Unit2
Practice Standards
A Patient's Bill of Rights
Intentional Torts--Assault, Battery, False Imprisonment, Slander and Libel and Invasion of Privacy
Unintentional Misconduct--Duty, Breach of Care, Cause and Injury
Legal Doctrine--Doctrine of Personal Liability, Respondeat Superior, Borrowed Servant, Res Ipsa Loquitor and Forseeability
Ethics--Autonomy, Beneficence, Confidentiality, Double Effect, Fidelity, Justice, Nonmaleficence, Paternalism, Sanctity, Veracity and Respect for Property
Morals--Value of Life, Principal of Goodness or Rightness, Principle of Justice or Fairness, Principle of Truth Telling ( Honesty) and Principle of Individual Freedom
Triage, The Lottery System and Save Doctor First
Paternalism, Radical individualism and The reciprocal view
Priestly Model and Engineering Model
Informed Consent
Introduction to Radiologic Sciences and Patient Care 5th Edition ( Adler and Carlton)
Chapter 22 - Pages 308-316
Chapter 24 - Pages 329-336
Here is what you must complete within Unit 2!!!
1. Reading Assignment
2. Read through the Lesson (read additional documents referred to in the lesson, i.e. Practice Standards, A Patient's Bill of Rights, etc.)
3. Complete Discussion #2 (post your response, read the responses of your classmates and respond to them with any comments you may have)
4. Complete the Unit 2 Critical Thinking Exercise (Instructions are in the Dropbox---Submit your paper through the dropbox)
5. The Unit 2 Exam
We teach you many technical skills in this program, but it is important that you know about the legal and ethical issues facing you as a medical professional. We live in a very litigious society and, more and more, radiologic technologists are being named in lawsuits! Interestingly, the suits are filed most often about "immoral" behavior, not technical skills! This means that you need to be aware of what constitutes good behavior! Now we will discuss some of these issues.
So, it is important to know where you stand, both legally and ethically! Then, you can make good informed decisions in the workplace! Of course, if you live by the Golden Rule, do unto others as you would have them do unto you, you'll never go wrong!
In this section, the following areas will be discussed: Practice Standards, A Patient's Bill of Rights, Medico-Legal Terms and Principles, Ethics and Morals
At this time, we will take a look at the Practice Standards for radiography. It is very important that you read and understand the Practice Standards by which our profession is guided.
These represent the legal standards that could affect us as practicing radiographers!
The written statement describes the radiographer's duties and responsibilities. The Practice Standards define the clinical practice, technical activities and professional responsibilities of imaging and therapeutic professionals.
GO BACK TO THE COURSE CONTENT, UNIT 2 AND CLICK ON THE PRACTICE STANDARDS DOCUMENT!!! READ THROUGH THE PRACTICE STANDARDS AND THEN COME BACK TO THE LESSON!
The Patient's Bill of Rights is a list of patient's rights. It offers some guidance and protection to patients by stating the responsibilities that the hospital and staff have for them and their families during hospitalization.
GO BACK TO THE COURSE CONTENT, UNIT 2 AND CLICK ON A PATIENT'S BILL OF RIGHTS DOCUMENT!!! READ THROUGH THE BILL OF RIGHTS AND THEN COME BACK TO THE LESSON!
The law that governs the relationships between individuals is known as civil law. The type of law that governs the rights between individuals in non-criminal actions is called torts. Torts are not easy to define, but a basic distinction is that they are violations of civil, as opposed to criminal, law. Tort law is personal injury law. The act may be malicious and intentional, or it may be the result of negligence and disregard for the rights of others. Torts include those conditions whereby the law allows for compensation to be paid to an individual when that individual is damaged or injured by another. There are two types of torts - those resulting from intentional action and those resulting from unintentional action.
There are several situations in which a tort action can be taken against the health professional because of some action that was deliberately taken.
Intentional tort includes:
1. Civil Assault
2. Civil Battery
3. False Imprisonment
4. Libel and Slander
5. Invasion of Privacy
Assault is performing or threatening to perform intentional injury for bodily harm to another by administration of (1) poison, (2) anesthetics, (3) narcotics, or (4) willful blows with weapons or other instruments. Assault is defined as the threat of touching in an injurious way. If the patient feels threatened and is caused to feel that he or she will be touched in a harmful manner, there may be justification for a charge of assault. To avoid this, it is absolutely essential that the radiographer explain what is going to happen and reassure the patient in any situation where the threat of harm may be an issue. Never use threats to gain a patient's cooperation. This applies when working with children as well as adults. A tort of civil assault can be filed if a patient is apprehensive of injury by the imprudent conduct of the radiographer. If found guilty, the radiographer could be held liable or responsible to provide financial compensation to the patient for damages that may have resulted from any apprehension.
