Medical Jurisprudence
Richard M. Watson, D.O.
Family Medicine Residency Program Director
Lankenau Medical Center
Last Updated: 1/17/16
Medical Jurisprudence
Definition: The branch of the law that deals with
the application of law to medicine.
Lecture Objectives
Identify and discuss high-yield topics.
Essentials of Medical Ethics
Autonomy: patients have the right to make their own
informed decisions even if contrary to medical advice.
Beneficence: care be provided with the intent of doing good
for the patient.
Non-maleficence: provide care under the assumption you are
not doing harm or minimizing harm to the patient.
Justice: distribution of your care and resources equitably.
HIPPA
Definition of HIPPA
Privacy rule requires health care providers to
obtain patient authorization to use or disclose
individually identifiable health information with
certain broad exceptions.
An eight year old child is brought to your office for a school entry
examination. During the exam you notice multiple bruises on the
childs back and legs in various stages of healing. You suspect
child abuse. Which of the following options is the most appropriate
action for you to take?
1. Confront the childs patient and threaten them with physical
violence if it happens again.
2. Call the childs neighbor to have them monitor the situation
for you.
3. Promptly notify the proper authorities about your suspicions.
4. Take the child into your custody.
An eight year old child is brought to your office for a school entry
examination. During the exam you notice multiple bruises on the
childs back and legs in various stages of healing. You suspect
child abuse. Which of the following options is the most appropriate
action for you to take?
1. Confront the childs patient and threaten them with physical
violence if it happens again.
2. Call the childs neighbor to have them monitor the situation
for you.
3. Promptly notify the proper authorities about your suspicions.
4. Take the child into your custody.
HIPPA Exceptions
Question
writers look
Notification of patient death to authorities for
exceptions
Court order
Serious contagious disease (CDC reporting)
Child abuse (must report) or suspicion of child abuse
Serious and immediate threat of harm to identifiable
person(s).
EMTALA
Emergency Medical Treatment & Labor Act
Significance: any patient presenting to the ED is to
be treated and stabilized regardless of medical
insurance.
Advanced Care Directive
An eighty year old man is brought to the ED by ambulance with his
wife after a sustaining injuries in a motor vehicle accident. The
man is alert and oriented but has suffered serious, potential life
threatening, lower extremity injuries. His wife informs you his
advanced directives on file state that he does not wish to have his
life prolonged in the event of serious medical disease/injury. What
should you do next?
1. Make the patient comfortable with proper pain management
and contact hospice.
2. After explaining to the patient the extent of his injuries,
suggested treatment and potential outcomes, ask the
patient for his decision.
3. Move on to your next patient in need of medical attention.
4. Medical care should be directed by his wife.
An eighty year old man is brought to the ED by ambulance with his
wife after a sustaining injuries in a motor vehicle accident. The
man is alert and oriented but has suffered serious, potential life
threatening, lower extremity injuries. His wife informs you his
advanced directives on file state that he does not wish to have his
life prolonged in the event of serious medical disease/injury. What
should you do next?
1. Make the patient comfortable with proper pain management
and contact hospice.
2. After explaining to the patient the extent of his injuries,
suggested treatment and potential outcomes, ask the
patient for his decision.
3. Move on to your next patient in need of medical attention.
4. Medical care should be directed by his wife.
Definition
A legal document in which a person specifies what actions
should be taken for their health if they are no longer able
to make decisions for themselves because of illness or
incapacity.
Does not come into effect until the patient is incapable of
making their own decisions.
Key
Point
Types
Living Will: list of items the patient wants or doesnt
want.
Durable Power of Attorney: patient appoints someone to
make decisions for them.
Patient Self Determination Act
1. The PSDA requires all health care agencies to recognize the
living will and durable power of attorney for health care.
2. The Act applies to hospitals, long-term care facilities, and home
health agencies that get Medicare and Medicaid reimbursement.
3. Under the PSDA, health care agencies must ask you whether
you have an advance directive.
4. They also must give you information about your rights under
state law.
Witnesses
1. Two (2) witnesses required.
2. Must be at least 18 yo.
3. Cannot be the healthcare provider, work for the healthcare
provider, work at the place you live.
4. Must know the patient.
5. One (1) of the two witnesses cannot be related or benefit
financially after the patients death.
6. Must see the patient sign the form.
Patient
Autonomy
Informed Consent
A 15 year old girl is brought to the ED by fire rescue. She is
unconscious. CT scan confirms intracranial injuries requiring
emergency surgery. Her parents are not available to provide
consent. What is the best available option?
1. Perform the life saving surgery since consent is implied in
this situation.
2. Do your best to stabilize the patient without performing
surgery.
3. Obtain a court order to perform the life saving surgery.
4. There is nothing you can do without parental consent.
A 15 year old girl is brought to the ED by fire rescue. She is
unconscious. CT scan confirms intracranial injuries requiring
emergency surgery. Her parents are not available to provide
consent. What is the best available option?
