existing AI technologies could integrate data mined from EHRs and social media in order to estimate the confidence of the prediction that a patient would consent to a given treatment.

• This computational process called an autonomy algorithm takes data about patients as input and derives a confidence estimate for a particular patient’s predicted health care‐related decision as an output.

• Such an algorithm, thoughtfully implemented and judiciously used, could address the triple burden posed by incapacitated patients: it could lead to improved respect for autonomy, reduced burnout of surrogates, and economic gains for society.


• In addition to increased accuracy, a computerized approach could alleviate some of the weight of making life‐and‐death decisions.

• An algorithm will not lose sleep if it predicts with a high degree of confidence that a person would wish for a life‐support machine to be turned off.

• The surrogate who ends life‐support may rest a little easier knowing that the autonomy algorithm has also concluded that this is likely what the patient would have wanted.

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Ethical issues:

• Just because we can be confident that a person would choose treatment X, it does not follow that this person should choose X.

• if increasingly massive data sets enable the autonomy algorithm to offer very high levels of predictive accuracy, should AI replace human decision makers, regardless of a patient’s decision‐making capacity?


• Autonomy algorithms could reflect existing biases.

• In one study the most significant predictor of treatment choice was the specialty of the consulting doctor; patients referred to urologists were most likely to choose surgery and those referred to radiation oncologists were most likely to choose radiotherapy.

• An algorithm trained on this data set would generate a high confidence estimate for the prediction that a patient seeing a urologist would choose surgery.

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• This association may not be due to genuine patient preference but reflective of the fact that patients are prone to being talked into a certain therapy by their clinician

• it would be a flaw and not a feature of the proposed autonomy algorithm to reinforce this fact.


• If patients with lower health literacy are more disposed to choose the (less effective) treatment X, then an algorithm trained on this data set might generate a high confidence estimate for the prediction that a patient with low health literacy would choose X. Of course, this does not mean that patients should choose X.

• This would be an example of an algorithm “learning” prejudice.

• The outputs of the autonomy algorithm need to be carefully interpreted by both clinicians and patients in order to avoid this trap.

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The Trolley Problem

• The first trolley scenario was an ethical problem proposed by Philippa Foot.

• It is about a trolley that is going down the tracks and is set on course to run down five people who are tied to the tracks. The driver of the trolley has the option to divert the trolley onto another track in which only one person is tied. Foot wondered whether or not the driver should divert the trolley.

The Trolley Problem

• Foot answered that the driver should divert the trolley. A simple calculation shows why this is so.

• If the driver keeps the trolley on its tracks, five people will be run over and die. If, by contrast, the driver diverts the trolley, only one person will die.

• It seems ethically acceptable to kill one person in order to save five.

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The Trolley Problem

Now lets apply the problem to a medical situation

• A surgeon considers a healthy individual, a perfect donor, who shows up at a hospital, and five terminally ill patients who could be cured with that person’s organs. Should that person be killed so that the other five survive?

• Why then is it that in the case of the trolley it is morally acceptable to kill one in order to save five, whereas in the case of the transplant it is not morally acceptable to kill one in order to save five?

The Trolley Problem

• The trolley problem supports the primacy of non‐maleficence in medical ethics.

• The five patients may die as a result of the transplant not taking place, but the surgeon is not ethically at fault since he has done no harm, and that is a doctor’s most important duty.

• In order to save the five, he would have had to kill the one person.

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The Trolley Problem

• As opposed to the doctor, the driver is not in a position to claim that his duty is to first do no harm. This is because the driver already has done some harm by setting the trolley on course to kill five people.

• His moral duty is to take additional action to minimize his initial harm. Killing one is not better than letting five die, but killing one is indeed better than killing five.

The Trolley Problem

• A child runs out into the street directly in front of your car. The second you see him, you hit the brakes to avoid hitting him. In that moment you are making a moral call that might shift risks from the pedestrian to you and the other people in the car, if any.

• In the case of AI systems, Is a self‐driving car able to make such moral judgments? Furthermore, if we were able to teach autonomous cars how to make an ethical decision, does it mean that we should actually do it?

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The Trolley Problem

• The car would be drawing on pre‐existing preferences developed equitably, ethically, and with the input from a representative group of people, more reflective of a collective human will than a split‐second decision taken by an individual person.

• The self‐driving car could however also be programmed to include the cultural differences and biases of that representative group.

Artificial Intelligence: Robotic Medicine

• In 2000, the Da Vinci Surgical System was the first robotic device approved by the FDA to perform surgical procedures.

• Since then, the system has conducted more than 20,000 surgeries.

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The Ethics of Robotic Medicine

• Recently, business leaders and academics have warned that current advances in AI may have major consequences to present society:

• • “ Humans, limited by slow biological evolution, couldn’t compete and would be superseded by A.I.”—Stephen Hawking in BBC interview 2014.

• • AI is our “biggest existential threat,” Elon Musk at Massachusetts Institute of Technology during an interview at the AeroAstro Centennial Symposium (2014).

• • “I am in the camp that is concerned about super intelligence.” Bill Gates (2015) wrote in an Ask Me Anything interview on the Reddit networking site.


• Experts agree that there is a one in two chance that high‐

level machine intelligence (defined as “a machine that

can carry out most human professions at least as well as

a typical human”) will be developed around 2040–2050,

rising to a 9 in 10 chance by 2075.

• These experts expect that systems will move on to super

intelligence (defined as “any intellect that greatly exceeds

the cognitive performance of humans in virtually all

domains of interest”) in less than 30 years thereafter.

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• Ethical perspectives of AI and robotics should be addressed in at least two ways:

• First, the engineers developing systems need to be aware of possible ethical challenges that should be considered including avoiding misuse and allowing for human inspection of the functionality of the algorithms and systems.

• Second, when moving toward advanced autonomous systems, the systems should themselves be able to perform ethical decision making to reduce the risk of unwanted behavior.


• Professor and science fiction writer Isaac Asimov (1920–1992) was already concerned in 1942 about the need for ethical rules for robot behavior. His three rules have often been referenced in the science fiction literature and among researchers who discuss robot morality:

1. A robot may not harm a human being, or through inaction, allow a human to be injured.

2. A robot must obey orders given by human beings except where such orders would conflict with the first law.

3. A robot must protect its own existence as long as such protection does not conflict with the first or second law.

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Beneficence

• AI assistive technology providing companionship for the elderly, apps recommending therapy, reminding patients about meds, identifying and responding to patients at suicide risk, sexual counseling for adolescents, mental health support, even assisting end of life decisions are all available and appear to be helpful and if effective, may provide tremendous good.

• Beneficence requires that the healthbots are accurate when they determine diagnosis, patient intent, and emotional responses and there should be failure transparency.


• Beneficence demands constant diligence to prevent programmed bias.

• We have a moral obligation to understand the full range of potential relationships between humans and intelligent machines.

• Who is responsible for assuring beneficent programming? What are the benefits, are they real and do they justify the still vague risks? These relationships could be as beneficial as our relationship with pets. Further research about the consequences of humans bonding with healthbots is an ethical necessity.

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Non Maleficence• Healthbots must not directly harm

or deceive humans. This includes not only intentional harm but also the more difficult to assess harm from unintended consequences.

• Desperate, lonely people will build relationships with bots

• Privacy and confidentiality must be maintained, and these systems must be very secure. Additionally, they should not be the source of undue influence (advertising) to the vulnerable.

• Robots may oversimplify and perhaps miss important emotional cues to the patient’s detriment. Premature closure and missed diagnoses cause real harm.


Autonomy

• Respecting an individual’s independent decisions about healthcare is a cornerstone of modern medicine.

• Is the vulnerable, senile, demented, disadvantaged person cared for by healthbots free of undue influence?

• Who decides whether a healthbot should influence a person whose judgment may be impaired?

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Justice

• Justice implies fairly meeting the needs of individuals. With growing demand for healthcare services and the need to comfort the elderly, justice may demand wide availability of healthbots.

• Making ethical decisions around the distribution of these resources will necessitate understanding the consequences of developing relationships and dependencies.

• On the other hand, a societal impact on the loss of healthcare providers’ employment widespread adoption of AI healthcare may have a negative impact on many.

Ethical Issues: Immigration Status

Question:

Should Immigration Status Information Be Included in a Patient’s Health Record?

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• Recording immigrant status can facilitate continuity of care and improve communication among clinicians.

• However it might expose patients or family members to immediate stigma and discrimination by nonimmigrant‐friendly clinicians or being exposed to immigration enforcement if staff contact immigration officials in violation of patient confidentiality.

• Patients may raise concerns about the purpose and risks of such documentation alongside fears about potential data sharing and violations of privacy and confidentiality.


Answer:

The clinicians’ primary professional and ethical responsibility is to provide quality care to all people regardless of immigration status or background.

Identifying stressors and modifiable social determinants of health might help facilitate comprehensive care for patients.

The ethical principle of beneficence compels clinicians to use known immigration status to benefit the patient.

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• Under HIPAA, personal identifiable information can be shared with others in limited circumstances, such as for treatment, payment, or public safety, or as required by law (e.g. by court order).

• Otherwise, disclosure of this information is generally only permitted when the patient consents.


• Explicit documentation of immigration status of patients and their family members in a health record should be avoided, particularly when risks outweigh benefits.

• If immigration status is needed to facilitate the patient’s receipt of services or resources, conversations with clinicians should be prioritized over written communications, or clinicians can use indirect language in the health record to describe social context (e.g, “immigration stressors” or “ineligible for insurance”). Patients should be assured of confidentiality, informed of privacy laws, and invited to discuss their concerns.

https://journalofethics.ama‐assn.org/cases accessed 3/23/19

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Ethics Within The Medical Specialties

Nursing Case Scenario

Case

• A nurse at a local Senior Residence facility refused to administer cardiopulmonary resuscitation (CPR) to an 87‐year‐old woman who collapsed in the facility’s dining hall because “It was against company policy.”

