Chapter 17 End-of-Life Issues When we finally know we are dying, And all other sentient beings are dying with us, We start to have a burning, almost heart-breaking sense of the fragility and preciousness of each moment and each being, and from this can grow a deep, clear, limitless compassion for all beings

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Chapter 17 End-of-Life Issues When we finally know we are dying, And all other sentient beings are dying with us, We start to have a burning, almost heart-breaking sense of the fragility and preciousness of each moment and each being, and from this can grow a deep, clear, limitless compassion for all beings. —Sogyal Rinpoche Learning Objectives (1 of 2) ? Discuss the human struggle to survive and the right to autonomous decision making. ? Describe how patient autonomy has been impacted by case law and legislative enactments. ? Discuss the following concepts: preservation of life with limits, euthanasia, advance directives, futility of treatment, withholding and withdrawal of treatment, and do-notresuscitate orders. Learning Objectives (2 of 2) ? Explain end-of-life issues as they relate to autopsy, organ donations, research, experimentation, and clinical trials. ? Describe how human genetics and stem cell research can have an impact on end-of-life issues. Dreams of Immortality ? Human struggle to survive ? Desire to prevent and cure illness ? Advances in medicine and power to prolong life ? Ethical and legal issues ? Involving entire life span ? From right to be born to right to die Patient Autonomy ? Right to make one’s own decisions ? Patient has the right to accept or refuse care even if it is beneficial to saving his or her life. ? Autonomy may be inapplicable in certain cases. ? Affected by one’s disabilities, mental status, maturity, or incapacity to make decisions No right is held more sacred, or is more carefully guarded, by the common law, than the right of every individual to the possession and control of his own person, free from all restraint or interference of others, unless by clear and unquestioned authority of law. —Union Pac. Ry. Co. v. Botsford (1891) Every human being of adult years and sound mind has a right to determine what shall be done with his own body and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages, except in cases of emergency where the patient is unconscious and where it is necessary to operate before consent can be obtained. —Schloendorff v. Society of New York Hospital (1914) Why Courts Get Involved: End-of-Life Issues ? Family members disagree as to the incompetent’s wishes ? Physicians disagree on the prognosis ? A patient’s wishes are unknown because he or she has always been incompetent. ? Evidence exists of wrongful motives or malpractice. In re Quinlan (1976) ? Constitutional right to privacy protects patient’s right to self-determination. ? A state’s interest does not justify interference with one’s right to refuse treatment. In re Storar (1981) ? Every human being of adult years and sound mind has the right to determine what shall be done with his or her own body. Superintendent of Belchertown State School v. Saikewicz (1977) ? Saikewicz allowed to refuse treatment ? Questions of life and death with regard to an incompetent should be the responsibility of the courts. ? Court took a “dim view of any attempt to shift ultimate decision-making responsibility away from duly established courts of proper jurisdiction to any committee, panel, or group, ad hoc or permanent.” In re Dinnerstein (1978) ? “No code” orders are valid to prevent the use of artificial resuscitative measures on incompetent terminally ill patients. In re Spring (1980) ? Patient’s mental impairment and his or her medical prognosis with or without treatment must be considered prior to seeking judicial approval to withdraw or withhold treatment from an incompetent patient. John F. Kennedy Memorial Hospital v. Bludworth (1981) ? The Florida Supreme Court took the lead and accepted the living will as persuasive evidence of an incompetent’s wishes. ? The Court allowed an incompetent patient’s wife to act as his guardian, and in accordance with the terms of a living will he executed in 1975, she could substitute her judgment for that of her husband. Satz v. Perlmutter (1978) ? Court required attending physician to certify patient was in a permanent vegetative state ? No reasonable chance for recovery ? Before family member or guardian could request termination of extraordinary means of medical treatment Constitutional Right to Refuse Care ? The Supreme Court analyzed the issues presented in the Cruzan case in terms of a Fourteenth Amendment liberty interest. ? A competent person has a constitutionally protected right grounded in the due-process clause to refuse life-saving hydration and nutrition. Legislative Response ? Chief Justice