1. Perform the life saving surgery since consent is implied in
this situation.
2. Do your best to stabilize the patient without performing
surgery.
3. Obtain a court order to perform the life saving surgery.
4. There is nothing you can do without parental consent.
Five Components of Informed Consent
1. Nature of procedure
Missing
2. Risk of procedure element(s)?
3. Alternatives to procedure
4. Expected benefits of procedure
5. Potential consequences of not doing anything
Application of Consent
Applies to adults with capacity to make decisions
Consent is implied in cases of emergency
Classic board Beneficence
question
Consent of Minors
Minors (under age 18) presumed to be
incompetent to make their own decisions.
Only parents or legal guardians can give legal
consent
Dont get tricked up
by other family
members
Exceptions to Parental Consent
Emergency Situations: minors life is at risk or at
risk of serious harm.
Emancipated minor: married, divorced,
independent & self supporting.
Specific Health Care Situations: STD tx,
contraception, prenatal care, substance abuse
What do
question writers Exceptions
look for?
Parens patriae
Grants power to the state to protect persons who
are legally unable to act on their own behalf.
Parents dont have the right to deny life saving
care to minors due to religious exemption.
Good question
material
Informed Refusal
Patient must be fully informed of the effects and
potential outcomes of refusing therapy including
potential harm.
Malpractice
Definition of Malpractice
Malpractice is a preventable error in patient care
that deviates from the standard of care in a local
community resulting in harm to the patient.
A law suit needs to be filed within the statute of
limitations.
Common Allegations
Failure to diagnose
Delay in diagnosis
Failure to follow up
Malpractice Claim Criteria
Duty Owed
Duty Breached
Causation
Damages
Physician only needs to prove one does not exist.
Important
Point
Duty Owed
Has a doctor-patient relationship been established?
A doctor-patient relationship is formed if a partial
history is taken and medical advice has been
provided.
Duty Breached
Has the physician failed to fulfill his/her duties to the
patient?
Did your actions fail to comply with the standard
of care in the local community?
Causation
Can the actions of the physician be attributed to the
patients complaint?
Are your actions responsible for the patients complaint?
Damages
Did the actions of the physician result in harm?
Maybe, maybe not.
What to Do?
Do what a reasonable, cautious, prudent physician
would do.
Follow the guidelines when practicing. Refer
to Evidenced Based Medicine when possible.
Guidelines and Evidenced Based Medicine are
unbiased, current, comprehensive,
recognizable and created by experts in the
field.
Many questions
based on existing
guidelines
Documentation
Poor medical record documentation is the leading
reason of medically defensible malpractice cases
resulting in settlement or lost at trial.
If you didnt document it, you didnt do it !
Another
important
point
Non Compliance
Ultimately the more learned partner - the physician -
should take the lead in giving patients information and
urging them to comply with recommendations.
Then document.
Document why the established goal is not being
achieved and that the patient has been informed of
the risks of continued noncompliance.
Copying & Pasting
The copying and pasting of one providers note into
another providers is:
Extremely common
Recent
Fraudulent development so
expect a question
Indefensible
Can produce inaccurate information
Patient Termination
You can terminate or fire a patient from your practice for all of the
following reasons except:
1. Failing to pay their bills for your service.
2. Not adhering to prescribed therapy.
3. Being abusive to office staff.
4. Incompatible personality.
5. None, all of the above are acceptable reasons for patient
termination
You can terminate or fire a patient from your practice for all of the
following reasons except:
1. Failing to pay their bills for your service.
2. Not adhering to prescribed therapy.
3. Being abusive to office staff.
4. Incompatible personality.
5. None, all of the above are acceptable reasons for patient
termination
Reasons for Patient Termination
Non Compliant Patient
Patient abusive to staff
Patient fails to pay bills
Incompatibility of personality
Disagreement with recommended therapy
Continual cancellation of appointments
Dishonesty
Initiation of legal proceedings against the physician
How to Document a Patient Firing
Medical record should contain:
Objective documentation of rational reason
Use a professional tone
Include a referral resource for patient to find a new physician
Provide adequate notice. Typically 30 days notice.
Absolutely no limiting of care during the notice period.
Maintain a copy of the letter of termination in the patient record.
Provide a copy of medical records upon receipt of proper
authorization.
Res Ipsa Loquitur
The Thing Speaks for Itself
Meaning: no single person can be identified for an
obvious negligent act so all involved are held
liable.
Example: patient goes to the OR for elective
cholecystectomy, suffers a fractured arm while
under anesthesia that is noticed post-op.
Respondent Superior
Let the Master Answer
Meaning: in many situations, the employer
(physician) is responsible for the actions of their
employees.
Example: patient calls office to speak to physician
for medical advice. Instead, inappropriate medical
advice is provided by the physicians medical
assistant resulting in harm.
The End