• Although the nurse called 911, and the dispatcher urged her to start CPR or to find someone who was willing to do so, the nurse refused. There was no Do Not Resuscitate (DNR) directive in place.

• Was the nurse’s behavior ethical?

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Nursing Case Scenario

Answer:

• Provision 2 of American Nurses Association Code of Ethics applies in this case.

• In the face of a company policy that refuses intervention in an emergency situation, the nurse still has a duty of care to a resident even though this facility does not provide skilled nursing care. Although the patient was living in an assisted living facility and not a nursing home, the American Nurses Association Code of Ethics for Nurses is clear: “The nurse’s primary commitment is to the patient, whether an individual, family, group or population.”

Pharmacy Case ScenarioCase

• On July 6, 2002, a University of Wisconsin‐Stout student, went to the K‐Mart in Menomonie, Wisconsin, to fill her prescription for oral contraceptives, birth control pills. The only pharmacist on duty, Neil Noesen, asked if she intended to use the prescription for contraception. When she replied in the affirmative, Noesen, a Roman Catholic, refused to fill the prescription, explaining that to do so would be against his religious beliefs.

• Is the pharmacist being ethical within the confines of his profession?

• What could the pharmacist have done to preserve his religious beliefs and serve the patient?

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Pharmacy Case ScenarioAnswer

• No. While the pharmacist is acting upon his religious beliefs in not serving the patient and stepping away, he leaves the patient with no other recourse for her prescription needs.

• The ordinary standard of care “requires that a pharmacist who exercises a conscientious objection to dispensing of a prescription must ensure that there is an alternative mechanism for the patient to receive his or her medication, including informing the patient of their options to obtain their prescription.”

• Noesen’s conduct constituted “a danger to the health, welfare, or safety of a patient and was practiced in a manner which substantially departs from the standard of care ordinarily exercised by a pharmacist and which harmed or could have harmed a patient.” Noesen could have referred or transferred the prescription.

Social Work Case ScenarioCase• Diane is a single social worker who has been in practice for 16

years. One night when she is out with her girlfriends, she runs into a former client, Bill whom she first met about two years ago when he and his teenaged daughter Susan came to see her about relationship difficulties they were experiencing. Diane worked with Bill and Susan for approximately 4 months until things improved and all parties agreed to terminate therapy. Bill has been divorced for six years. When they see each other at the restaurant, Diane and Bill talk briefly. She learns that Susan is away at college, and that father and daughter have been doing well. She does not really think anything about it until he calls her the following week to ask her out to dinner. Diane tells Bill that she will have to think about it, and agrees to call him back later in the week. While Diane feels some attraction toward Bill and knows that it has been over two years since their last professional encounter, she also wants to think about all the ethical considerations that would come into play if she were to date and pursue an intimate relationship with Bill. What important ethical issue will Diane have to consider?

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Social Work Case Scenario

Answer:

NASW Code of Ethics

1.09 Sexual Relationships

c) Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers‐‐not their clients‐‐who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.

Social Work Case Scenario

• If Diane decides to pursue a relationship with Bill it will be up to her to demonstrate that there has been no undue harm to him or Susan.

• Diane should document the process and the appropriate precautions taken to establish that she has acted thoughtfully and with care.

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Physical Therapy Case Scenario

Case

• Steve is a new PT in a busy regional health center. The PT department has just installed a set of new recumbent semi‐elliptical cross trainers and Steve has not demonstrated sufficient competency in the use of these trainers yet. This morning a patient has turned up with a prescription for elliptical exercise.

• What is the best course of action for Steve to take in this case?

Physical Therapy Case Scenario

Answer:• Steve should ask a supervisor or a more experienced

colleague for help rather than risk injury to his patient. He should also familiarize himself with the new equipment.

• Principle 6B of the Code of Ethics for the Physical Therapist clearly states that physical therapists should “take responsibility for their professional development based on critical self‐assessment and reflection on changes in physical therapist practice, education, healthcare delivery, and technology.”

• Principle 3C states that physical therapists “shall make judgments within their scope of practice and level of expertise and shall communicate with, collaborate with, or refer to peers or other healthcare professionals when necessary.”

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Case Management Scenario

Case

• The patient, Mr. Howard is terminally ill with a malignant pancreatic tumor. He is on life support, unconscious, and unresponsive to the treatment. The healthcare team in charge of Mr. Howard decides that continuing his treatment is not helping but only prolonging his suffering instead. Mr. Howard’s immediate family members including his healthcare proxy are extremely religious and insist on continued aggressive, life‐prolonging treatment to preserve the sanctity of his life.

• a) As a case manager on the healthcare team would you go along with the recommendation to terminate Mr. Howard’s treatment?

• b) What ethical factor should determine the next step in Mr. Howard’s treatment?

Case Management Scenario

Answer:

a) In the face of an existing healthcare proxy appointed by Mr. Howard you, along with the rest of the healthcare team, will have no choice but to honor the wishes of the proxy.

b) The principal of autonomy applies here. In this case the autonomy is extended to the healthcare proxy appointed by Mr. Howard.

This situation is very common in medical practice and can be extremely frustrating for the professionals involved. However, ethical and legal considerations would favor the wishes of the healthcare proxy and members of the family acting in good faith to determine Mr. Howard’s wishes for further treatment.

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Dietitian Case Scenario

Case

• A 36‐year‐old female presents with numbness, tingling and sensory loss in her hands and feet, weakness in the lower limbs, and disequilibrium, with difficulty in writing, gait, walking up and down stairs, driving. She was a dance‐master, and after three months she was not able to work. She has no significant past medical history but reveals that she has followed a strict vegan diet for years.

– 1) What is the most likely explanation for the patient’s symptoms?

– 2) As a dietitian, what would you recommend to the patient to alleviate her symptoms?

– 3) What would your dietary advice to the patient be, keeping in mind professional ethics as a dietary professional, particularly Principal 1 (Non‐Maleficence) and one or more of the standards under Principal 1?

Dietitian Case ScenarioAnswer:

a) The patient most likely has severe nutritional deficiencies.

b) After confirming the specific deficiencies the patient should be given nutritional supplementation and dietary advice.

c) As a dietary professional you are free to compare and contrast the different dietary regimens and nutritional supplements that are available without coercing the patient to change her preferences. . In doing so you must adhere to Principle 1 of Academy/CDR Code of Ethics for the Nutrition and Dietetics Profession: Competence and professional development in practice (Non‐Maleficence).

In discussing the patient’s dietary regimen and possible nutritional deficiencies you must provide nutritional information that is evidence based. Any suggestions to address such deficiencies must comport with the patient’s choice of dietary regimen (Principle 1e: Make evidence‐based practice decisions, taking into account the unique values and circumstances of the patient/client and community, in combination with the practitioner’s expertise and judgment.

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Dietitian Case Scenario

• The discussion on nutritional supplements must proceed in a respectful and sensitive manner keeping in mind that dietary preferences are as diverse as the individuals that practice them (Principle 1g: Act in a caring and respectful manner, mindful of individual differences, cultural, and ethnic diversity.)

• This is an exercise of professional knowledge and expertise applied while respecting the autonomy of the patient.

• Discussion:

• Individuals on a Vegan diet are particularly susceptible to nutritional deficiencies. The most common deficiencies are involving Vitamins B12 and D3 and nutrients like Omega‐3 fatty acids, Zinc, and Iron.

Controversies In Medical Ethics

Physician‐assisted suicide:

• If we respect autonomy, can we deny a patient’s request to die?

• Should doctors, traditionally committed to prolonging life, be involved in assisted suicide?

• How can providers honor the conflicting requirements of non‐maleficence, beneficence, and autonomy at the same time with this issue?

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Conflicts of interest:

• Informed consent and patient autonomy requires providers to tell patients what matters to their decision‐making

• This should include the potential for conflicts of interest such as provider relationships with drug companies.

• Here, truthfulness is a primary ethical issue.


Relief of suffering at the end of life:

• To honor the principle of beneficence, providers should try to relieve suffering at to the best of their ability.

• However, some of the drugs that relieve suffering at the end of life can also hasten death. The double‐effect rule helps you make decisions in these difficult situations.

• The doctrine of double effect is often invoked to explain the permissibility of an action that causes a serious harm, such as the death of a human being, as a side effect of promoting some good end.

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Medical mistakes:

• Mistakes happen in all walks of life. But medical mistakes have the potential for hurting people and thereby violating the principle of non‐maleficence.

• Learning how to prevent mistakes, openly reporting mistakes, and learning from mistakes help you to respect the principles of non‐maleficence, justice, and beneficence.


Confidentiality:

• All four principles play a part in this issue.

• Can a patient’s medical information be kept confidential in the electronic age?

• When can confidentiality be breached? And who is allowed access to confidential information?

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Healthcare rationing:

• Justice is the principle that applies in this issue.

• How can we fairly allocate limited healthcare resources to as many people as possible, without limiting resources to those who currently have them?

• Is it possible to reach a bare minimum of care for all?


Stem cell and genetic research:

• The frontiers of medicine exist in research. How can we balance beneficence and justice if embryos must be destroyed to perhaps find cures for devastating diseases?

• Should a patient know everything there is to know about his health and potential health risks? And can research be harmful to some in order to benefit many?

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• Should organs for transplantation be able to be

purchased?

• Should people suffering from a genetic disease,

where future misery is predicted, be allowed to

have children?