Battery consists of touching a person without permission. Again, a clear explanation of what is to be done is essential. If the patient refuses to be touched, that wish must be respected. Actually, battery implies that the touch is a willful act to harm or provoke, but even the most well-intentioned touch may fall into this category if it has been expressly forbidden by the patient. This should not prevent the radiographer from placing a reassuring hand on the patient's shoulder, as long as the patient has not forbidden it, when there is no attempt to harm or invade the patient's privacy. On the other hand, a radiograph taken against a patient's will, or on the wrong patient, could be construed as battery. This emphasizes the need for consistently double checking patient identification. If a patient refuses a particular hypodermic injection, and the nurse approaches the patient and attempts to administer the medication, it would be an assault. If the nurse administers the injection, it would be a battery. The battery is the assault carried out or completed. Therefore, the patient must be conscious for an assault to occur. An unconscious patient may be the victim of battery.
There are certain circumstances when an individual committing battery will not be liable for battery. These are circumstances in which the conduct is said to be privileged, e.g., a radiographer restraining a patient who is obviously about to strike or injure other patients and/or himself/herself. The action of the radiographer to protect other patients and their interests outweighs the damage that may be sustained by restraining the patient and his/her interest. Holding a babies arms and legs to get an image is okay, but you must explain what you are going to do to the parent or guardian in the room.
False imprisonment is intentional confinement without authorization by one who physically constricts a person using force, threat of force, or confining clothing or structures. False imprisonment becomes an issue when the patient wishes to leave and is not allowed to do so. Inappropriate use of physical restraints may also constitute false imprisonment. The confinement must be intentional and without legal justification. Freedom from unlawful restraint is a right protected by law. If the patient is improperly restrained, the law allows redress in the form of damages for this tort. The proof of all the elements of false imprisonment must be established in order to support that an illegal act was done. In situations where patients are a danger to themselves or to others, the patient may be restrained. A situation where false imprisonment may arise is when a radiographer uses a brat-board to restrain a child and does not explain to the parents the reason for the restraint.
Libel is written defamation of character. Oral defamation is termed slander. These are torts that affect the reputation and name of another. The basic element of the tort of defamation is that the oral or written communication is made to another person other than the one defamed. The law does recognize certain relationships that require an individual be allowed to speak without fear of being sued for defamation of character, e.g., radiology department supervisors who must evaluate employees or give references regarding an employee's work have a qualified privilege. Radiographers can protect themselves from this civil tort by using caution when conversing within the hearing distance of patients.
Invasion of privacy charges may result when confidentiality of information has not been maintained or when the patient's body has been improperly and unnecessarily exposed or touched. Protection of the patient's modesty is vitally important when performing radiographic procedures.
Whenever a radiographer unintentionally causes injury to a patient, it may be determined that a negligent act has been committed. Negligence refers to the neglect or omission of reasonable care or caution. The standard of reasonable care is based upon the " Doctrine of the Reasonably Prudent Man ". This standard requires that a person perform as any reasonable man of ordinary prudence, with comparable education and skills, would perform under similar circumstances. In the relationship between a professional person and a patient or client, there is an implied contract to provide reasonable care. An act of negligence in the context of such a relationship is defined as malpractice. Negligence, as used in malpractice law, is not necessarily the same as carelessness. A person's conduct can be held to be negligent, in the legal sense, if a person acts carefully. For example, if a radiographer attempts a procedure for which he/she has had no prior training or experience and does it carefully, the conduct, nevertheless, can be deemed negligent if harm results to the patient.
For a radiographer to be found negligent in a court and be held liable for damages, the civil proceedings must establish the following elements:
1. Duty expected of the radiographer (standard of care)
2. Breach of duty by the radiographer
3. Cause of injury due to the radiographer's negligence
4. Injury to the patient actually occurred
The courts will interview experts in the field or workers within the occupation to determine if the proper standard of care has been followed.
The radiographer has the duty to perform radiographic procedures acting as any reasonable and prudent radiographer would have acted under similar circumstances. He /she is bound to perform the procedure following accepted protocols and policies and following the "routine" for the department. A radiographer would not leave an infant unattended.