Dore of the Washington Supreme Court voiced his opinion that a legislative response to right-to-die issues could be better addressed by the legislature. ? Patient Self-Determination Act of 1990 ? Enacted to ensure that patients are informed of their rights to execute advance directives and accept or refuse medical care Patient Self-Determination Act of 1990 ? Enacted to ensure patients are informed of rights to execute advance directives and accept or refuse medical care. ? Each state is required under PSDA to provide a description of the law regarding advance directives to providers. ? Whether based on state statutes or judicial decisions ? Providers must ensure written policies and procedures regarding advance directives are established. Defining Death: Brain Death Criteria ? Black’s Law: “irreversible cessation of all brain functions including the brain stem” Harvard Ad Hoc Committee: Brain Death Criteria (1968) ? Patient shows total unawareness to external stimuli and unresponsiveness to painful stimuli. ? No movements or breathing: All spontaneous muscular movement, spontaneous respiration, and response to stimuli are absent. ? No reflexes: Fixed, dilated pupils; no eye movement even when hit or turned, or when ice water is placed in the ear; no response to noxious stimuli; no tendon reflexes. American Medical Association (1974) ? Committee of the Harvard Medical School to Examine the Definition of Brain Death ? Death occurs when there is “irreversible cessation of all brain functions, including the brain stem.” New York Court of Appeals ? Evidence of a patient’s intention to reject prolongation of life by artificial means ? Persistent statements regarding individual’s beliefs ? Desirability of the commitment to those beliefs ? Seriousness with which such statements were made ? Inferences that may be drawn from surrounding circumstances —In re Westchester County Medical Center ex rel. O’Connor Futility of Treatment ? Physician recognizes effect of treatment will be of no benefit to the patient. ? Morally, a physician has a duty to inform the patient when there is little likelihood of success. ? Determination as to futility of medical care is a scientific decision. Do-Not-Resuscitate Orders ? Do-not-resuscitate (DNR) orders written by a physician indicate that in the event of cardiac or respiratory arrest no resuscitative measures should be used to revive the patient. ? Competent patients make their own DNR decisions. Withholding and Withdrawal of Treatment (1 of 2) ? Withholding of treatment ? Decision not to initiate treatment or medical intervention for the patient ? Withdrawal of treatment ? Decision to discontinue treatment or medical interventions for the patient when death is imminent and cannot be prevented by available treatment Withholding and Withdrawal of Treatment (2 of 2) ? Considerations ? Patient is in a terminal condition and there is a reasonable expectation of imminent death of the patient. ? Patient is in a non-cognitive state with no reasonable possibility of regaining cognitive function. ? Restoration of cardiac function will last for brief period Euthanasia (1 of 2) ? Mercy killing ? e.g., hopelessly ill, injured, incapacitation ? Active euthanasia ? Intentional commission of an act ? Administering the patient with a lethal drug ? Passive euthanasia ? Withholding or withdrawing life-saving treatment (e.g., removal of a respirator) Euthanasia (2 of 2) ? Voluntary euthanasia ? Occurs when suffering incurable patient makes decision to die ? Involuntary euthanasia ? Occurs when a person other than incurable makes decision to terminate life of an incompetent or a non-consenting competent person’s life Euthanasia: Ramifications ? ? ? ? ? ? Why Why not How Who Where When Euthanasia: Issues Regarding Euthanasia ? If lawful ? Long-term ramifications ? What about abortions? ? Right to die ? Civil wrong: Negligence ? Criminal offense ? Voluntary ? Involuntary Physician-Assisted Suicide ? Michigan and assisted suicide ? Oregon’s Death with Dignity Act of 1994 ? U.S. Supreme Court ? Prohibition of assisted suicide ruled constitutional ? Assisted suicide law ruled constitutional ? States legislate assisted suicide ? California, D.C., Oregon, Montana, Washington, & Vermont Advance Directives ? Instructions specifying what actions should be taken in event the individual becomes incapacitated and can no longer make healthcare decisions due to incapacity ? Obligation to make preferences known ? Patients have an obligation to make care preferences known. ? Uncertainty as to patient’s desires should be resolved in favor of preserving life. Advance Directives: Living Will ? Instrument or legal document that describes those treatments an individual wishes or does not wish to receive should he or she become incapacitated and unable to communicate treatment decisions ? Dying without a living will ? Living Will Declaration Upheld Advance Directives: Healthcare Proxy ? Legal document that allows a person to appoint a healthcare agent to make treatment decisions in the event he or she becomes incapacitated and is unable to make decisions for himself or herself Advance Directives: Durable Power of Attorney ? Legal device that permits one individual, known as the “principal,” to give to another person, called the “attorney-in-fact,” the authority to act on his or her behalf Advance Directives: Surrogate Decision Making ? Agent who acts on behalf of a patient who lacks the capacity to participate in a particular decision ? Substituted judgment ? Form of surrogate decision making where surrogate attempts to establish what decision the patient would have made if that patient were competent to do so Advance Directives: Guardianship ? Legal mechanism by which the court declares a person incompetent and appoints a guardian Autopsy (1 of 2) ? Autopsy consent statutes ? Authorization by decedent ? Authorization by other than decedent Autopsy (2 of 2) ? Scope and extent of consent ? Fraudulently obtained consent ? Unclaimed dead bodies Organ Donation and Transplantation (1 of 2) ? Federal regulations require hospitals to have, and implement, written protocols regarding the organization’s organ procurement. ? Regulations impose notification duties concerning informing families of potential donors. ? Discretion and sensitivity should be used in dealing with families. Organ Donation and Transplantation (2 of 2) ? Educating hospital staff on variety of issues involved with donation matters, in order to facilitate timely donation and transplantation ? Who lives? Who dies? Who decides? ? Determination of death ? Uniform Anatomical Gift Act ? Failure to obtain consent Research, Experimentation, and Clinical Trials (1 of 2) ? ? ? ? ? Institutional Review Board Informed consent Research subject’s bill of rights Failure to obtain informed consent Duty to warn Research, Experimentation, and Clinical Trials (2 of 2) ? Patents delay research ? Nursing facilities ? Patient understood risks Human Genetics ? Describes the study of inheritance as it occurs in human beings ? Genetic markers ? DNA sequences with a known location on a chromosome that can be used to identify specific cells and diseases, as well as individuals and species Genetic Information Nondiscrimination Act (2008) ? Prohibits discrimination on the basis of genetic information with respect to the availability of health insurance and employment Stem Cell Research ? Embryonic stem cells are used to create organs and various body tissues. ? Opponents argue that use of stem cells is a slippery slope to reproductive cloning and fundamentally devalues the worth of a human being. ? Medical researchers argue it is necessary to pursue embryonic stem cell research because the resultant technologies could have significant medical potential. Review Questions (1 of 2) 1. Describe how patient autonomy has been impacted by case law and legislative enactments. 2. Discuss the following concepts: preservation of life with limits, euthanasia, advance directives, futility of treatment, withholding and withdrawal of treatment, and do-not-resuscitate orders. 3. Explain end-of-life issues as they relate to autopsy, organ donations, research experimentation, and clinical trials. Review Questions (2 of 2) 4. Describe how human genetics and stem cell research can have an impact on end-of-life issues. 5. Discuss the importance of genetic markers. 6. Explain the reason the Genetic Information Nondiscrimination Act was enacted. Chapter 13 Information Management & Patient Records Learning Objectives (1 of 2) ? Describe the contents of medical records. ? Explain the importance of maintaining complete and accurate records. ? Explain the ownership of and who can access a patient’s medical record. ? Describe the advantages and disadvantages of electronic medical records. Learning Objectives (2 of 2) ? Describe why the medical record is important in legal proceedings. ? Describe a variety of ways in which medical records have been falsified. ? Explain what is meant by the medical record battleground. Information Management (1 of 3) ? ? ? ? ? Determine customer needs Set goals and establish priorities Improve accuracy of data collection Provide uniformity in data collection definitions Limit duplication of entries Information Management (2 of 3) ? Deliver timely and accurate information ? Provide easy access to information ? Maintain security and confidentiality of information ? Enhance patient care activities ? Improve collaboration through information sharing Information Management (3 of 3) ? Establish disaster plans for information recovery ? Provide orientation and staff training ? Annual review of information management plan ? ? ? ? Scope Organization Objectives Effectiveness Medical