• Should individuals be allowed to use scarce

healthcare resources when death is inevitable?

Code Of Ethics: Nursing

• American Nurses Association Code of Ethics for Nurses 2016• Provision 1 The nurse practices with compassion and respect for inherent

dignity, worth and unique attributes of every person.

• Provision 2 The nurse’s primary commitment is to the patient, whether an individual, family group, community or population

• Provision 3 The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

• Provision 4 The nurse has authority, accountability, and responsibility for nursing practice: makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.

• Provision 5 The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.

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Code Of Ethics: Nursing

• Provision 6 The nurse, through individual and collective effort, establishes, maintains , and improves the ethical environment of the work settings and conditions of employment that are conducive to safe, quality health care.

• Provision 7 The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.

• Provision 8 The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities.

• Provision 9 The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

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State Practice Differences for Nurse Practitioners

Full Scope of Practice

• In states with full scope of practice laws, nurse practitioners are allowed to:

• Evaluate and diagnose patients

• Order and interpret diagnostic tests

• Treat patients from start to finish, including prescribing medications

• Nurse practitioners are given full scope of practice under the exclusive authority of the state board of nursing and without physician oversight.

State Practice Differences for Nurse Practitioners

Reduced Scope of Practice

• Reduced scope of practice, under a regulated collaborative agreement, allows nurse practitioners to diagnose and treat patients but requires physician oversight to prescribe medications.

Restricted Scope of Practice

• In states with restricted scope of practice, nurse practitioners are required to have physician oversight to treat and diagnose patients and to prescribe medications.

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A pharmacist respects the covenantal relationship between the patient and pharmacist.Considering the patient‐pharmacist relationship as a covenant means that a pharmacist has moral obligations in response to the gift of trust received from society. In return for this gift, a pharmacist promises to help individuals achieve optimum benefit from their medications, to be committed to their welfare, and to maintain their trust.A pharmacist promotes the good of every patient in a caring, compassionate, and confidential manner.A pharmacist places concern for the well‐being of the patient at the center of professional practice. In doing so, a pharmacist considers needs stated by the patient as well as those defined by health science. A pharmacist is dedicated to protecting the dignity of the patient. With a caring attitude and a compassionate spirit, a pharmacist focuses on serving the patient in a private and confidential manner.A pharmacist respects the autonomy and dignity of each patient.A pharmacist promotes the right of self‐determination and recognizes individual self‐worth by encouraging patients to participate in decisions about their health.

A pharmacist acts with honesty and integrity in professional relationships.A pharmacist has a duty to tell the truth and to act with conviction of conscience. A pharmacist avoids discriminatory practices, behavior or work conditions that impair professional judgment, and actions that compromise dedication to the best interests of patients.A pharmacist maintains professional competence.A pharmacist has a duty to maintain knowledge and abilities as new medications, devices, and technologies become available and as health information advances.A pharmacist respects the values and abilities of colleagues and other health professionals.When appropriate, a pharmacist asks for the consultation of colleagues or other health professionals or refers the patient. A pharmacist acknowledges that colleagues and other health professionals may differ in the beliefs and values they apply to the care of the patient.A pharmacist serves individual, community, and societal needs.The primary obligation of a pharmacist is to individual patients. However, the obligations of a pharmacist may at times extend beyond the individual to the community and society. In these situations, the pharmacist recognizes the responsibilities that accompany these obligations and acts accordingly.A pharmacist seeks justice in the distribution of health resources.When health resources are allocated, a pharmacist is fair and equitable, balancing the needs of patients and society.

A pharmacist communicates with patients in terms that are understandable. In all cases, a pharmacist respects personal and cultural differences among patients.

THE PHARMACY CODE OF ETHICS

CODE OF ETHICS: SOCIAL WORK

Code of Ethics of the National Association of Social WorkersEthical principles based on social work’s core values of service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. These principles set forth ideals to which all social workers should aspire.

• Value: Service

• Ethical Principle: Social workers’ primary goal is to help people in need and to address social problems.

• Social workers elevate service to others above self‐interest. Social workers draw on their knowledge, values, and skills to help people in need and to address social problems. Social workers are encouraged to volunteer some portion of their professional skills with no expectation of significant financial return (pro bono service).

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• Value: Social Justice• Ethical Principle: Social workers challenge social injustice. • Social workers pursue social change, particularly with and

on behalf of vulnerable and oppressed individuals and groups of people. Social workers’ social change efforts are focused primarily on issues of poverty, unemployment, discrimination, and other forms of social injustice. These activities seek to promote sensitivity to and knowledge about oppression and cultural and ethnic diversity. Social workers strive to ensure access to needed information, services, and resources; equality of opportunity; and meaningful participation in decision making for all people.


• Value: Dignity and Worth of the Person• Ethical Principle: Social workers respect the inherent

dignity and worth of the person. Social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients’ socially responsible self‐determination. Social workers seek to enhance clients’ capacity and opportunity to change and to address their own needs. Social workers are cognizant of their dual responsibility to clients and to the broader society. They seek to resolve conflicts between clients’ interests and the broader society’s interests in a socially responsible manner consistent with the values, ethical principles, and ethical standards of the profession.

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Code Of Ethics: Social Work

• Value: Importance of Human Relationships

• Ethical Principle: Social workers recognize the central importance of human relationships.

• Social workers understand that relationships between and among people are an important vehicle for change. Social workers engage people as partners in the helping process. Social workers seek to strengthen relationships among people in a purposeful effort to promote, restore, maintain, and enhance the wellbeing of individuals, families, social groups, organizations, and communities.


• Value: Integrity

• Ethical Principle: Social workers behave in a trustworthy manner.

• Social workers are continually aware of the profession’s mission, values, ethical principles, and ethical standards and practice in a manner consistent with them. Social workers act honestly and responsibly and promote ethical practices on the part of the organizations with which they are affiliated.

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• Value: Competence

• Ethical principle: Social workers practice within their areas of competence and develop and enhance their professional expertise.

• Social workers continually strive to increase their professional knowledge and skills and to apply them in practice.

• Social workers should aspire to contribute to the knowledge base of the profession.

https://www.socialworkers.org/About/Ethics/Code‐of‐Ethics/Code‐of‐Ethics‐English

CODE OF ETHICS:PHYSICAL THERAPY

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CODE OF ETHICS: PHYSICAL THERAPY

CODE OF ETHICS: PHYSICAL THERAPY

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(Commission for Case Management Certification, 2015)PreambleCase management is a professional, collaborative and interdisciplinary practice guided by the Code of Professional Conduct (the Code).The objective of the is to protect the public interest. The Code consists of Principles, Rules of Conduct, and Standards for Professional Conduct, as well as the Commission for Case Manager Certification (CCMC) Procedures for Processing Complaints.The Principles provide normative guidelines and are advisory in nature. The Rules of Conduct and the Standards for Professional Conduct prescribe the level of conduct required of every Board‐Certified Case Manager (“CCM®”). Compliance with these levels of conduct is mandatory. Board‐Certified Case Managers (CCMs) who become aware of unethical behavior of others are obligated to report such alleged infractions. Enforcement will be through the CCMC Procedures for Processing Complaints. In addition, BoardCertified Case Managers (CCMs) who face ethical dilemmas regarding their own practice and/or ethical challenges that arise in the course of professional practice are encouraged to consult the Code frequently for advice. An opinion can be requested from CCMC’s Ethics & Professional Conduct Committee...Board‐Certified Case Managers (CCMs) recognize that their actions or inactions can aid or hinder clients in achieving their objectives. Board‐Certified Case Managers (CCMs) accept responsibility for their behavior. Board‐Certified Case Managers (CCMs) may be called upon to provide a variety of services and they are obligated to do so in a manner that is consistent with their education, skills, moral character, and within the boundary of their competence and experience. In providing services, Board‐Certified Case Managers (CCMs) must adhere to the Code of Professional Conduct for Case Managers as well as the professional code of ethics for their specific professional discipline...

PrinciplesPRINCIPLE 1: Board‐Certified Case Managers (CCMs) will place the public interest above their own at all times.PRINCIPLE 2: Board‐Certified Case Managers (CCMs) will respect the rights and inherent dignity of all of their clients.PRINCIPLE 3: Board‐Certified Case Managers (CCMs) will always maintain objectivity in their relationships with clients.PRINCIPLE 4: Board‐Certified Case Managers (CCMs) will act with integrity and fidelity with clients and others.PRINCIPLE 5: Board‐Certified Case Managers (CCMs) will maintain their competency at a level that ensures their clients will receive the highest quality of service.PRINCIPLE 6: Board‐Certified Case Managers (CCMs) will honor the integrity of the CCM designation and adhere to the requirements for its use.PRINCIPLE 7: Board‐Certified Case Managers (CCMs) will obey all laws and regulations.PRINCIPLE 8: Board‐Certified Case Managers (CCMs) will help maintain the integrity of the Code, by responding to requests for public comments to review and revise the code, thus helping ensure its consistency with current practice.

CODE OF PROFESSIONAL CONDUCT FOR CASE MANAGERS

CCMC Rules Of ConductViolation of any of these rules may result in disciplinary action by the Commission up to and including revocation of the individual’s certification.RULE 1: A Board‐Certified Case Manager (CCM) will not intentionally falsify an application or other documents.RULE 2: A Board‐Certified Case Manager (CCM) will not be convicted of a felony.RULE 3: A Board‐Certified Case Manager (CCM) will not violate the code of ethics governingthe profession upon which the individual’s eligibility for the CCM designation is based.RULE 4: A Board‐Certified Case Manager (CCM) will not lose the primary professional credential upon which eligibility for the CCM designation is based.RULE 5: A Board‐Certified Case Manager (CCM) will not violate or breach the Standards for Professional Conduct.RULE 6: A Board‐Certified Case Manager (CCM) will not violate the rules and regulations governing the taking of the certification examination and maintenance of CCM Certification.Standards For Board‐Certified Case Manager (CCM) ConductSECTION 1: THE CLIENT ADVOCATEBoard‐Certified Case Managers (CCMs) will serve as advocates for their clients and perform a comprehensive assessment to identify the client’s needs; they will identify options and provide choices,

when available and appropriate.