The radiographer has a duty to provide radiographs that are of optimum quality for the physician's diagnosis. If the patient's condition deteriorates due to the radiographer's failure to provide optimum quality radiographs or images for the physician to interpret, there is a breach of Standard Care. This would be resolved in court with the assistance of expert witnesses.
A patient's injury must be the direct result of a radiographer's negligence. The radiographer has the duty to ensure that a dizzy or semiconscious patient does not fall from an x-ray table. It would be a breach of duty if the radiographer left the patient unattended in the x-ray room. There would be a direct connection between the patient falling and the radiographer leaving the room.
If a patient falls from an x-ray table because the radiographer leaves the room, but the patient is not injured, the patient cannot expect to receive compensation for nonexistent injuries. A personal injury or tort will not be successful in establishing liability if there are no damages. To determine if negligence exists, the court will determine if a "reasonable man" could have anticipated the harmful results. Once again, the court will interview experts or workers in an occupation to determine if the proper standard of care has been followed. Proximate or legal cause must show a connection between the act and the resultant injury or harm. A cause-effect relationship must exist, and the cause must be substantial enough to lead reasonable men to conclude that it is indeed the cause of harm. To establish a claim of Malpractice then, a claimant must prove the satisfaction of the court that three things are true:
1. The patient has sustained some loss, damage, or injury
2. The person or institution being sued is the party at fault or responsible for the loss
3. The loss is attributable to negligence or improper practice
If there is one rule that every radiographer should know and clearly understand, it is the fundamental rule of law that every person is liable for his/her negligent conduct. This is known as the "Doctrine of Personal Liability". This means that even though someone else may be sued and held liable under another rule of law, it does not negate one's own responsibility.
The "Doctrine of Respondeat Superior" (let the master answer or respond) is a legal doctrine that holds an employer liable for negligent acts of employees that occur while they are carrying out his/her orders or otherwise serving his/her interests. The Doctrine of Respondeat Superior applies only when there is an employee/employer relationship and only with respect to negligent acts committed within the scope of that employment. The theory behind the doctrine is that one who is an employer should be held legally responsible for the conduct of those employees whose actions he is obligated to direct or control. Often the critical test in determining liability is who had control over the employee?
The "Doctrine of borrowed Servant" can be applied to a radiographer who is performing radiographic procedures under the guidance and direction of the radiologist. The radiologist must be involved in the daily performance of radiographers and see to it that they perform their duties properly. The classic example occurs in the operating room, where the surgical personnel, as employees of the hospital, are paid and controlled by the hospital administration. But that same employee is directed and controlled by the surgeon during the operation. Similarly, the courts may envision that a hospital-employed radiographer comes under the control of the radiologists in the department. In a negligence suit against a radiographer, the hospital may attempt to regain compensation for indemnification or loss from the radiology group or radiologist in charge.
The "Doctrine of Res Ipsa Loquitur" (the thing speaks for itself), are cases where the procedures begin with the facts of evidence and proceed to establish that these facts would not have been true if there had not been negligence on someone's part. In these cases, the defendant is required to prove his innocence. For example, a pair of forceps has been left in a patient's abdomen after a surgical procedure. That the forceps are in the patient is a provable fact. They were not in the patient before surgery, and could only be in the patient as a result of negligence on the part of the surgical team.
A simple definition is that an individual could reasonably foresee that certain action or inaction on his/her part could result in injury to another person. It also means that the injury actually suffered must be related to the foreseeable injury. Routine equipment check, or a program of quality control is important in overcoming this doctrine.
Now that we've covered the legal issues facing radiographers, let's consider the ethical ones. This area is harder to quantify and as medicine advances, the answers to ethical questions are harder to find. While ethical behavior may seem hard to define, there are guidelines here just as there are with legal issues. We will examine ethical issues in more detail after you read the ARRT Standard of Ethics. The ARRT Standard of Ethics document includes the Code of Ethics and the Rules of Ethics.
GO BACK TO THE COURSE CONTENT, UNIT 2 AND CLICK ON THE ARRT STANDARDS OF ETHICS DOCUMENT!!! READ THROUGH THE STANDARDS OF ETHICS AND THEN COME BACK TO THE LESSON!
Ethics comes from the Greek ethos, meaning character. Ethics pertain to the individual character of a person or persons. Ethics also can be defined as the study of morality. Here are some ethical terms that you need to know.
