outpatient ethics for the internist: neglected professional dilemmas
DESCRIPTION
Outpatient Ethics for the Internist: Neglected Professional Dilemmas. Cynthia M.A. Geppert, MD, MA, PhD, MPH, MSBE Chief Consultation Psychiatry & Ethics New Mexico Veterans Affairs Health Care System - PowerPoint PPT PresentationTRANSCRIPT
OUTPATIENT ETHICS FOR THE INTERNIST:
NEGLECTED PROFESSIONAL DILEMMAS
Cynthia M.A. Geppert, MD, MA, PhD, MPH, MSBE
Chief Consultation Psychiatry & Ethics New Mexico Veterans Affairs Health Care System
Professor of Psychiatry and Director of Ethics Education University of New Mexico School of
Medicine
A
cute crises
I
nvolves technology
E
nd-of-life
D
ramatic
W
ithholding care
T
ransient MD-PT relationship
C
hronic disease
I
nvolves psychosocial
P
reventive
R
outine
I
nappropriate care
O
ngoing MD-PT relationship
DIFFERENCES IN OUTPATIENT & INPATIENT ETHOS
Inpatient Outpatient
FREQUENCY & TYPE OF OUTPATIENT ETHICAL PROBLEMS
L
ittle research compared to inpatient dilemmas and much of it outdated or
conducted in Europe.
1
988 study of 562 IM office visits.
E
thical problems defined as conflicts between other ethical issues and
physician’s moral obligation of beneficence.
E
thical problems were present in 30% of encounters 84/280 patients and in
21% of office visits.
C
osts of care (11%)
P
sychological factors influencing
patient preferences (9.6%)
C
ompetence & capacity to choose
(7.1%)
R
efusal of treatment (6.4%)
MOST COMMON ETHICAL PROBLEMS
I
nformed consent (5.7%)
C
onfidentiality (3.2%)
M
ore frequently encountered in
patients over 60.
(
Connelly JE, DalleMura S. Ethical problems in the
medical office. JAMA 1989; 260:812-5.)
1. Impaired drivers
2. Third-party information
3. HIPAA and privacy
4. Adolescent
confidentiality
5. Life-threatening non-
adherence
6. Demands for inappropriate
treatment
7. Lying for patients
8. Discharging Difficult patients
TOP 10 ETHICS ISSUES IN PRIMARY CARE
Confidentiality-Consent Physician-Patient Relationship
Professionalism
9. PCP versus Consultant
10. Impaired physician
# 1 IMPAIRED DRIVERS
C
ase: Mr. F is a 75-year old widower with mild dementia,
BPH, DJD and CAD who presents to your office for an ER
follow up visit. Mr. F was involved in an MVA and sustained
some minor lacerations and contusions. Mr. F wears
hearing aids and his vision was recently checked. MMSE
performed in the office is 19. Mr. F lives independently in
an apartment in town but has no family in the state.
DRIVING, CONTINUED
W
hen you suggest he might no longer be safe to drive, he is
indignant, citing his safe driving record. “If I can’t drive, I
might as well be dead.” He does agree to limit his driving
to daytime hours and short trips. One month later his
daughter calls from out of state and tells you he has hit a
parked car and it is time for you to “make him give up his
license.” Can you do that? Is it legal? Is it ethical?
P
hysician/medical reporting
I
mmunity
L
egal protection
D
MV follow-up
O
ther reporting
N
ot anonymous or confidential
REPORTING PROCEDURES NEW MEXICO
D
river is informed by mail that his/her
license will be cancelled in 30 days
unless he/she submits a medical
report stating that he/she is
medically fit to drive. If a report is
not submitted, the license will be
cancelled.
W
ill accept information from courts,
other DMVs, police, and family
members.
A
utonomy of patient versus do no
harm to the public.
C
onfidentiality versus truth-telling.
R
equires medical assessment for
possible reversible causes.
M
ust fail least restrictive
alternative.
ETHICAL ISSUES
W
ork with family to secure
keys/cars.
S
ocial services for alternative
modes of transportation.
B
e transparent with patient and
permit voluntary surrender of
license.
# 2 THIRD-PARTY INFORMATION
M
rs. C calls and leaves the following message with your
nurse: “My husband is not telling you that he is drinking
again even with the pain medications the doctor
prescribed. He is verbally abusive to me when he is drunk.
Please don’t tell my husband I called but I wanted the
doctor to know that my husband doesn’t tell the truth to
him.” You didn’t ask but now do you tell?
CONFIDENTIALITY
A
CP Ethics Manual (6th ed, p. 76) states that the “physician is not
obliged to keep secrets from the patient.”
M
D should recommend the wife encourage her husband to tell the MD
about the drinking and offer to facilitate a conversation.
C
linical judgment regarding disclosing the information and its source
depends on what is best for the patient, not the wife.
You just hired a new office
manager who likes to read
technical manuals for fun.
She says several routine
office practices are violations
of HIPAA and could result in
fines or worse. Is she right or
just annoying?