SECTION 2: PROFESSIONAL RESPONSIBILITYS 1 — REPRESENTATION OF PRACTICEBoard‐Certified Case Managers (CCMs) will practice only within the boundaries of their role or competence, based on their education, skills, and professional experience. They will not misrepresent their role or competence to clients.S 2 — COMPETENCECase Management competence is the professional responsibility of the Board‐Certified Case Manager, and is defined by educational preparation, ongoing professional development, and related work experience.S 3 — REPRESENTATION OF QUALIFICATIONSBoard‐Certified Case Managers (CCMs) will represent the possession of the CCM credential to imply the depth of knowledge, skills, and professional capabilities as intended and demonstrated by the achievement of board certification.S 4 — LEGAL AND BENEFIT SYSTEM REQUIREMENTSBoard‐Certified Case Managers (CCMs) will obey state and federal laws and the unique requirements of the various reimbursement systems by which clients are covered.S 5 — USE OF CCM DESIGNATIONThe designation of Certified Case Manager and the initials “CCM” may only be used by individuals currently certified by the Commission for Case Manager Certification. The credential is only to be used by the individual to whom it is granted, and cannot be transferred to another

individual or applied to an organization.


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S 6 — CONFLICT OF INTERESTBoard‐Certified Case Managers (CCMs) will fully disclose any conflict of interest to all affected parties, and will not take unfair advantage of any professional relationship or exploit others for personal gain. If, after full disclosure, an objection is made by any affected party, the BoardCertified Case Manager (CCM) will withdraw from further participation in the case.S 7 — REPORTING MISCONDUCTAnyone possessing knowledge not protected as confidential that a Board‐Certified Case Manager (CCM) may have committed a violation as to the provisions of this Code is required to promptly report such knowledge to CCMC.S 8 — COMPLIANCE WITH PROCEEDINGSBoard‐Certified Case Managers (CCMs) will assist in the process of enforcing the Code by cooperating with inquiries, participating in proceedings, and complying with the directives of the Ethics & Professional Conduct Committee.SECTION 3: CASE MANAGER/CLIENT RELATIONSHIPSS 9 — DESCRIPTION OF SERVICESBoard‐Certified Case Managers (CCMs) will provide the necessary information to educate and empower clients to make informed decisions. At a minimum, Board‐Certified Case Managers (CCMs) will provide information to clients about case management services, including a description of services, benefits, risks, alternatives and the right to refuse services. Where applicable, Board‐Certified Case Managers (CCMs) will also provide the client with information about the cost of case management services prior to initiation of such services.S 10 — RELATIONSHIPS WITH CLIENTSBoard‐Certified Case Managers (CCMs) will maintain objectivity in their professional relationships, will not impose their values on their clients, and will not enter into a relationship with a client (business, personal, or otherwise) that interferes with that objectivity.

S 11 — TERMINATION OF SERVICESPrior to the discontinuation of case management services, Board‐Certified Case Managers (CCMs) will document notification of discontinuation to all relevant parties consistent with applicable statutes and regulations.

SECTION 4: CONFIDENTIALITY, PRIVACY, SECURITY AND RECORDKEEPING S 12 — LEGAL COMPLIANCEBoard‐Certified Case Managers (CCMs) will be knowledgeable about and act in accordance with federal, state, and local laws and procedures related to the scope of their practice regarding client consent, confidentiality, and the release of information. S 13 — DISCLOSUREBoard‐Certified Case Managers (CCMs) will inform the client that information obtained through the relationship may be disclosed to third parties, as prescribed by law. S 14 — CLIENT PROTECTED HEALTH INFORMATIONAs required by law, Board‐Certified Case Managers (CCMs) will hold as confidential the client’s protected health information, including data used for training, research, publication, and/or marketing unless a lawful, written release regarding this use is obtained from the client/legal representative.


S 15 — RECORDSBoard‐Certified Case Managers (CCMs) will maintain client records, whether written, taped, computerized, or stored in any other medium, in a manner designed to ensure confidentiality.S 16 — ELECTRONIC MEDIABoard‐Certified Case Managers (CCMs) will be knowledgeable about, and comply with, the legal requirements for privacy, confidentiality and security of the transmission and use of electronic health information. Board‐Certified Case Managers (CCMs) will be accurate, honest, and unbiased in reporting the results of their professional activities to appropriate third parties.S 17 — RECORDS: MAINTENANCE/STORAGE AND DISPOSALBoard‐Certified Case Managers (CCMs) will maintain the security of records necessary for rendering professional services to their clients and as required by applicable laws, regulations, or agency/institution procedures, (including but not limited to secured or locked files, data encryption, etc.). Subsequent to file closure, records will be maintained for the number of years consistent with jurisdictional requirements or for a longer period during which maintenance of such records is necessary or helpful to provide reasonably anticipated future services to the client. After that time, records will be destroyed in a manner assuring preservation of confidentiality, such as by shredding or other appropriate means of destruction.SECTION 5: PROFESSIONAL RELATIONSHIPSS 18 — TESTIMONYBoard‐Certified Case Managers (CCMs), when providing testimony in a judicial or non‐ judicial forum, will be impartial and limit testimony to their specific fields of expertise.

S 19 — DUAL RELATIONSHIPSDual relationships can exist between the Board‐Certified Case Manager and the client, payor, employer, friend, relative, research study and/or other entities. All dual relationships and the nature of those relationships must be disclosed by describing the role and responsibilities of the Board‐Certified Case Manager (CCM).S 20 — UNPROFESSIONAL BEHAVIORIt is unprofessional behavior if the Board‐Certified Case Manager (CCM):• commits a criminal act;• engages in conduct involving dishonesty, fraud, deceit, or misrepresentation;• engages in conduct involving discrimination against a client because of race, ethnicity, religion, age, gender, sexual orientation, national origin, marital status, or disability/ handicap;• fails to maintain appropriate professional boundaries with the client;• engages in sexually intimate behavior with a client; or accepts as a client an individual with whom the BoardCertified Case Manager (CCM) has been sexually intimate;• inappropriately discloses information about a client via social media or other means.S 21 — FEESBoard‐Certified Case Managers (CCMs) will advise the referral source/payor of their fee structure in advance of the rendering of any services and will also furnish, upon request, detailed, accurate time and expense records. No fee arrangements will be made that could

compromise health care for the client.


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S 22 — ADVERTISINGBoard‐Certified Case Managers (CCMs) who describe/ advertise services will do so in a manner that accurately informs the public of the skills and expertise being offered. Descriptions/advertisements by a Board‐Certified Case Manager (CCM) will not contain false, inaccurate, misleading, out‐of‐context, or otherwise deceptive material or statements. If statements from former clients are used, the Board‐Certified Case Manager (CCM) will have a written, signed, and dated release from these former clients. All advertising will be factually accurate and will not contain exaggerated claims as to costs and/or results.S 23 — SOLICITATIONBoard‐Certified Case Managers (CCMs) will not reward, pay, or compensate any individual, company, or entity for directing or referring clients, other than as permitted by law and/or corporate policy.S 24 — RESEARCH: LEGAL COMPLIANCEBoard‐Certified Case Managers (CCMs) will plan, design, conduct, and report research in a manner that reflects cultural sensitivity; is culturally appropriate; and is consistent with pertinent ethical principles, federal and state laws, host institution regulations, and scientific standards governing research with human participants.S 25 — RESEARCH: SUBJECT PRIVACYBoard‐Certified Case Managers (CCMs) who collect data, aid in research, report research results, or make original data available will protect the identity of the respective subjects unless appropriate authorizations from the subjects have been

obtained as required by law


(eatright.org. Academy of Nutrition and Dietetics, 2018)Preamble:When providing services the nutrition and dietetics practitioner adheres to the core values of customer focus, integrity, innovation, social responsibility, and diversity. Science‐based decisions, derived from the best available research and evidence, are the underpinnings of ethical conduct and practice.This Code applies to nutrition and dietetics practitioners who act in a wide variety of capacities, provides general principles and specific ethical standards for situations frequently encountered in daily practice. The primary goal is the protection of the individuals, groups, organizations, communities, or populations with whom the practitioner works and interacts.The nutrition and dietetics practitioner supports and promotes high standards of professional practice, accepting the obligation to protect clients, the public and the profession; upholds the Academy of Nutrition and Dietetics (Academy) and its credentialing agency the Commission on Dietetic Registration (CDR) Code of Ethics for the Nutrition and Dietetics Profession; and shall report perceived violations of the Code through established processes.The Academy/CDR Code of Ethics for the Nutrition and Dietetics Profession establishes the principles and ethical standards that underlie the nutrition and dietetics practitioner’s roles and conduct. All individuals to whom the Code applies are referred to as “nutrition and dietetics practitioners.” By accepting membership in the Academy and/or accepting and maintaining CDR credentials, all nutrition and dietetics practitioners agree to abide by the Code.

