Doctor patient relationships, ethics and decision-making capacity

Doctor patient relationships, ethics and decision making capacity:

1. Patients exercise “autonomy” in making informed decisions. Physician’s responsibility is to provide all options for treatment but the patient’s decision is final on what type of treatment or no treatment.
2. Informed consent can be revoked at any time, even orally. The patient should be able to understand and comprehend the consent form. Exceptions to informed consent are made in an emergency situation, legally incompetent patient (e.g. severe dementia), therapeutic privilege and in cases where the patient has waived the right to informed consent. Therapeutic privilege is when physicians may withhold information about a patient’s diagnosis or treatment when disclosing it would pose a serious psychological threat, so serious a threat as to be medically contraindicated.
3. Parental consent should be obtained to treat minors (< 18 years of age). Exceptions are medical emergencies, issues related to drug abuse, contraception, pregnancy and sexually transmitted diseases. Emancipated minors - those in the military, married or financially self sufficient) do not need parental consent.

Advance Directives

• Durable power of attorney or health care surrogate/power of attorney: It appoints an individual or individuals as the decision-maker(s) on the patient’s behalf if they are incapacitated and unable to express their desires for treatment.
• Living will: It specifies the wishes of a patient with respect to DNR (do not resuscitate) , CPR, mechanical ventilation, feeding tubes, dialysis etc. DNR means no cardiopulmonary resuscitation and intubation, not cessation of all treatment.
• The living will is only used if the individual is unable to give informed consent.
• When a patient who lacks decision-making capacity has no advance directive and there is no surrogate available and willing to make treatment decisions on the patient’s behalf, or no surrogate can be identified, the attending physician should seek assistance from an ethics committee or other appropriate resource in ascertaining the patient’s best interest.
• An appropriate surrogate is a person who knows the patient best and can more accurately predict the patients wishes. Typically the hierarchy is - spouse-adult children-parents-siblings-other relatives.

4. Patient’s health records are private and nobody including spouse or children have access to them unless the patient so desires.
5. Physicians are allowed to provide adequate analgesia including opiates, to patients with terminal diagnoses if the patient so desires although it carries risk of respiratory depression. Euthanasia or physician assisted suicide is illegal.
6. If a family member requests that certain information (for example, prognostic information in the case of a stroke or malignancy) be withheld from a patient, the physician should ask the patient if he or she would prefer to be told everything or would prefer his or her family to filter information. If a patient explicitly requests that health-related information be conveyed to family members or other loved ones instead of directly to the patient, it is appropriate to honor that request.
7. Romantic relationships with patients are unethical.
8. If a patient under your care confides to you about plans to harm someone, inform the police as well as the intended victim.
9. Acknowledge if a patient is angry and apologize.
10. If an error was made the patient needs to be notified, even if the error did not cause any harm to the patient.
11. Child abuse and elder abuse are reportable to authorities. Most state laws require partner abuse to be reported to authorities.
12. It is mandatory to report reportable diseases, breaching patient confidentiality.
13. Treatment should not be continued if the patient is clinically dead, even if the family demands so. Ethics committee or courts may intervene in such matters.