#3 HIPAA IN THE OFFICE
1. You call patients by name in
the waiting room.
2. Your receptionist leaves
appointment reminders on
patients’ answering machines.
3. Your nurse regularly
communicates health
information to patient’s
spouses.
HIPAA THE HIPPO
She is wrong. Physicians’ offices can use patient sign-up sheets
or call out patients’ names so long as the information disclosed
is appropriately limited e.g., no medical diagnoses.
These are both what is technically called “incidental
disclosure,” when other patients hear or see another patient’s
name
Disclosures are only permitted if other reasonable safeguards
and the minimum necessary standard has been met.
MESSAGES ON MACHINES
H
IPAA permits a physician’s office staff to leave a message on a
patient’s answering machine so long as the message limits the
information to the appointment time reminder or request for a
call back.
U
nless the patient has previously requested confidential contact,
such as by mail to the patient’s office rather then his home.
COMMUNICATING TO FAMILY
H
IPAA allows physicians to communicate information to family members
or significant others about the patient’s care even if the patient is NOT
present or has not given explicit permission for the physician to
disclose health information, IF:
I
n her professional judgment the physician believes such disclosure is
in the patient’s best interest.
N
OT if the patient has explicitly instructed the physician not to disclose
any health information to specific family members or friends.
#4 ADOLESCENT CONFIDENTIALITY
M
iss R is a 17-year-old high school junior whose mother has been
in your practice for years. Miss R comes to the office requesting
birth control because she is sexually active with her long-time
boyfriend and doesn’t want to “get pregnant and mess up the
college thing.” She asks that you not tell her parents she
requested contraception because as you know they are strong
Christians and would not approve of her sexual activity. Do you
give the pill?
THE LAW: CONFIDENTIAL SERVICES FOR MINORS IN NEW MEXICO
§ 24-8-5 NMSA 1978 … Contraception
N
either the state… nor any health facility furnishing family
planning services shall subject any person to any standard or
requirement as a prerequisite for receipt of any requested family
planning service…[exceptions do not address age of client].
THE ETHICS
A
dolescent privacy and autonomy versus the rights of parents to
decide what is best for their children.
T
ry to persuade the adolescent to tell their parents and offer to
mediate meeting.
S
uggest a public health clinic so that the parents do not get the
insurance bill but the adolescent gets the contraception.
#5 LIFE-THREATENING NON-COMPLIANCE
M
rs. S is a 64-year-old woman with alcohol dependence and
a personality disorder, who is on coumadin for a DVT and
PE 6 months ago. She has been erratic in her adherence to
coumadin monitoring and is now admitted to the hospital
with an INR of 7 thought secondary to heavy alcohol use
and overtaking her coumadin when intoxicated. Do you
continue coumadin?
STEPS PRIOR TO STOPPING
A
ssess decisional capacity
S
trongly counsel substance use treatment including anti-craving
medication.
C
onsider a coumadin agreement with the patient so you an document a trial
before discontinuation.
E
nlist family or friends to help her monitor her coumadin at home.
DISCONTINUATION
A
re there any other anticoagulation options to minimize the danger?
C
onduct an evidence-based assessment of the risk/benefit profile of continuing
coumadin.
O
btain a consultation from a colleague.
E
xtensively document the informed consent discussion with patient.
A
dvise of warning signs and symptoms of thrombosis or bleeding.
#8 DEMANDS FOR INAPPROPRIATE TREATMENT
M
iss A is a 37-year-old unmarried woman with BMI of 26,
requesting thyroid medication. She has seen TV advertisements
for thyroid hormone clinics but none of them are on her
insurance plan. She denies constipation, cold intolerance,
skin/hair changes, and other symptoms, aside from inability to
lose weight. Her physical examination is normal and TSH is 1
U/ml. Why does she want the thyroid and do you prescribe it?
STANDARD OF CARE
A
CP Ethics Manual (6th edition, p. 75-76) “Although
the physician must address the patient’s concerns,
he or she is not required to violate fundamental
personal values, standards of medical care or ethical
practice or the law.”
REFUSING INAPPROPRIATE REQUESTS ETHICALLY
T
ry to understand the patient’s needs and beliefs – here Miss S clearly
wants to lose weight the easy way.
E
ducate patients regarding the risks of inappropriate treatments such as
osteoporosis with thyroid replacement.
A
ttempt to come to a mutually acceptable resolution.
I
f you cannot agree, then offer to refer.
#7 LYING FOR PATIENTS
M
r. K is a 38-year-old father of 3 whose wife, also in your practice,
has lupus. Mr. K was recently laid off from his warehouse job.
He comes asking if you can fill out workman’s compensation
forms indicating his knee was injured on the job. This will give
him time to go back to school in information technology. Your
records show that on his initial visit 2 years ago Mr. K reported
he injured his knee playing high school soccer. Do you fill out
the forms?
5
7% for cardiac bypass
5
6.2% for arterial vascularization
4
7.5% for intravenous pain medication and
nutrition
3
4.8% for screening mammography
3
2.1% for emergent psychiatric referral
2
.5% cosmetic rhinoplasty
169 board certified internists
surveyed on whether they
would use deception in 6
clinical scenarios.