Principles and Standards:1. Competence and professional development in practice (Non‐maleficence)Nutrition and dietetics practitioners shall:

a. Practice using an evidence‐based approach within areas of competence, continuously develop and enhance expertise, and recognize limitations.b. Demonstrate in depth scientific knowledge of food, human nutrition and behavior.c. Assess the validity and applicability of scientific evidence without personal bias.d. Interpret, apply, participate in and/or generate research to enhance practice,innovation, and discovery.e. Make evidence‐based practice decisions, taking into account the unique valuesand circumstances of the patient/client and community, in combination with thepractitioner’s expertise and judgment.f. Recognize and exercise professional judgment within the limits of individualqualifications and collaborate with others, seek counsel, and make referrals asappropriate.g. Act in a caring and respectful manner, mindful of individual differences, cultural,and ethnic diversity.h. Practice within the limits of their scope and collaborate with the inter‐professionalteam.2. Integrity in personal and organizational behaviors and practices (Autonomy)Nutrition and dietetics practitioners shall:a. Disclose any conflicts of interest, including any financial interests in products or services that are recommended. Refrain from accepting gifts or services which potentially influence or which may give the appearance of influencing professional judgment.

CODE OF ETHICS FOR DIETETICS PRACTITIONERS

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Comply with all applicable laws and regulations, including obtaining/maintaining a state license or certification if engaged in practice governed by nutrition and dietetics statutes.c. Maintain and appropriately use credentials.d. Respect intellectual property rights, including citation and recognition of theideasand work of others, regardless of the medium (e.g. written, oral, electronic).e. Provide accurate and truthful information in all communications.f. Report inappropriate behavior or treatment of a patient/client by another nutritionand dietetics practitioner or other professionals.g. Document, code and bill to most accurately reflect the character and extent ofdelivered services.h. Respect patient/client’s autonomy. Safeguard patient/client confidentialityaccording to current regulations and laws.i. Implement appropriate measures to protect personal health information usingappropriate techniques (e.g., encryption).3. Professionalism (Beneficence)Nutrition and dietetics practitioners shall:a. Participate in and contribute to decisions that affect the well‐being of patients/clients.b. Respect the values, rights, knowledge, and skills of colleagues and other professionals.c. Demonstrate respect, constructive dialogue, civility and professionalism in allcommunications, including social media.d. Refrain from communicating false, fraudulent, deceptive, misleading, disparaging

or unfair statements or claims.

Uphold professional boundaries and refrain from romantic relationships with anypatients/clients, surrogates, supervisees, or students.f. Refrain from verbal/physical/emotional/sexual harassment.g. Provide objective evaluations of performance for employees, coworkers, andstudents and candidates for employment, professional association memberships, awards, or scholarships, making all reasonable efforts to avoid bias in the professional evaluation of others.h. Communicate at an appropriate level to promote health literacy.i. Contribute to the advancement and competence of others, including colleagues,students, and the public.4. Social responsibility for local, regional, national, global nutrition and well‐being (Justice)Nutrition and dietetics practitioners shall:a. Collaborate with others to reduce health disparities and protect human rights.b. Promote fairness and objectivity with fair and equitable treatment.c. Contribute time and expertise to activities that promote respect, integrity, andcompetence of the profession.d. Promote the unique role of nutrition and dietetics practitioners.e. Engage in service that benefits the community and to enhance the public’s trust inthe profession.f. Seek leadership opportunities in professional, community, and service organizations

to enhance health and nutritional status while protecting the public.

CODE OF ETHICS FOR DIETETICS PRACTITIONERS

Thank You!

Rajinder Hullon, M.D., [email protected]

© INR (Institute for Natural Resources), 2019

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Continuing Education Seminar

INR Corporation NAME_____________________________________________ (please print) DATE _____________________________________________

Examination PROFESSION ______________________________________

Course Title: Medical Ethics & Legal Issues SEMINAR LOCATION:_______________________________ INSTRUCTOR: _____________________________________

For each item below please circle the correct response. Circle only one response per item. 1. The four major principles of medical ethics are: a) Autonomy, beneficence, non-maleficence and justice b) Privacy, autonomy, beneficence and justice c) Autonomy, beneficence, universality and justice d) Autonomy, beneficence, non-maleficence and morality e) Autonomy, morality, veracity and goodwill 2. The most important consideration regarding the information in informed consent is that: a) It be understood by the patient b) It must be communicated free of emotion c) It must be technically accurate d) It must be delivered in writing e) It must be strictly medical 3. What should you do if you recognize a conflict between the known wishes of a patient and the decision of their surrogate (the patient has recently become incompetent)? a) Immediately call the police b) Refer the matter to superiors c) First, harm the surrogate, then the patient d) First, do no harm, but be ready to seek court intervention e) First, do no harm, then contact parents or guardians 4. Autonomy is: a) Selfishness b) The right to be selfish c) Self-awareness d) Self-promotion e) Self-governance 5. Which of the following refers to the behaviors the medical professionals with moral integrity are expected to exhibit? a) Courtesy b) Mores c) Customs d) Medical ethics e) None of the above

6. The three issues that determine an incident of battery are:

a) The patient has been given false information about a treatment

b) The patient is judged incompetent to consent to treatment and has received improper care

c) Care that the patient has refused is forced upon them without court authorization

d) All of the above e) None of the above

7. ______________ is an ethical principle that states that communication between a patient and a provider must remain private.

a) Autonomy b) Honesty c) Consent d) Confidentiality e) HIPAA 8. ______________ is the major principle of medical ethics that states that physicians and other medical professionals must act in the best interest of the patient. a) Justice b) Autonomy c) Non-maleficence d) Beneficence e) Veracity 9. The principles of ____________ and ___________ must be balanced to be certain that any risks involved in medical treatment or procedures are outweighed by the benefit to the patient. a) Autonomy and privacy b) Dignity and justice c) Beneficence and non-maleficence d) Ethics and beneficence e) Morality and virtue

10. ___________ is the ethical principle most applicable to the highly publicized issue of universal healthcare. a) Justice b) Autonomy c) Non-maleficence d) Beneficence e) Value

Continuing Education Seminar

INR Corporation NAME_____________________________________________ (please print) DATE _____________________________________________

Examination PROFESSION ______________________________________

Course Title: Medical Ethics & Legal Issues SEMINAR LOCATION:_______________________________ INSTRUCTOR: _____________________________________

For each item below please circle the correct response. Circle only one response per item. 11. A __________ system is a process by which treatment is prioritized based on needed personnel and those who are most critically ill or injured. a) Disaster b) Quarantine c) Pandemic d) Triage e) Honor 12. “Actions that can be taken to help prevent or remove harms or to simply improve the situation of others" are: a) Beneficent actions b) Confidentiality maintaining actions c) Use of evidence based medicine d) All of the above e) None of the above 13. Which of the following actions helps to ensure patient confidentiality?

a) Discarding old records by throwing them into the trash

b) Verifying the phone number of the receiving location before faxing confidential material

c) Sending confidential material via e-mail d) All of the above e) None of the above 14. In which of the following situations can you release medical records? a) When ordered by a subpoena b) When asked by a certified insurance agent c) When dictated by law d) Both a and c e) All of the above 15. When confidential information is stored on a

computer, you should not? a) Leave the monitor unattended if confidential

information is displayed on it b) Send confidential information over e-mail c) Print confidential information on a shared printer d) Leave a printer unattended while printing

confidential material e) Do any of the above

16. The administration of a lethal agent by a person to a patient with an incurable disease or condition is called: a) Thanasia b) Thanatomania c) Euphoria d) Euthanasia e) None of the above 17. Who owns the physical medical record? a) Patient b) Court c) Physician d) Public e) Government 18. Permission from a patient to allow touching, examination,

or treatment by a healthcare professional is called: a) Consent b) Privilege c) Protocol d) Contract e) Standard of care 19. Which of the following is a durable power of attorney for making health care decisions? a) Health care proxy b) Geriatrics c) Curative care d) Palliative care e) Legal counsel

20. Informed consent is not required when: a) The procedure is simple and common b) There is a life-threatening emergency c) The patient’s mental status prevents a reasonable informed consent

d) All of the above e) None of the above

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Continuing Education Seminar INR Corporation NAME______________________________________________

(please print) DATE ______________________________________________

Questionnaire PROFESSION _______________________________________

Course Title: Medical Ethics & Legal Issues SEMINAR LOCATION:________________________________ INSTRUCTOR: ______________________________________

I. Please circle the appropriate number indicating the extent to which you agree or disagree with the following statements. The rating scale ranges from 1 to 5, where 1 = disagree and 5 = agree.

Strongly Disagree

Strongly Agree

A. The course content was consistent with stated learning objectives. 1 2 3 4 5 B. The course content was appropriate for the intended audience. 1 2 3 4 5 C. To what extent did you achieve each of the course’s major objectives?

1) define and distinguish between ethics, morals, and values. 1 2 3 4 5 2) describe and discuss the 4 principles of medical ethics. 1 2 3 4 5 3) identify the ethical obligations in a clinician-patient relationship. 1 2 3 4 5 4) explain the issues surrounding patient consent and confidentiality with respect to patient autonomy and HIPAA (Health Insurance Portability and Accountability Act).

1 2 3 4 5

5) discuss the lack of capacity of the patient and healthcare proxies. 1 2 3 4 5

6) examine the role of ethics in complex medical developments artificial intelligence and robotics.