Record: Means of Communication (1 of 2) ? Documentation of patient’s: ? ? ? ? Illness Symptoms Diagnosis Treatment Medical Record: Means of Communication (2 of 2) ? Communication tool (e.g., progress notes) ? Protect legal interests of patient and provider ? Provide database for use in statistical reporting ? Continuing education ? Research ? Provide information for billing Medical Record Contents (1 of 5) ? Admission record ? ? ? ? ? ? ? Age Address Reason for admission Social security number Marital status Religion Health insurance Medical Record Contents (2 of 5) ? Consent authorization for treatment ? Advance directives ? History and physical exam ? Diagnosis ? Information that supports the diagnosis ? Patient screenings and assessments Medical Record Contents (3 of 5) ? ? ? ? Treatment plan Physicians’ orders Progress notes Nursing notes ? Integrated record includes physician progress and nursing notes along with the notes of other disciplines Medical Record Contents (4 of 5) ? Diagnostic reports ? For example, EKG, EEG, laboratory, and imaging ? ? ? ? ? Consultation reports Vital signs Fluid intake and output Pain management records Anesthesia assessment Medical Record Contents (5 of 5) ? ? ? ? ? Operative reports Medication administration records Discharge planning Patient education Discharge summaries Documentation of Care ? ? ? ? ? ? Record accurate entries Nurse’s charting Documentation and reimbursement Charting by exception Failure to maintain records Medical record battleground Privacy Act of 1974 5 U.S.C. 552 ? Enacted to safeguard individual privacy from misuse of federal records, to give individuals access to records concerning themselves that are maintained by federal agencies, and to establish a Privacy Protection Safety Commission. Health Insurance Portability and Accountability Act (HIPAA) ? Designed to protect the privacy, confidentiality, and security of patient information ? Standards apply to all health information in all formats. HIPAA: Privacy Provision (1 of 2) ? Patients are able to access their records and request correction of errors. ? Patients must be informed of how personal information will be used. ? Patient consent for release of information for marketing purposes required. ? Patients can ask insurers and providers to take reasonable steps to ensure their communications are confidential. ? Patients can file privacy-related complaints. HIPAA: Privacy Provision (2 of 2) ? Health insurers or providers document their privacy procedures. ? Health insurers or providers designate a privacy officer and train their employees. ? Providers may use patient information without patient consent for: ? Purposes of providing treatment ? Obtaining payment for services ? Performing non-treatment operational tasks of the provider’s business HIPAA: Security Provision (1 of 3) ? ? ? ? ? ? Policies and procedures are designed to show how the entity will comply with the act. Entities must adopt a written set of privacy policies and procedures. The privacy officer develops and implements policies and procedures. Policies and procedures must reference management oversight & organization buy-in to comply with documented security controls. Procedures identify employees who will have access to protected health information. Access to protected health information (PHI) in all forms is restricted to employees who have a need for it to complete job function. HIPAA: Security Provision (2 of 3) ? Procedures address access authorization, establishment, modification, and termination. ? There is an ongoing training program. ? Entities that outsource business processes to a third party ensure vendors have framework to comply with HIPAA. ? Care is taken to determine if the vendor further outsources any data handling functions to other vendors, while monitoring whether appropriate contracts and controls are in place. ? There is a contingency plan for responding to emergencies. ? Covered entities are responsible for backing up their data and having disaster recovery procedures in place. HIPAA: Security Provision (3 of 3) ? Recovery plan should document data priority and failure analysis, testing activities, and change control procedures. ? Internal audits review operations with goal of identifying potential security violations. ? Policies and procedures document scope, frequency, and procedures of audits. ? Audits are routine and event based. ? Procedures document instructions for addressing and responding to security breaches. HIPAA: Physical Safeguards (1 of 2) ? Responsibility for security must be assigned to a specific person or department. ? Controls must govern the introduction and removal of hardware and software from the network. ? When equipment is retired, it must be disposed of properly to ensure that PHI is not compromised. ? Access to equipment containing health information should be carefully ...