Legal and Medical Ethics on the PANCE

As we all know, the PANCE will evolve and change from time to time.  You can learn all the details in our PANCE Blueprint article here.  Today, we will be discussing a newer section of the PANCE, which is regarding legal and medical ethics.

There are a list of basic principles, that PA students preparing to take the PANCE, must now be prepared for.

These topics include:

  • Informed consent and refusal
  • Cultural and religious beliefs related to health care
  • Living will
  • Organ donation
  • Advance directives
  • Do not resuscitate
  • Do not intubate
  • Code status
  • Medical power of attorney
  • Patient and provider rights and responsibilities
  • Privacy
  • Security
  • Accountability related to medical records

 

Medical and legal ethical issues can come about in every encounter with each patient you see.  In the vast majority of cases, the moral choice or decision is clear; unfortunately, there are situations with patients, family members, and others that can become complicated and aren’t so straight forward. 

The good news is there are guidelines in place, which can help us make the right decisions.

The first thing we need to be aware of is the definition of the relationship between the physician assistant and patient.

The AAPA states:

PAs practice medicine with physician supervision; therefore, the care that a PA provides is an extension of the care of the supervising physician. The patient–PA relationship is also a patient–PA–physician relationship.

PAs are professionally and ethically committed to providing nondiscriminatory care to all patients. While PAs are not expected to ignore their own personal values, scientific or ethical standards, or the law, they should not allow their personal beliefs to restrict patient access to care.

A PA has an ethical duty to offer each patient the full range of information on relevant options for their health care. If personal moral, religious, or ethical beliefs prevent a PA from offering the full range of treatments available or care the patient desires, the PA has an ethical duty to refer a patient to another qualified provider”

 

Statement of Values of the PA Profession

 

The AAPA published a list of values all physician assistants must abide by:

  • PAs hold as their primary responsibility the health, safety, welfare, and dignity of all human beings.
  • PAs uphold the tenets of patient autonomy, beneficence, nonmaleficence, and justice.
  • PAs recognize and promote the value of diversity.
  • PAs treat equally all persons who seek their care.
  • PAs hold in confidence the information shared in the course of practicing medicine.
  • PAs assess their personal capabilities and limitations, striving always to improve their medical practice.
  • PAs actively seek to expand their knowledge and skills, keeping abreast of advances in medicine.
  • PAs work with other members of the health care team to provide compassionate and effective care of patients.
  • PAs use their knowledge and experience to contribute to an improved community.
  • PAs respect their professional relationship with physicians.
  • PAs share and expand knowledge within the profession

 

Nonmaleficence, Beneficence, and Justice

Nonmaleficence is the basic right that all health care professionals follow, which is to do no harm.  This is part of the Hippocratic Oath in which all healthcare providers take.

Beneficence is the action of benefiting the patient.  Sometimes not doing certain things, whether it be a test, procedure, or starting a medication that can harm a patient, is considered beneficence. 

Additionally, you want to do your best to use the given healthcare modalities and therapies to help your patients.

Beneficence ultimately boils down to the adage: just because you have something, does not mean that you need to use it.

Meaning just because you can do a procedure or use a particular medication, does not mean you always should, even if there is a potential indication for said therapy. 

Everything is based on each individual person, situation, and case.

The goal is to act in the patient’s best interest.

Justice means that patients should receive similar care and distribution of resources across the board.

 

 

Patient Autonomy

Patient autonomy has been a critical change in medicine over the past decade.  It is often referred to as patient-centered care.  Autonomy is the ability for the patient to make a decision, as well as to think and decide for one’s self.  A patient has the right to refuse treatment, testings, and procedures, and/or to choose their own treatment.

This newer trend in medicine should encourage a relationship between the patient and healthcare provider; ultimately this encourages autonomy and not paternalism. 

In a paternalistic relationship, one party would tell the other what was going to occur regarding their care without any dialogue for alternative therapies.

Something that goes along with autonomy, is the principle of informed consent.  Encouraging patient autonomy means that health care providers must explain the potential options a patient has. 

In these instances, that patient must be appropriately informed so they can make the best decision possible for their own personal care.

With any possible medical treatment or procedure, the patient must know the benefits and the possible risks associated. 

For example, a peripherally inserted centralized catheter (PICC line), provides a fantastic way to give antibiotics, fluids, and/or other medications to patients.  However, the provider must let the patient know of the potential associated risks that can occur, such as damage to the artery or nerves, and/or the risk of infection.

