Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement.

Background and Rationale: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as "unrepresented." There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice.Purpose and Objectives: This multisociety statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting.Methods: An interprofessional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law.Main Results: The committee designed its policy recommendations to promote five ethical goals: 1) to protect highly vulnerable patients, 2) to demonstrate respect for persons, 3) to provide appropriate medical care, 4) to safeguard against unacceptable discrimination, and 5) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: 1) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; 2) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; 3) institutions should manage decision-making for unrepresented patients using input from a diverse interprofessional, multidisciplinary committee rather than ad hoc by treating clinicians; 4) institutions should use all available information on the patient's preferences and values to guide treatment decisions; 5) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; 6) institutions should employ this fair process even when state law authorizes procedures with less oversight.Conclusions: This multisociety statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.

Teaching legal competencies through an individualized elective in medicine and law.

Medical education, including education intended to prepare future physicians to care to older individuals, should include development and implementation of competencies relating to a physician's ability to understand and interact with the legal environment and legal actors who will affect the practice of medicine. The wisdom of integrating legal knowledge into the medical curriculum has been documented, and literature discusses the content and methods of teaching medical students and residents about law and the legal system. This article describes one unique but replicable, pedagogical approach to preparing future physicians to thrive in their inevitably interprofessional careers as they fulfill the fiduciary responsibilities that lie at the heart of their therapeutic and advocacy relationships with older patients.

Medical Malpractice in Dermatology-Part II: What To Do Once You Have Been Served with a Lawsuit.

Facing a malpractice lawsuit can be a daunting and traumatic experience for healthcare practitioners, with most clinicians naïve to the legal landscape. It is crucial for physicians to know and understand the malpractice system and his or her role once challenged with litigation. We present part II of a two-part series addressing the most common medicolegal questions that cause a great deal of anxiety. Part I focused upon risk-management strategies and prevention of malpractice lawsuits, whereas part II provides helpful suggestions and guidance for the physician who has been served with a lawsuit complaint. Herein, we address the best approach concerning what to do and what not to do after receipt of a legal claim, during the deposition, and during the trial phases. We also discuss routine concerns that may arise during the development of the case, including the personal, financial, and career implications of a malpractice lawsuit and how these can be best managed. The defense strategies discussed in this paper are not a guide separate from legal representation to winning a lawsuit, but may help physicians prepare for and cope with a medical malpractice lawsuit. This article is written from a US perspective, and therefore not all of the statements made herein will be applicable in other countries. Within the USA, medical practitioners must be familiar with their own state and local laws and should consult with their own legal counsel to obtain advice about specific questions.

Medical Malpractice in Dermatology-Part I: Reducing the Risks of a Lawsuit.

Malpractice risk is a common source of concern for the practicing physician. Dermatologists experience fewer lawsuits than most other specialists in medicine, but the risk is not negligible. All physicians should familiarize themselves with areas of potential risk and avoid medico-legal pitfalls. We present Part I of a two-part series addressing medico-legal questions common to most practitioners that cause a great deal of anxiety. Part I will focus upon risk management and prevention of future malpractice lawsuits, and Part II deals with suggestions and guidance once a lawsuit occurs. Herein, we discuss the primary sources of malpractice lawsuits delivered against healthcare practitioners including issues with informed consent, patient noncompliance, medical negligence, and inappropriate documentation, including use of electronic medical records. The overall goal is to effectively avoid these common sources of litigation. The risk management strategies discussed in this paper are relevant to the everyday practitioner and may offer physicians some degree of protection from potential liability.

Overcoming Legal Impediments to Physician Orders for Life-Sustaining Treatment.