More likely to use deception if
less time in practice, clinical
situation more severe, managed
care penetration higher
Freeman VG et al. Lying for patients. Arch
Intern Med. 1999;159:2263-70.
PHYSICIAN DECEPTION OF THIRD PARTIES
DOES USING DECEPTION SOLVE ETHICAL PROBLEMS
R
epresents a conflict between traditional patient advocacy and newer
professional obligations of just resource allocation.
L
ying for patients can have unintended and opposite effects of
compromising physician integrity and diminishing public trust in the
profession.
R
eflects burdens and unfairness of reimbursement systems best
addressed through policy reform.
ACP ON DISABILITY
“
Physicians may see a patient whose problems do not fit
standard definitions of disability, but who nevertheless seem
deserving of assistance. Physicians should not distort medical
information or misrepresent the patient’s functional status in an
attempt to help patients. Doing so jeopardizes the
trustworthiness of the physician as well as his or her ability to
advocate for patients who truly meet disability or exemption
criteria.” (p.80)
#8 DISCHARGING DIFFICULT PATIENTS
M
iss Y is a 31-year-old with fibromyalgia, migraine headache, and
benzodiazepine dependence, who has repeatedly no-showed
scheduled appointments and then demanded urgent visits. She calls
the office multiple times a day and when staff cannot immediately
attend to her needs becomes abusive. She has refused to follow an
exercise plan or accept referrals for mental health care and
threatens to sue if she is not given alprazolam. Can she be
legitimately discharged from the practice or is this patient
abandonment of a challenging patient?
ABANDONING A PATIENT
N
either ethical nor legal when:
T
here is an urgent or emergency situation.
N
o other clinician can provide a necessary service in the area/setting.
W
ould compromise the patient’s health.
Y
ou do not follow appropriate steps.
DISCHARGING A PATIENT
Y
ou can ethically and legally discharge a patient, IF you:
H
ave documented attempts to resolve conflicts.
T
ransfer records and care to another provider.
C
opies of all records: information belongs to patient; record to the
practice.
#9 CONSULTANT VERSUS PCP
D
r. S practices in Rio Rancho. He has been treating Mr. C for many years
for chronic pain from severe spinal stenosis, most recently with
oxycodone 10 mg QID, with only modest relief.
D
r. S sends Mr. C to a local pain specialist, Dr. I, for further work up and
treatment recommendations. Dr. I documents in his consultation that
the patient is receiving a dangerous amount of short-acting opioids and
recommends immediate and complete taper off opioids.
I
s Dr. S ethically or legally obliged to follow the consultant’s
recommendations?
PCP RULES
A
CP Ethics Manual (6th edition, p. 92)
“
The physician who does not agree with the consultant’s
recommendations is free to call in another consultant. The interests
of the patient should remain paramount in this process.”
“
Unless authority has been formally transferred elsewhere, the
responsibility for the patient’s care lies with the principal physician.”
#10 IMPAIRED PHYSICIAN
Y
ou work in a small group primary care practice. Dr. Z is 52 with
well-controlled diabetes and been a good partner for 10 years.
Over the last few months he has been showing up late for work,
not reachable on call, and your nurse has complained he is
irritable and tremulous at work. You have told him you are
worried about him, but he denies there is any problem, saying he
is just having trouble with his blood sugar. Where do you go from
here with your concerns?
ETHICAL OBLIGATION
A
CP Ethics Manual (6th ed. P. 92) “Every physician is
responsible for protecting patients from an impaired
physician and for assisting an impaired colleague.
Fear of mistake, embarrassment or possible
litigation should not deter or delay identification of
an impaired colleague.”
REPORTING A COLLEAGUE
F
irst try informal intervention, perhaps with the entire group or a trusted
colleague.
O
ffer to assist in referring to treatment, including monitored physician
treatment program.
C
onsult legal counsel, hospital chief of staff, or clinic administrator on process.
L
et the physician know you will have to report him if he does not take
preventive action.
PRIMARY CARE ETHICS
“
Because primary care is characterized by many repeated
episodes of relatively mundane events instead of a few
sharply defined crises requiring instant decisions, the way in
which these ethical issues arise and the peculiar flavor they
develop in a primary care setting may be more difficult to
discern than the way in which ethical issues crop up in
intensive care unit.” (
Brody H, Tomlinson T. Ethics in primary care: setting aside common misunderstandings.1989;
Primary Care 1986;13:225-240.)
RESOURCES FOR ANSWERS
A
merican Board of Internal Medicine Advancing Professionalism to Improve Health
Care http://www.abimfoundation.org
A
MA Virtual Mentor for Ethics and Professionalism http
://www.ama-assn.org/ama/pub/physician-resources/medical-ethics.page?
A
merican College of Physicians Center for Ethics and Professionalism
http://www.acponline.org/running_practice/ethics/
U
niversity of Washington Ethics in Medicine
http://depts.washington.edu/bioethx/index.html