Autonomy - the right to make decisions without being pressured
Beneficence - all acts should be meant to obtain a good result
Confidentiality - the right to privacy
Double Effect - some actions produce both a good and bad affect
Fidelity - keeping promises or fulfilling commitments
Justice - equal treatment
Nonmaleficence - do no harm and prevent harm
Paternalism - making a decision for another because "you know best"
Sanctity - all life is precious
Veracity - honesty
Respect for Property - do not waste or damage the property of others
Now that you know what ethics are and you have read through some of the terminology, it is time to take a look at morals. Socrates said, "The unexamined custom or tradition is not worth living". So, how do we define moral behavior.
Morality comes from the Latin moralis, meaning customs or manners. Morality seems to point to the relationships between human beings. Morality deals with human conduct and human values. Morality deals with how humans treat other beings so as to promote mutual welfare, growth, creativity and meaning. It is also to strive for what is good over what is bad and what is right over what is wrong. Taken one step further, a moral system should contain certain guidelines that can be used to check for ethical correctness.
For our purposes, we will choose the following five values to review:
1. Value of Life
2. Principal of Goodness or Rightness
3. Principle of Justice or Fairness
4. Principle of Truth Telling ( Honesty)
5. Principle of Individual Freedom
The value of life guideline says, "Human beings should revere life and accept death". This means every life, not just the lives you choose to place value on.
The principle of goodness or rightness includes:
1. Beneficence - to promote goodness over badness and to do good
2. Nonmaleficence - to cause no harm and prevent harm
But, how do you define "goodness" or "badness", "right" or "wrong"?
For goodness, we could use the terms happiness, pleasure, harmony, life, freedom, honor, etc.
For badness, We could use the terms pain, lack of excellence, unhappiness, etc.
The principle of justice or fairness deals with the "fair" distribution of good and bad. Here are some questions you can ask yourself. How should this or how is this done in the medical profession? Who should be treated fairly? Should all patients be treated fairly? Does a "guilty" patient deserve different treatment? Can you be objective?
Now that you have asked yourself these questions, we will take a look at how this affects the medical profession. We will discuss several areas involved with this principle.
Triage
Have you ever heard the term triage?
Triage is the prioritization of patients for medical treatment. It is the prioritizing of sick or injured people for treatment according to the seriousness of their condition or injury. For example, when a patient enters the emergency room he or she is taken to triage where his/her medical situation will be evaluated. After he/she is evaluated, treatment can begin. Triage really comes into play when there is a major incident that has occurred. There has to be a way to decide which patients will be treated first and which ones will have to wait. If any of you have seen the movie Pearl Harbor, there is a great example of triage in that movie. When the bombs hit Pearl Harbor, there were too many victims to be seen and treated. Many healthcare workers were assessing patients and deciding what treatment they would receive. The patients were triaged in three ways:
1. Those who are likely to live
2. Those who are likely to die regardless of care
3. And those that immediate care might make a positive difference in the outcome
Those who were likely to die regardless of care were marked and left to die. The others were treated.
The Lottery System
For the lottery system, names are drawn to see who will receive treatment. For example, if 17 people need dialysis, but there are only slots for 10 people, how do you choose who will receive the dialysis. How do you choose between a housewife and mother, a lawyer, a doctor, an executive, a member of the clergy, a teacher or a laborer. All of these people are equally deserving of the treatment. So, their names are put in a drawing and the ten names that get pulled out are chosen to receive the dialysis treatment. This is considered the just and fair way to choose who will receive treatment because, with a drawing, they all have an equal chance of obtaining the good.
Save Doctors First
For saved doctors first, in an emergency situation, medical professionals who can be put back into service after receiving medical attention should have first priority. Then, patients who can, with some certainty, be saved should be next.
There's one other question I would like to ask you. Why is AIDS reported anonymously, but leprosy or hepatitis are reported with names? Can you answer this?
The reason AIDS is reported anonymously is because there is a stigma connected with AIDS. People must understand what it means to have HIV and AIDS. There are laws that protect those with AIDS because they could lose their jobs, societal status, friends and family if their condition is known. As healthcare professionals, we do not have the right to know if the patient has AIDS unless the patient decides to tell us. This is why you should use universal precautions on all patients.