1 2 3 4 5

D. The length of time to complete this course matches the number of CE credits approved. 1 2 3 4 5 E. The teaching and learning methods, including active learning strategies, were appropriate. 1 2 3 4 5 F. The instructor was knowledgeable of the subject and was well qualified. 1 2 3 4 5 G. The learning assessment activities, including the post-test, were appropriate. 1 2 3 4 5 H. Overall, the seminar met my educational needs, and the educational materials were useful. 1 2 3 4 5 I. Useful, new knowledge was presented at this program. 1 2 3 4 5 J. The physical facilities were conducive to learning. 1 2 3 4 5

____________________________________________________________________________________________________________________________________

II. I would recommend this course to a professional colleague. Yes ________ Not sure ________ No ________ III. I would recommend this instructor to a professional colleague. Yes ________ Not sure ________ No ________ IV. Did this course provide you with helpful and useful information to change your practice? Yes _______ No _______ If yes, how do you intend to change your practice?

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Copyright 2020, INR (Institute for Natural Resources). All Rights Reserved.

V. The presentation was balanced and free of commercial influence or bias. Yes ________ No________ If no, please explain: VI. How much did you learn as a result of this CE program? VII. How useful was the content of this CE program for your practice or other professional development? VIII. Please use this space for additional comments.

ME-07-19

Very Little

Great Deal

1 2 3 4 5

Not Useful

A Little Useful

Some what Useful

A Good Deal Useful

Extremely Useful

Category a: Home-study Books (Please complete the purchase form on page 8)

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*w/any purchase: “Addiction – 4th edition” *Limited to one per customerw/purchase of $99 or more: “Emotional & Social Intelligence – 2nd edition”w/purchase of $199 or more: Pain Relief (See page 8 for more details)

also v is i t WWW.INRSEMINARS.COMHealth UpdateHOME-STUDY COURSES

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Globesity: Ten Things You Didn’t Know Were Making You Fat by Clare Fleishman, MS, RD

5 CONTACT HOURS *Not for Dietetic (rD/rDN) creDit (credit available for other professions)It is estimated that 1.4 billion adults—one in three across the globe—are overweight. Registered dietitian and health writer Clare Fleishman explores surprising new suspects contributing to our planet’s expanding girth. This important work examines how we live in a new century and why obesity has become a major

killer from the American Midwest to the cities of Europe and across the deserts of Africa.

Healing Power of Sleep - 2nd Editionby Mary O’Brien, MD

5 CONTACT HOURSMillions of us struggle with sleep several nights a week, if not every night. In The Healing Power of Sleep, Dr. O’Brien explains the basics of sleep architecture, the effects of common illnesses on sleep, how our daily habits can help or hinder sleep, and straightforward solutions.

The Hungry Brainby Laura Pawlak, PhD, MS

5 CONTACT HOURSThe Hungry Brain explores new discoveries about the brain’s hunger for pleasure and calories—the so-called “irresistible” foods—and how one can control temptation. The book discusses the latest scientif ic f indings about nutrients that speed memory processing and protect against Alzheimer’s disease—including a brain homework plan and a

grocery list to make it happen!

Integrative Healingby Z Altug PT, DPT, MS, CSCS

4 CONTACT HOURS Connect your mind and body for maximum wellness with this beginner's guide to Eastern and Western philosophies of body movement. Licensed physical therapist and health writer, Dr. Ziya Altug shows you exactly how to achieve total wellness by incorporating mindfulness and meditative practice into a healthy lifestyle. His book is filled with practical exercise photographs, tables, checklists and charts to help

patients and clients track their progress toward their wellness goals. This book is one of the winners of the 2018 Clinician Non-Research Publication Award from the California Physical Therapy Association.

Love Me Trueby Jason B. Whiting, PhD, LMFT

4 CONTACT HOURSThis course will explore ways partners get caught in patterns of subtle and blatant deception. It will use fun stories from real couples and examples from research to examine how cognitive and emotional processes cause blindness and rationalization, and distort couples’ perceptions. This course will identify research-based strategies to increase trust and connection, and professionals can use this information

to identify and appropriately address issues related to self-deception and honesty in the individuals with whom they work.

Media Mazeby Eric Rasmussen, PhD

4 CONTACT HOURSThis course will explore the prevalence of children’s media use, many of the media effects that are of most concern to those interested in the well-being of youth, and the social scientific theories that explain how children’s brains cognitively and emotionally process media content. Finally, the course identifies specific strategies that can be taken to help youth avoid the potentially negative effects, and enjoy the potentially

positive effects, of media exposure.

Pain Reliefby David Cosio, PhD, ABPP

4 CONTACT HOURSHaving worked as a pain clinic psychologist for over 10 years, Dr. David Cosio shares a wealth of strategies for dealing with this evergrowing epidemic in everyday circumstances—without relying on addictive medications. Pain Relief combines new insights into the perception of pain with practical, interdisciplinary treatments. Discover key coping skills for helping people with chronic pain, steps to

creating a comprehensive pain management plan, and over 20 different available pain management modalities.

Screen Savvyby Ryan J. Anderson, PhD

4 CONTACT HOURSThis course will help the reader examine the impact of common digital media usage on individuals, families, and society. Course participants will learn about both positive and negative effects of modern media, and will explore the concerning trends of societal norms in this area. Readers will receive an in-depth explanation of process addictions and the phenomenon of Internet Gaming Disorder (IGD). Guidelines and strategies

for creating a sustainable relationship with digital media are set forth.

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Successful Aging - 2nd Editionby Mary O’Brien, MD

4 CONTACT HOURSThis home-study course describes the best ways to age healthfully and improve your patients’ quality of life at any age, including tips on how to cultivate a youthful attitude, safeguard against stress and chronic illness, improve dietary and exercise habits, maximize memory and beef up energy, enhance financial security, and live a long and rewarding life.

Sugar, Salt & Fat - 2nd Editionby Gina Willett, PhD, RD

4 CONTACT HOURSThis home-study course outlines the various factors that make foods palatable. It provides evidence that the "hyperpalatability" of our current food supply is undermining our normal satiety signals, motivating the drive to eat even when there is no physiologic need for food. This course presents evidence that repeated exposure to high quantities of palatable foods (i.e., those high in sugar, fat and salt) can

alter the brain in ways similar to drugs of abuse, essentially "rewiring" the brain to promote compulsive eating and loss of control over food.

Yoga Formaby Romy Phillips, MFA , E-RYT500, C-IAYT

*Not for ce creDit*Learn to use traditional yoga routines to relieve the pain from common injuries and conditions. With simple lists of asanas and sample sequences for different proficiency levels and physical limitations, this in-depth guide to teaching and sharing yoga is perfect for yoga instructors and fitness and healthcare professionals. Learn which specific poses to suggest for injury prevention as well as which to recommend for those

who are struggling with spinal or back injuries.

The Fearless Mindby Craig L. Manning, PhD

*Not for ce creDit*Life is a performance whether you're on the field, in the courtroom, or running a household. But many of us, when asked to perform, are overcome by fear. We lose our confidence and allow our insecurities to hinder us. In The Fearless Mind, sports psychologist Dr. Craig Manning will help you overcome your fears, expel anxiety, build confidence, and become a high-performing individual no matter what your field. Learn

how to unlock your mind and reach your greatest dreams. There are many mental pathways to performance, but there is only one pathway to true success having a fearless mind.

Weight Perfect - 3rd Editionby Mary O’Brien, MD

6 CONTACT HOURSThis home-study course describes the newest research on losing weight and maintaining weight loss for life. The book provides details about the connection between weight gain and medical conditions, and obesity and sleeplessness. It also gives information about popular weight loss plans, describes scientific studies on the effectiveness of these plans, and discusses research on the connection between

emotions, cravings and overeating.

Irritating the Ones You Love by Jeff Auerbach, PsyD

4 CONTACT HOURS Irritating the Ones You Love explores how “unconscious” reasons control so much of our choices and behavior in relationships—the hidden reasons we are drawn to particular partners, and how, unknowingly, the past affects our reactions in present situations. This book provides tools to help readers uncover the hidden influences on them so that they can choose partners for the “right” reasons, grow as human beings, stop

making the same mistakes when issues arise with their partner, and make their relationships more intimate and happy.

Living to be 100 - 2nd Editionby Michael Howard, PhD

4 CONTACT HOURSDo you want to live the longest, healthiest, happiest life you can with the best mental and physical functioning? This home-study course is literally about the secret to life: the lifestyle choices you can make that wll increase the odds of having the longest and healthiest life you can. You will find out that there are 16 lifestyle characteristics that these oldest people tend to have in common, no matter where they live in the world.

Major Depression & Bipolar Disorders - 3rd Editionby David Longo, PhD

4 CONTACT HOURSThis book contains a synopsis of the genetic, biological, and psychological theories pertaining to bipolar spectrum disorders. An update of diagnostic considerations, assessment instruments, and evidence-based treatment techniques commonly employed in diagnosing, assessing, and treating bipolar spectrum disorder patients is provided. The most recent literature is presented throughout the book

concerning the appropriate data-based applications, outcomes, and limitations of the assessment and treatment procedures.




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Category B: Good deals Home-study packages

...continued on next page



WEB_ Page 3 2012020

Category C: Hot topics 3 contact hours (Please complete purchase form on page 8)

Webinar Price $20Regular Price $30

• Addiction: Alternatives to Abstinence - 4th Ed. (B. Sternberg, PhD): Identifies the three major treatment models for addictive behaviors and a brief history of each: a) the moral model, b) the medical model, c) the harm reduction model.

• Alzheimer's - 3rd Ed. (M. O’Brien, MD): Describes Alzheimer’s disease. Identifies the 10 warning signs of Alzheimer’s disease.

• Antioxidants: A Balancing Act with Free Radicals - 3rd Ed. (N. Katz, MD, PhD): Identifies what free radicals and antioxidants are, their functions, and how they interact.

• Appetite Control & Suppression (G. Willett, PhD, RD): Describes how appetite is normally regulated. Cites how appetite can become dysregulated and contribute to weight gain and obesity.

• Autism - 3rd Ed. (N. Katz, MD, PhD & B. Sternberg, PhD): Describes the differences between the previous DSM-IV, and the current DSM-5 in terms of how autism, autism spectrum disorder (ASD), and related disorders are viewed and diagnosed,

• Brain Food - 3rd Ed. (A. St. Charles, PhD, RD, LDN): Discusses how foods and vitamins may improve memory and brain function. Describes how the DASH and Mediterranean diets may play a key role in brain health.

• Cancer Prevention - 4th Ed. (A. St. Charles, PhD, RD, LDN & M. O’Brien, MD): Describes the lifestyle and dietary changes that can help prevent the development of cancer. Discusses the benefits and drawbacks associated with some of the tools used to screen for cancer.

• Caring for Patients with Alzheimer’s & Other Dementias - 2nd Ed. (B. Sternberg, PhD): Lists methods to assist patients with memory and communication problems.

• Cognitive Behavior Therapy - 3rd Ed. (M. Howard, PhD): Identifies the major components of cognitive behavioral therapy and the causative relationship between environmental events, thoughts, emotions, and behavior.

• Diabetes: A Comprehensive Overview - 2nd Ed. (A. St. Charles, PhD, RD, LDN): Describes the key features of prediabetes, type 1, type 2, and gestational diabetes. Identifies the hormones involved in blood glucose control.

• Eating Right at Midlife & Beyond (A. St. Charles, PhD, RD, LDN): Identifies the physiological changes that typically occur with age. Outlines a healthy eating plan for older adults.

• Emotional & Social Intelligence - 2nd Ed. (B. Sternberg, PhD): Explains the concept of emotional intelligence. Describes the relationship between emotions and the brain. Explains the concept of social intelligence and its components.

• Fibromyalgia - 3rd Ed. (N. Katz, MD, PhD): Examines fibromyalgia treatments. Reviews the pathogenesis, etiology, and clinical presentation of fibromyalgia. Discusses the role of sleep disorders in the clinical management of fibromyalgia.

• Gluten & the Brain - 2nd Ed. (A. St. Charles, PhD, RD, LDN): Discusses the role gluten may play in contributing to celiac disease and non-celiac glucose sensitivity. Lists the main food sources of gluten.

Depression & the Brain by N. Katz, MD, PhD15 CONTACT HOURS Loss of Control: Fighting Back with Full Strength - 2nd Edition

by B. Sternberg, PhD (3 hrs) Neurotransmitters: The Bridges of the Brain - 2nd Edition (3 hrs) Poles Apart: Unipolar vs. Bipolar Depression - 3rd Edition (3 hrs) Achieving Remission in Depression - 3rd Edition (3 hrs) Eating Disorders - 3rd Edition (3 hrs)

Tranquility Time by N. Katz, MD, PhD15 CONTACT HOURS Stop Losing Sleep - 4th Edition (3 hrs) Stimulants: Caffeine, Amphetamines, etc. - 4th Edition (3 hrs) Anti-Anxiety Drugs - 4th Edition (3 hrs) Non-Traditional Approaches: Anxiety, Insomnia, & Depression -

4th Edition by B. Sternberg, PhD (3 hrs) Brain & Stress: PTSD & Adjustment Disorder - 4th Edition (3 hrs)

Women’s Healthby M. O’Brien, MD15 CONTACT HOURS Menopause - 5th Edition (3 hrs) Migraines & Headaches - 5th Edition (3 hrs) Insomnia - 5th Edition (3 hrs) Chronic Pain - 5th Edition (3 hrs) Depression - 5th Edition (3 hrs)




NEWLY

UPDATED!

NEWLY

UPDATED!

REMINDERS1. Health Update courses are approved by most licensing boards. Approvals may vary within each profession and each state. Books are approved for varying numbers of CE hours.

To claim CE credit, complete the examination and mail the examination page to BIOMED. Your diploma/certificate will be forwarded to you within three working days of receipt of your exam. It is your responsibility to notify your licensing board to receive credit.

2. Most home studies will be accepted up to three years after purchase. Although courses within a package may be “split” among several people, only one diploma will be issued per submitted exam. Only the original exam page will be accepted. BIOMED and most professional licensing boards will not accept photocopies or faxes of the examination page. Credit will not be issued for unused home studies. Copies of exam will be accepted for an additional fee based on the number of contact hours. Please attach check to copy. If you have any questions, please call BIOMED at (800)229-4997.

Single Home-study Courses Available Only from INR Webinars!Webinar Price $20 Regular Price $30 3 contact hours

(Please complete purchase form on page 8)

BIOMED

WEB_ Page 4 2012020

• Hospice & Palliative Care (M. O’Brien, MD): Discusses the goals and challenges involved in palliative care. Describes major symptoms encountered in terminal illness and treatment options.

• Humor & Healing - 2nd Ed. (B. Sternberg, PhD): Discusses the use of humor in health care settings and the role of humor for health care professionals.

• Inflammation - 3rd Ed. (A. St. Charles, PhD, RD, LDN): Differentiates between acute and chronic inflammation. Identifies the mechanisms of combating infection/disease.

• Irritable Bowel Syndrome - 4th Ed. (M. O’Brien, MD): Identifies the differences between functional gastrointestinal disorders and inflammatory bowel diseases.

• Keeping Balance & Preventing Falls - 3rd Ed. (M. Howard, PhD): Lists causes and health hazards of falls. Outlines methods of preventing falls among the elderly.

• Knee Pain - 4th Ed. (R. Hullon, MD, JD): Describes the anatomical structure of the knee. Identifies the different types of knee injuries and their manifestations. Differentiates between major and minor injuries and the causes of knee pain. Explains strategies for preventing knee pain.

• Leg & Foot Pain (W. Schroeder, PhD, OTR, & W. Dubner, DPM): Describes how leg and foot pathologies can impair functional ability. Outlines evidence-based interventions for each condition.

• Low Back Pain - 5th Ed. (R. Hullon, MD, JD): Defines low back pain. Describes the prevalence of this condition within the U.S. Identifies the different causes of low back pain. Describes some of the treatment approaches employed. Discusses ways to prevent low back pain.

• Medical Ethics - 4th Ed. (R. Hullon, MD, JD): Explains the issues surrounding patient consent, including formed consent, voluntary consent, and competent consent.

• The Mediterranean Diet - 3rd Ed. (A. St. Charles, PhD, RD, LDN): Describes the food-based guidelines that make up the Mediterranean pyramid. Explains the significance of physical activity, diet, and social interaction as part of the Mediterranean way of life.

• Memory Loss & Forgetfulness - 3rd Ed. (B. Sternberg, PhD): Identifies the memory changes that take place in normal aging. Discusses how mild cognitive impairment (MCI) differs from memory loss in normal aging and from dementia.

• Neck & Shoulder Pain - 3rd Ed. (R. Hullon, MD, JD): Defines the differences in presentation of signs and symptoms among neck and shoulder disorders.

• Omega-3 Fatty Acids - 3rd Ed. (N. Katz, MD, PhD): Covers the benefits and risks associated with the popular dietary supplement, omega-3 fatty acids. Examines the role of these acids in preventing heart disease and breast cancer and brain health.

• On Loss & Grief - 3rd Ed. (A. St. Charles, PhD, RD, LDN): Identifies emotional, cognitive, behavioral, social, and physical responses to loss. Discusses the role of grief counseling and when it may be useful.

• Osteoporosis (A. St. Charles, PhD, RD, LDN): Describes the signs and symptoms of osteoporosis and its main risk factors. Identifies the role of diet and exercise in the prevention and treatment of bone loss.

• Pet Therapy - 3rd Ed. (B. Sternberg, PhD): Describes the aspects of the relationship between humans and their pets that contribute to health and well-being.

• Positive Psychology - 3rd Ed. (B. Sternberg, PhD): Describes the origin and goals of the “positive psychology.” Lists the factors that contribute to happiness and life satisfaction.

• The Power of Walking - 2nd Ed. (M. O’Brien, MD & A. St. Charles, PhD, RD, LDN): Describes the health benefits of walking. Explains how walking can reduce the risk of various diseases, including diabetes, heart disease, cancer, depression, and dementia.

• Probiotics - 3rd Ed. (B. Sternberg, PhD & C. Fleishman MS, RD): Discusses how probiotics affect the healthy immune system. Identifies good food sources of probiotics and prebiotics.

• Psychology of Bullying - 3rd Ed. (B. Sternberg, PhD): Describes individual, family, and social factors related to child and youth bullying. Discusses cyber bullying and associated problems.

• Reducing Stress - 3rd Ed. (B. Sternberg, PhD): Explains how the body responds to and processes stress. Understands the impact of stress on risk for heart disease and the physiological mechanisms that may mediate this link. Identifies a number of interventions for reducing stress.

• Skin Care, Allergies, & Wrinkles - 3rd Ed. (B. Hayes, MD, PhD, FAAD): Explains the diagnosis and newest treatments for skin conditions and skin allergies. Describes new laser treatments for wrinkles and other skin conditions.

• Social Anxiety- 2nd Ed. (B. Sternberg, PhD): Defines social anxiety. Describes the symptoms, causes, and treatment strategies for social anxiety.

• Understanding Anxiety- 3rd Ed. (B. Sternberg, PhD): Explains the difference between normal anxiety and an anxiety disorder. Describes the causes of anxiety.

• Understanding Cholesterol - 2nd Ed. (A. St. Charles, PhD, RD, LDN): Lists the various lipid components of total cholesterol and describes how they are formed in the body. Describes the physiological function of each lipid faction.