The patient must also be educated, on other potential options for treatment, that may be suitable.  They also have the right to decline or refuse any possible medical treatment, medication, or procedure. 

Additionally, the patient must be educated and aware of the potential outcome and/or consequences of not having the procedure, treatment, or medication.

As you have read, there is much more to medicine than simply knowing the medical facts and/or learning how to diagnose patients.  One must be able to communicate with patients about their options adequately.

Once a patient has this required knowledge, a patient can then make an informed decision and can appropriately give informed consent.

 

 

The Patient’s Rights

Patients also have a set of rights that health care providers must abide by.  These rights are listed in every clinic, hospital, and health care facility and are in the open for anyone to read, usually by an entrance or reception desk.  These rights are also given to the patient who is establishing care with a new healthcare provider.

These bills or rights will often include several of the following… 

  • The patient has the right to be fully informed regarding any medical treatment, procedure as well as being informed about their medical conditions.
  • Patients have the right to know that their medical information and record is private and confidential.  This is known as the patient-provider privilege, and this confidentiality between the patient and provider is crucial to creating a good relationship.
  • Patients have the right to be treated by the health care provider that they choose to be treated by.  This also pertains to consultations and specialists as well.  The patient has the right to refuse any part or all of the recommended medical treatment.  No matter how strongly a therapy is recommended, the patient still has the right to refuse if of sound mind.
  • The patient has the right to continue to see and be treated by the same provider or to switch health care providers if they are unhappy with the services they received from a past provider.

 

As stated in the second bullet point, it’s important that a patients’ medical record be kept private at all times, unless explicit written permission has been given to the physician assistant to share.

There are, however, exceptions in which permission isn’t required:

  • Workers compensation
  • Communicable diseases
  • HIV
  • Gun/Knife wounds
  • Abuse
  • Substance Abuse

Keep in mind that the laws and regulations might vary per jurisdiction.

The chart is the legal property of the practice. However, the information contained within the chart is property of the patient. Because of this, the patient has the right to know what is noted in their chart.

 

Physician Assistant Rights

The PA is under no obligation to care for a patient if there isn’t any pre-existing relationship. The exception here is in an emergency situation.

In an emergency situation, the physician assistant is expected to care for every patient and to arrange the proper follow up care.

 

Regarding the care of family members, the AAPA states:

“Treating oneself, co-workers, close friends, family members, or students whom the PA supervises or teaches may be unethical or create conflicts of interest.

For example, it might be ethically acceptable to treat one’s own child for a case of otitis media but it probably is not acceptable to treat one’s spouse for depression. PAs should be aware that their judgment might be less than objective in cases involving friends, family members, students, and colleagues and that providing “curbside” care might sway the individual from establishing an ongoing relationship with a provider.

If it becomes necessary to treat a family member or close associate, a formal patient-provider relationship should be established, and the PA should consider transferring the patient’s care to another provider as soon as it is practical.

If a close associate requests care, the PA may wish to assist by helping them find an appropriate provider. There may be exceptions to this guideline, for example, when a PA runs an employee health center or works in occupational medicine. Even in those situations, the PA should be sure they do not provide informal treatment, but provide appropriate medical care in a formally established patient-provider relationship.”

 

Medical Ethics Miscellaneous

  • PAs should place service to patients before personal material gain.
  • It’s discouraged to accept gifts of any kind as this can influence the clinicinan’s judgement.
  • A physician assistant should not misrepresent their professional identity.
  • It’s unethical for a physician assistant to have any sexual relationship with a patient and/or with anyone who has influence over a patient.
  • PA’s should report any clinician who is performing illegal or unethical conduct. They should also report clinicians who are impaired due to a physical illness, mental health illness, and/or loss of motor skills. The goal is to put patients first and to protect the public.
  • If alternative medicine is requested by the patient, there is an ethical obligation to understand the therapy. If the alternative therapy is deemed to be harmful, it’s the clinicians ethical obligation to dissuade against its use.

 

In Conclusion…

For the PANCE, prospective test takers should be aware of and accustomed to the terms and rights of legal and medical ethics, and be able to apply these to medical circumstances and situations. 

These issues are not only applicable on the PANCE, but they will be pertinent for day to day clinical practice. 

Just like with any relationship, communication is the key, and this is no different in the patient-provider relationship.

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