The principle of truth telling is the basis of meaningful communication. Here are some questions you can ask yourself. What happens to relationship that does not embrace this principle? Is the relationship meaningful if it is surrounded by lies? Do you think it is ever okay to omit the truth?
Lying is an intentionally deceptive message in the form of a statement. Lying by omission, involves the not stating of certain information that is vital to a decision, relationship or other important human activity. It is appropriate for us to follow the old saying, "honesty is the best policy".
With the principle of individual freedom, you to choose how to be moral within the framework of the four other principles. It also says that everyone deserves freedom of choice--- including your patience.
there are three major views about what the relationship between patient and a medical professional might be.These include:
1. Paternalism
2. Radical individualism
3. The reciprocal view
Paternalism is characterized by the statement, "The doctor always knows best". Essentially, the physician acts as a patient's parent by making all the decisions. Paternalism can be further divided into the engineering model or priestly model.
In the priestly model, medical professionals are seen as infallible "icons". By virtue of their advanced education, they must be right. They should benefit the patient and do no harm to the patient.
In the engineering model the medical professional treats the patient as a "malfunctioning" biological machine that needs to be "fixed". In this model value judgments are irrelevant as are emotions on either side. So, this model is a value free and purely scientific model.
Some factors that encourage people to support paternalism are: patient can be confused by complex information, patients don't want to hear the information, patients shouldn't be frightened by medical professionals, the odds of a poor outcome are usually rare, describing side effects can cause them to occur in a patient (power of suggestion). This particularly applies to informed consent.
Informed consent:
1. Explains the procedure
2. Explains the pain associated before, during and after the procedure
3. Explains the possible complications
4. Explains how long the procedure should take
GO BACK TO THE COURSE CONTENT, UNIT 2 AND CLICK ON AN INFORMED CONSENT!!! READ THROUGH THE INFORMED CONSENT AND THEN COME BACK TO THE LESSON!
Radical individualism is at the opposite end of the spectrum. It suggests that since patients have absolute rights over their own bodies, they should be able to reject any and all recommendations by medical personnel. In essence, all discussions are in the hands of the patients. Justification for this is that doctors are human and they can make mistakes.
The reciprocal view is referred to as the "team approach". Patients and their families are key members of the team and all healthcare professionals work together for the good of the patient. In this view, should the relationship be one of equality between the patient and the medical professional or perhaps a verbal or written contract between two individuals? Written contracts would include forms like the durable power of attorney, consent forms and do not resuscitate forms. Do you enter into a contract when you work with a patient? The contract you enter into with the patient is that you will take care of the him/her and get the best possible images.
What kinds of questions do you think a patient has a right to ask? Which ones can you answer?
One family practice doctor in Seattle furnished his patients with a list of questions to ask. The list included:
1. What is wrong with me?
2. What caused it?
3. What should be done about it?
4. What will it cost?
5. How long will it take?
6. What test should be done and why?
7. What is my prognosis?
8. What will you do next?
9. Is it necessary?
10. Is it dangerous?
11. Do I have any alternatives? if so, what are they?
12. If I must go into the hospital, how long will I be there?
13. How long will I be laid up and when can I go back to school or work?
A list of questions can really help to stimulate communication between doctors and patients and also enhance the doctor-patient relationship. This list of questions would be answered by a physician. Radiologic Technologists must be careful with the information that they give to a patient. We do not give results of images or medical imaging studies to patients. It is out of the scope of our practice to read any image. We can and should let the patient know that the Radiologist will read his/her images and send a report to his/her doctor.
•Competence: Knowing and adhering to professional standards and maintaining professional competence reduce liability exposure
•Compliance: The compliance by health professionals with policies and procedures in the medical office and hospital avoids patient injuries and litigation
•Charting: Charting completely, consistently, and objectively can be the best defense against a malpractice claim
•Communication: Patient injuries and resulting malpractice cases can be avoided by improving communication among healthcare professionals
•Confidentiality: Protecting the confidentiality of medical information is a legal and ethical responsibility of health professionals
•Courtesy: A courteous attitude and demeanor can improve patient rapport and lessen the likelihood of lawsuits
•Caution: Personal injuries can occur unexpectedly on the premises and may lead to lawsuits
Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act of 1996, is a set of rules to be followed by doctors, hospitals and other health care providers. HIPAA helps ensure that all medical records, medical billing, and patient accounts meet certain consistent standards with regard to documentation, handling and privacy.
HIPAA Laws and Regulations are divided into five Rules: