Chapter 9 Healthcare Professional Legal-Ethical Issues
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You will find some very interesting content in Chapter 9.
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Learning Objectives
Identify a variety of ethical and legal issues that arise in selected healthcare professions (e.g., nursing, emergency services, laboratory, pharmacy, radiology).
Explain how practicing one’s professional code of ethics can assist in resolving day-to-day issues that arise during patient care.
Explain difference between certification & licensure of a health care professional.
Identify helpful suggestions that help caregivers provide high-quality care.
Introduction (1 of 2)
Codes of ethics
Demand high level of integrity, honesty, and responsibility.
Provide guidance when faced with ethical dilemmas.
Created in response to actual or anticipated ethical conflicts.
Introduction (2 of 2)
Codes vary depending on risks associated with a particular profession.
Codes for psychologists define relationships with clients in greater depth due to personal one-to-one relationships.
Codes for lab technicians and technologists differ because they have little or no direct contact with patients.
Code of ethics: “Pledge accuracy and reliability in performance of tests.”
Paramedics
States have enacted legislation that provides civil immunity to paramedics who render emergency lifesaving services.
Morena v. South Hills Health Systems: Paramedics were not negligent in transporting a victim of a shooting to the nearest available hospital, rather than to another hospital located 5 or 6 miles farther away.
Riffe v. Vereb Ambulance Service, Inc.: A patient was administered 44 times the normal dosage of lidocaine. The court held that the liability of medical technicians could not be imputed to the hospital.
Paramedics: Categories (1 of 2)
Emergency Medical Responder
Initiate immediate lifesaving care.
Emergency Medical Technician
Provide basic emergency medical care and transportation for critical and emergent patients.
Advanced Emergency Medical Technician
Provide basic and limited advanced emergency medical care and transportation.
Paramedics: Categories (2 of 2)
Paramedic
Primary focus is to provide advanced emergency medical care for critical and emergent patients who access the emergency medical system.
Complex knowledge and skills necessary to provide patient care and transportation.
Nursing (1 of 5)
Nursing is the honor and privilege of caring for the needs of individuals in their time of need. The responsibility is one of growth to develop the mind, soul, and physical well-being of oneself as well as the one cared for.
—Author unknown
Nursing (2 of 5)
Nurse is generally the one medical professional the patient sees more than any other.
Nurse is in a position to monitor the patient’s illness, response to medication, display of pain and discomfort, and general condition.
Patient care, as well as the nurse’s observations, should be recorded on a regular basis.
Nursing (3 of 5)
Registered nurse
Passed a state registration.
Licensed to practice nursing.
Scope of practice:
Patient assessment
Analyzing laboratory reports
Patient teaching and counseling
Executing medical regimen
Operating medical equipment
Nursing (4 of 5)
Advanced practice registered nurses
RNs with advanced training
Nurse practitioners
Clinical nurse specialists
Nurse anesthetists
Nurse midwives
Nursing (5 of 5)
Specialty duty nurse
Float staff
Agency personnel
Nursing assistants
Student nurses
Negligent Acts in Nursing (1 of 2)
Nurse assessments and diagnosis
Ambiguous medication order
Wrong dosage of a medication
Medicating the wrong patient
Failure to note an order change
Failure to follow instructions
Negligent Acts in Nursing (2 of 2)
Failure to report physician negligence
Failure to question patient discharge
Failure to observe patient’s changing condition
Failure to chart observations
Chiropractors
Required to exercise the same degree of care, judgment, and skill exercised by reasonable. chiropractors under like or similar circumstances
Same standard applies to all professionals.
Chiropractors: Poor Judgment and Immoral Conduct
Nebraska law holds that a license to practice a healthcare profession may be revoked when licensee is guilty of immoral conduct. Patients rely upon chiropractor’s honesty, integrity, sound professional judgment, and compliance with applicable governmental regulations.
Dentistry
Dentists must treat patients within their scope of practice.
Performance of elective cosmetic procedures generally violates the statutory limits of the scope of dentistry.
Case: Dentistry Practice Outside the Scope of Practice
Performed cosmetic procedures
Facelift
Eyelid revision
Facial laser resurfacing
Case: Inappropriate Sexual Conduct by Dentist (1 of 2)
Dentist performed sexual acts on a patient while patient was under conscious sedation.
Discuss the legal and ethical issues.
Case: Inappropriate Sexual Conduct by Dentist (2 of 2)
Legal issues
Criminal (sexual abuse)
Ethical issues
Trust
Professional code of ethics
Case: Unlawful Administration of Nitrous Oxide (1 of 2)
A hearing panel found the dental hygienist guilty of administering nitrous oxide without being properly licensed. In addition, the hearing panel found that the hygienist had failed to accurately record in the patient's chart that she had administered nitrous oxide.
Case: Unlawful Administration of Nitrous Oxide (2 of 2)
Describe how both the ethical and legal issues are intertwined in this case.
Describe how the core values of a dental hygienist were violated in this case.
Case: Patient Injured During Procedure
Dental assistant was left unsupervised.
Cut patient’s tongue while taking impressions for dentures.
Court of Appeals held evidence sufficient to infer negligence.
Dietary
Dietitians must practice dietetics based on:
Scientific principles and current practice.
Need to integrate dietitians into patient care team.
Incidence and recognition of malnutrition:
Reality Check: Patient’s diet order inappropriate
Case: Patient suffers malnutrition
Reality Check: Patient’s nutritional status not addressed
Malnutrition remains largely unidentified concern
Emergency Department
Federal and state statutes impose a duty on hospitals to provide emergency care.
Statutes require hospitals to provide some degree of emergency service.
If the public is aware that a hospital furnishes emergency services and relies on that knowledge, the hospital has a duty to provide those services to the public.
Emergency Department: Case Reviews
South Dakota: Failure to respond
Wait times lengthen at emergency rooms
On-call physician fails to respond
Timely response may require a phone call
Emergency department lifeline
Timely response required
Case: Emergency Department and the Tick (1 of 3)
Mrs. Smith had an autoimmune disease. To complicate her life, she had a tick embedded in her skin, kicking its tiny legs in the middle of her back. It was Saturday night and nowhere to go but to the local hospital’s emergency department.
Case: Emergency Department and the Tick (2 of 3)
Upon entry to the emergency department there was a sign:
3-hour wait for triage
5-hour wait for a physician
Mrs. Smith was told that she would have to wait.
Discuss the legal and ethical issues.
Case: Emergency Department and the Tick (3 of 3)
Legal issues
2-hour wait for triage
What is the concern for other patients who may be delayed and have a life-threatening event (e.g., MI, CVA, abdominal aneurysm) occur while waiting for triage?
Ethical issues
Compassion
Laboratory
Utilizes screening tests of blood, urine, or other substances to help diagnose disease, better understand the disease process, and monitor levels of therapeutic drugs.
Medical Technologist
Duties
Protect the welfare of patients and the tests conducted above all else.
Avoid dishonest, unethical conduct or behavior.
Functions of the Modern Lab (1 of 2)
Monitor therapeutic ranges.
Measure blood levels for toxicity.
Place and monitor instrumentation on patient units.
Provide education and training for nursing staff.
Example: Glucose monitoring.
Provide information as to nutritional status of patients.
Functions of the Modern Lab (2 of 2)
Provide valuable data used in research studies.
Provide data on most effective and economical antibiotic for treating patients.
Serve in a consultative role for physicians.
Provide important data as to therapeutic levels of various drugs.
Case: Inaccurate Lab Reports (1 of 3)
Lab technologists, aware that the test results for HIV of several hundred patients were incorrect, reported the inaccurate results as correct. Ten percent of the patients were told that they were HIV positive. Follow-up testing revealed only one HIV-positive patient.
Discuss the legal and ethical issues.
Case: Inaccurate Lab Reports (2 of 3)
Describe a laboratory technician‘s professional responsibility to report accurate laboratory tests.
Should a laboratory technician report less than accurate laboratory reports if required to do so by his or her supervisor? Explain your answer.
Case: Inaccurate Lab Reports (3 of 3)
Legal issues
Fraud
Ethical issues
Nonmaleficience
Truthfulness
Professional codes of ethics
Refusal to Perform HIV Testing
The Court of Appeals of Indiana in Stepp v. Review Board of the Indiana Employment Security Division held that the technician was dismissed for just cause and that the laboratory did not waive its right to compel employees to perform assigned tasks.
Medical Assistant
Unlicensed person who provides administrative, clerical, and/or technical support to licensed practitioner.
Employment of medical assistants is expected to grow:
Technological advances in medicine
Growth of aging population
Medical Assistant: Code of Ethics
Render service with full respect for the dignity of humanity.
Respect confidential information.
Uphold the honor and high principles of the profession.
Seek to continually improve knowledge and skills of medical assistants.
Case: Passing the Buck (1 of 3)
Mrs. Smith, an acutely ill patient in pain, arrives for a scheduled CT scan at a hospital outpatient center to rule out a stroke. The physician’s order that had been faxed to the center did not specify if the scan was to be performed without contrast. The medical assistant said to Mrs. Smith, “You will have to have your physician rewrite your prescription before we can perform the exam.”
Case: Passing the Buck (2 of 3)
Mrs. Smith was distressed. The medical assistant said, “He can fax it to us!” The medical assistant, pointing to a phone, then said, “There is a phone over there. The fax number is on the wall.” Mr. Smith said he would make the call.
Discuss the legal and ethical issues.
Case: Passing the Buck (3 of 3)
Legal issues
Negligence?
Subjecting the patient to unnecessary stress could aggravate her medical problems.
Ethical issues
Beneficence
Professional codes of ethics
Compassion
Medical Records
Healthcare organizations are required to maintain a medical record for each patient.
Medical records must be complete, accurate, current, readily accessible, and systematically organized.
Medical Records: Code of Ethics
Place service before material gain.
Preserve and protect medical records.
Refuse to participate in or conceal unethical practices or procedures.
Preserve confidential nature of professional determinations made by the staff committees.
Strive to advance knowledge and practice of medical record administration.
Purpose of the Medical Record (1 of 2)
Provides a planning tool for patient care.
Records the course of a patient’s treatment and the changes in a patient’s condition.
Documents the communications between the practitioner responsible for the patient and other healthcare professional who contribute to the patient’s care.
Purpose of the Medical Record (2 of 2)
Assist in protecting the legal interests of the patient, the organization, and the practitioner.
Provide a database for use in statistical reporting, continuing education, and research.
Provide information necessary for third-party billing and regulatory agencies.
Pharmacy (1 of 3)
Practice of pharmacy essentially includes:
Preparing medications
Compounding medications
Dispensing medications
Retailing medications
Pharmacy (2 of 3)
Dispensing and administration of drugs
Drug substitution
Expanding role of the pharmacist
Duty to monitor patient’s medications
Pharmacy (3 of 3)
Warning patients about potential for overdose
Refusal to honor questionable prescriptions
Reducing medical errors
Case: Administration of Wrong Medication (1 of 2)
Mrs. Jones was administered the wrong medication. As a result, he suffered a serious reaction. The nurse executive instructs the staff nurse, “Don’t tell anyone.”
Discuss the legal and ethical issues.
Case: Administration of Wrong Medication (2 of 2)
Legal issues
Negligence
Ethical issues
Autonomy
Truthfulness
Regulatory issues
Joint Commission standards require reporting of mistakes made during the care of a patient.
Physical Therapy
Physical therapy is the art and science of preventing and treating neuromuscular or musculoskeletal disabilities through the evaluation of an individual’s disability and rehabilitation potential.
Physical Therapy: Treatment Modalities
Physical exercise
Heat
Cold
Electricity
Water
Light
Neuromuscular procedures
Case: Interpreting Physician’s Orders
Physical Therapists’ Code of Ethics, Principle 3.4 states: “Any alteration of a program or extension of services beyond the program should be undertaken in consultation with the referring practitioner.”
Resistive exercises were not set forth in the original prescription, Boulet stated that consultation with physician was necessary before plaintiff could be advanced to that level.
Case: Resident Neglect
Physical therapist charged with resident neglect for refusing to allow an 82-year-old nursing facility resident to go to the bathroom before starting his therapy treatment session.
Court held that evidence supported the verdict of resident neglect.
Physical Therapy: Patient’s Care Questions (1 of 2)
What records have you seen?
Have you discussed my treatment plan with my physician?
What were my physician’s specific orders?
Physical Therapy: Patient’s Care Questions (2 of 2)
May I see them?
What precautions have you been asked to follow with me?
Have you seen my imaging studies?
Has anyone discussed them with you?
Physician’s Assistant (1 of 2)
Extension of physician practices.
Licensed to practice medicine under a physician’s supervision.
PA practice regulated differently in different states.
Physician’s Assistant (2 of 2)
PAs responsible for negligent acts.
Employer of a PA can be held liable for PA’s negligent acts on basis of respondeat superior.
A physician may delegate to a PA:
Suturing of minor wounds
Administering injections
Performing routine history and physical exams
Physician May Not Delegate
The physician may not delegate a task when regulations specify the physician must perform it personally or when the delegation is prohibited under state law or by the facility’s own policies.
Psychology: Code of Ethics (1 of 2)
10.07 Therapy With Former Sexual Partners
Psychologists do not accept as therapy clients/patients persons with whom they have engaged in sexual intimacies.
Psychology: Code of Ethics (2 of 2)
10.08 Sexual Intimacies With Former Therapy Clients/Patients
(a) Psychologists do not engage in sexual intimacies with former clients/patients for at least two years after cessation or termination of therapy.
(b) Psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstance.
Psychologist: Case Studies
Failure to minimize harm: Unethical conduct
Sexual harassment
Reporting child abuse
Psychologist: Improprieties with Clients (1 of 2)
The Board of Psychologist Examiners revoked a psychologist’s license for sexual improprieties. The psychologist argued that therapy had terminated before the sexual relationships began.
What did the court of Appeals decide? Why?
Psychologist: Improprieties with Clients (2 of 2)
Court of Appeals stated evidence supported the board’s conclusion that the psychologist had violated an ethical standard in caring for her patients.
When a psychologist’s personal interests intrude into the practitioner–client relationship, the practitioner is obliged to seek objectivity through a third party.
Radiology: Code of Ethics
The radiologic technologist assesses situations; exercises care, discretion, and judgment; assumes responsibility for professional decisions; and acts in the best interest of the patient.
Case: Failure to Restrain Causes Patient Fall
Jury found the hospital negligent for leaving the plaintiff unattended or failing to restrain her, which proximately caused her fall and injury.
Ethical and legal issues
Code of ethics: Failure to assess and address patient needs.
Negligence: Resulted in patient injury.
Respiratory Therapists (1 of 2)
Respiratory care involves the treatment, management, diagnostic testing, and control of patients with cardiopulmonary deficits.
Respiratory therapist is a person employed in the practice of respiratory care who has the knowledge and skill necessary to administer respiratory care.
As with other healthcare professions, respiratory technicians are expected to comply with their professional code of ethics.
Respiratory Therapists (2 of 2)
Ethical and legal issues
Failure to restock “code cart”
Results in brain death
Evidence presented at trial established hospital’s breach of duty in not having code cart properly restocked, which resulted in a 3-minute delay in intubation.
Social Work
Social workers in the hospital setting assist patients and families with:
Psychosocial issues
Obtaining insurance coverage
Making difficult care decisions
Assisting the patient and family in planning for post discharge care
Caseworker Fired After Baby Dies
A District of Columbia social worker was fired Tuesday following the death of a baby who was reported as neglected, city officials said. The city’s Child and Family Service Agency received a call about the 6-month-boy in March, but the social worker assigned to the case never visited the child, interim Attorney General Peter Nickles said.
—Nikita Stewart, The Washington Post, July 8, 2008
Social Workers Underutilized
Allocation of hospital resources with dwindling dollars has served to make hiring of social workers a low priority for healthcare organizations.
Social workers are needed to address the myriad of social issues that arise in the delivery of patient care.
Certification of Healthcare Professionals
Certification of healthcare professionals is the recognition by a governmental or professional association that an individual’s expertise meets the standards of that group.
Licensing of Healthcare Professionals
Licensure can be defined as the process by which some competent authority grants permission to a qualified individual or entity to perform certain specified activities that would be illegal without a license.
Suspension and Revocation of a License
Licensing boards have the authority to suspend or revoke a license for violation of specified norms of conduct:
Procurement of a license by fraud
Unprofessional, dishonorable, immoral, or illegal conduct
Performance of specific actions prohibited by statute and malpractice.
Suspension and revocation procedures in state licensing acts
Helpful Advice (1 of 5)
Break down the barriers between departments and work as a team.
Abide by the ethical code of one’s profession.
Do not criticize the professional skills of others.
Maintain complete medical records.
Provide each patient with medical care comparable with national standards.
Seek the aid of professional medical consultants when indicated.
Helpful Advice (2 of 5)
Obtain informed consent for diagnostic and therapeutic procedures.
Inform the patient of the risks, benefits, and alternatives to proposed procedures.
Practice the specialty in which you have been trained.
Participate in continuing education programs.
Keep patient information confidential.
Helpful Advice (3 of 5)
Check patient equipment regularly, and monitor it for safe use.
When terminating a professional relationship, give adequate written notice to the patient.
Authenticate all telephone orders.
Obtain a qualified substitute when you will be absent from your practice
Helpful Advice (4 of 5)
Be a good listener, and allow each patient sufficient time to express fears and anxieties.
Develop and implement an interdisciplinary plan of care for each patient.
Safely administer patient medications.
Closely monitor each patient’s response to treatment.
Helpful Advice (5 of 5)
Provide education and teaching to patients.
Foster a sense of trust and feeling of significance.
Communicate with the patient and other caregivers.
Provide cost-effective care without sacrificing quality.
Review Questions
Describe how ethics and law have an impact on various healthcare professions discussed in this chapter.
Discuss the ethical and legal implications of practicing outside one’s scope of practice.
Discuss the circumstances under which a hospital has a duty to provide emergency services to the public.
Are sexual improprieties acceptable with clients as long as they do not take place during treatment? Explain your answer.
Consider under what circumstances a professional’s legal responsibilities may overlap with his or her ethical duties.
Describe how and why the scope of practice for various professionals (e.g., nurses and pharmacists) is changing.
Review Questions
Discuss what action a caregiver should take, if any, if a physician’s written orders appear questionable.
Describe a professional’s responsibilities when a patient’s condition takes a turn for the worse.
Describe the difference between the certification and licensing of a healthcare professional.
Review Questions
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