• Vitamin D: Vitamin, Hormone, & Protector - 3rd Ed. (A. St. Charles, PhD, RD, LDN): Describes the role that vitamin D may play in the physiological function of various systems. Lists the current guidelines for supplementation of vitamin D.

• Vitamins, Minerals, & Supplements (A. St. Charles, PhD, RD, LDN): Identifies the vitamins and minerals needed for growth and normal development. Discusses the drawbacks/concerns of over-supplementation.

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Obesity, Diet, & Behaviorby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Explain the complex nature of body fat and why both too much and too little are deleterious to health. 2) Describe how genes, eating behavior, macronutrients, physiology, microorganisms, and the environment

interact to produce obesity. 3) Outline how the food industry’s production of hyperpalatable foods fuels sweet, fat, and salt addiction and the obesity epidemic. 4) Identify the most effective diets that could produce long-lasting results in weight loss.

Opioids & Marijuanaby Nikita Katz, PhD, MDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Outline the neurologic, genetic, and social mechanisms of opioid abuse, especially in relation to the nationwide, opioid health emergency. 2) List diagnostic signs and psychological “red flags” common in opioid abuse and opioid

overdose. 3) Summarize the current guidelines for the use of opioids in patients with acute and chronic pain. 4) List the parameters of opioid use and abuse to be documented in all clinical, dental, and health care settings. 5) Explain opioid replacement therapy and the use of opioid antagonists in acute overdose.

Probiotics, Food, & the Immune Systempresented by Laura Pawlak, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Identify the human microbiota, including benecial bacteria (probiotics). 2) Describe the effects of probiotics with regard to the digestive, nervous, and immune systems. 3) List the pro- and anti-inflammatory influences, including those

influences related to such substances as essential lipids and amino acids. 4) Compare and contrast approaches used to reduce inflammation. 5) Recognize ways to prevent disease and disability in the aging population.

PTSD, Trauma, & Anxiety Disordersby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe the structure and function of neurons, glia, neurotransmitters, and brain regions. 2) Explain how the brain produces and is affected by anxiety, trauma disorders, and depression. 3) Determine how stress

is the foundation for anxiety, PTSD (post-traumatic stress disorder), trauma, and many depressions. 4) Describe the new criteria for the diagnosis of PTSD, trauma disorders, and anxiety disorders.

The Science of Fat & Sugarby Laura Pawlak, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Identify metabolism and physiology of lipids and carbohydrates in health and disease as well as in the aged individual. 2) List the approaches to a patient suffering from metabolic disease from the nursing,

pharmacological, psychological, and physical therapy standpoints. 3) Compare and contrast appetite suppressants and other medications that induce weight loss. 4) Discuss the recent discoveries in neurochemistry and neuroscience of the link between behavioral pathology and metabolic disease. 5) Compare and contrast the healthy and the potentially dangerous weight loss strategies and long-term effects of fad diets.

The Sleep-Loss Epidemicby Raj Hullon, MD,JDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe the stages, cycling, and circadian rhythms of sleep. 2) Cite evidence connecting sleep deprivation and sleep disorders to heart disease, stroke, diabetes, and dementia. 3) List the major sleep medications

with their uses and adverse effects. 4) Describe the connection between dental pain and sleep disruption. 5) Cite the diagnostic criteria, symptoms, course, and treatment for the major sleep disorders.

Better Habits, Better Healthby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe how personality types, core beliefs, and behavioral habits affect chronic illness. 2) Discuss the most common chronic illnesses and the key factors in prevention and management. 3) Explain how stress, anxiety,

and depression influence chronic illnesses. 4) Describe practical behavioral habits for coping with disabling chronic conditions like pain, cancer, arthritis, and other diseases. 5) List ways to help patients develop healthier habits in terms of nutrition, activity, preventive medical and dental care, and emotional well-being.

Brain Health: Mood, Metabolism, & Cognitionby Gina Willett, Ph.D., R.D.VIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe key factors that are essential for a healthy brain, and how these impact both cognitive function and mental health. 2) Characterize Alzheimer’s disease as a neurodegenerative disorder of the brain; characterize

depression as a neuropsychiatric disorder of the brain. 3) Describe how obesity and diabetes impact cognitive and mental health.

Brain Trauma, Concussion, & Dementiaby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe the brain structures and functions that are most vulnerable to trauma. 2) Outline the major steps in assessing patients with brain trauma and predicting disability. 3) Discuss key clinical features of concussions,

penetrating head injuries, and blast injuries. 4) Describe the relationship between brain trauma and dementing illness such as Alzheimer’s and chronic traumatic encephalopathy. 5) Outline the rehabilitation strategies most likely to improve outcomes in patients with brain trauma. 6) Discuss the practical steps to prevent brain trauma from motor vehicle accidents, falls, and sports.

Coping with Chronic Pain by David Cosio, PhD, ABPPVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Explain the current state of pain management in the United States. 2) Describe the multidisciplinary approach to pain management. 3) Summarize the 23 different pain management modalities currently available. 4) Describe

steps to create a comprehensive pain management plan. 5) List the five key coping skills for helping chronic pain patients. 6) Discuss treatment options for chronic dental and facial pain.

The Gut-Brain Connectionby Gina Willett, PhD, RDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Explain the concept of the gut-brain axis, and its implications for health and disease. 2) Describe how microbes and their metabolites communicate with the body and the brain. 3) Explain how the microbiome-gut-

brain axis influences the development of neurodegenerative, neuropsychiatric, and neurodevelopmental disorders. 4) Describe how microbial metabolites regulate immune and metabolic pathways in the body, and how this may impact risk of allergies, autoimmune diseases, obesity and diabetes. 5) Explain how the ecology of the oral microbiome impacts both gut and systemic health; discuss implications for modern-day oral healthcare.

Inflammation, Chronic Illness, & the Brainpresented by Michelle Albers, PhD, RDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Identify clinical signs & symptoms of inflammation. 2) Demonstrate the connections between inflammatory processes and chronic illness. 3) Describe the role of inflammation in specific illnesses such as heart

disease, COPD, diabetes, arthritis and dementia. 4) List practical strategies to reduce levels of inflammation in clinical practice. 5) Explain the rationale for good dental prophylaxis and skin care in patients with chronic illness.

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Stress, Resilience, & Happinessby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe how perception, thinking, emotions, and memory combine to produce cognitive appraisals and behavior. 2) Outline the causes, components, and management of psychological stress. 3) Define resilience and

explain the factors that compose the ability to “bounce back” from stressful events 4) List the major components of the positive-psychology approach to increasing life satisfaction. 5) Determine the elements of happiness and optimism and how to apply them to increase well-being.

Understanding Addictionsby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe the main brain functions that contribute to addictive behavior. 2) Explain the major ways that addiction changes the brains of addicts. 3) Describe how drugs mimic and alter neurotransmitters which provoke the

psychological effects of addiction. 4) Explain the difference between drug dependence, tolerance, and addiction. 5) Describe the clinical consequences of addiction to food, opioids, street drugs, and alcohol. 6) List and compare the major treatment options for legal and illegal drug addictions.

Understanding Aging & Longevityby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe how the biopsychosocial model of health and how disease impacts aging, health, life span, and longevity. 2) Explain the differences between normal aging and age-related disease and their effects on life span

and longevity, including periodontal disease. 3) Determine the effects of genetics, epigenetics, and the environment on aging. 4) Describe how the body and brain age at the cellular, tissue, organ, and organ system levels. 5) Determine the causes of recent increases in life expectancy in the world and the United States.

Understanding Diabetesby Gina Willett, PhD, RDVIDEO PRESENTATION - 2 DVDS (6 contact hrs)Participants completing this course will be able to: 1) Compare and contrast the different forms of diabetes. 2) Explain why the number of cases of Type 2 diabetes is expanding worldwide. 3) Describe how gut health impacts metabolic health and diabetes risk. 4) Outline potential

complications of diabetes as well as appropriate interventions. 5) Characterize how insulin resistance and Type 2 diabetes are linked to other conditions such as cognitive decline, depression, cancer sleep disorders, and periodontal disease.

Understanding Mental Disordersby Michael E. Howard, PhDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) Describe how the brain produces behavior and how learned patterns of behavior become a personality. 2) List the personality disorders and explain how they disrupt relationships. 3) Determine how to diagnose and treat the

major anxiety disorders, including dental anxiety, and outline the effects of early life stress, medical disorders, and medications on anxiety. 4) Describe the characteristics of posttraumatic stress disorder and obsessive-compulsive disorder and explain why they are no longer grouped with anxiety disorders.

Understanding Painby Nikita Katz, PhD, MDVIDEO PRESENTATION - 1 DVD (6 contact hrs)Participants completing this course will be able to: 1) List the neurologic processes causing pain and suffering and the principles of pain assessment. 2) Discuss treatment modalities for primary and secondary headaches, including migraine and rare cephalagias.

3) List the “red flags” of medication abuse and approaches to reduce opioid addiction. 4) Describe the differential diagnosis of dental vs. cervical and cervicogenic pain and the appropriate intervention for both. 5) List steps involved in the diagnosis and management of spinal pain, including physical and occupation therapy.

Mindful Stress Reduction Practices by Kent HowardAvailable Format: VIDEO PRESENTATION - 1 DVD (not for cE crEdit) This DVD introduces stress reduction techniques using: Tai Chi and Qi-Gong Chair-Assisted Yoga Stretches Meditation Postures and Practices Breathing Techniques for Relaxation

Mindful Stress Reduction Volume II by Kent HowardAvailable Format: VIDEO PRESENTATION - 1 DVD (not for cE crEdit) This DVD includes more stress reduction techniques, including meditative movement routines and mindful breathing exercises.

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