The Physician Orders for Life-Sustaining Treatment (POLST), otherwise known as the POLST paradigm, represents the next generation in end-of-life (EOL) planning for certain patients who wish to exercise prospective control over their own medical treatment in their final days. As is true for any physician treatment orders, a POLST is written in consultation with the patient or patient's surrogate. There are a number of practical impediments to widespread adoption and implementation of the POLST paradigm in medical practice. One of these impediments has to do with some physicians' anxiety about potential negative legal repercussions they might suffer for writing or following a patient's POLST; this is the focus of the present article. After describing the POLST paradigm and physicians' anxieties about it, this article argues that the feared potential negative legal consequences of writing or following a patient's POLST are not well founded. Instead of succumbing to legal and ethical paralysis, resulting in the failure to integrate the POLST paradigm robustly into practice, physicians should feel comfortable under current and developing law to write and honor POLSTs for appropriate patients. This article explains the basis for such physician comfort.

Front office staff as medical educators, risk creators, and risk managers.

The author describes his own negative series of encounters with the front office staff of a large specialty medical practice during a recent lengthy episode of significant medical distress. The author suggests several reasons, including legal risk management, that medical students should be exposed as part of their education to the interactions of patients with front office staffs (not just physicians) to get a fuller picture of patients' actual experiences with the health care system.

Defensive medicine: No wonder policymakers are confused.

Discussions regarding defensive medical practice often result in proposals for public policy actions. Such proposals generally are premised on assumptions about defensive medicine, namely, that it (a) is driven by physicians' legal anxieties, (b) constitutes bad medical practice, (c) drives up health care costs, (d) varies depending on a jurisdiction's particular tort law climate, (e) depends on medical specialty and a physician's own prior experience as a malpractice defendant, and (f) is a rational response to actual legal risks confronting physicians. This article examines a sample of recent literature focusing on defensive medicine and finds that the messages conveyed vary widely, helping to explain the confusion experienced by many policymakers trying to improve the quality and affordability of health care.

Older persons and compromised decisional capacity: the role of public policy in defining and developing core professional competencies.

Issues frequently arise concerning the cognitive and emotional ability of older individuals to make certain legally significant decisions. In confronting these issues, the professional involvement of both attorneys and physicians (and other health care professionals), acting both individually and collaboratively, is desirable. This article describes the possible contributions of public policy in developing, through fostering innovations in medical and legal education, core competencies for physicians and attorneys that are essential to improving interprofessional collaboration on behalf of older individuals suspected of being compromised in their ability to make certain significant decisions. Additionally, ideas are suggested to address certain aspects of the current policy environment that may inhibit attorneys and physicians from optimal interprofessional interaction in this sphere.

I'm getting turned off: emerging consensus on deactivating cardiac implantable electronic devices.

The surgical insertion of permanent heart rhythm (resynchronization) devices within individuals who have chronic cardiac deficiencies is widespread and increasing. It is predictable that some individuals who have had a permanent heart rhythm device implanted will subsequently reach a point, physically and/or emotionally, at which they (or their surrogates) indicate the desire that their own resynchronization be removed or deactivated. Despite continuing controversy, a professional international consensus has begun to emerge over the past few years, concerning the fundamental legal and ethical principles that ought to guide clinical practice regarding the deactivation of cardiac implantable electrical devices (CIEDs). The central legal and ethical principles of the emerging professional consensus in this sphere are briefly summarized in this article, along with some thoughts about the challenges of translating those principles into clinical practice for specific patients.

The POLST paradigm for patients with advanced, irreversible illness: a therapeutic jurisprudence basis for legal codification.

The Physician Orders for Life Sustaining Treatment (POLST) Paradigm attempts to improve the experiences of individuals with serious, irreversible illness, and their families. In some jurisdictions, the POLST is authorized in law. In other jurisdictions, efforts are underway or contemplated to encourage use of POLST for appropriate individuals, but the concept is not yet in law. An argument needs to be made to policymakers that POLST will have a therapeutic effect on patients and families. In making that argument, the analytical lens of therapeutic jurisprudence (TJ) may be useful. This article proposes a POLST legal strategy using TJ. TJ may be used to evaluate data regarding psychological effects on patients and families who are experiencing medical care with or without POLST; the TJ analysis then should be considered by policymakers in enacting POLST laws to codify clinical consensus, and in turn the law so enacted would exert a positive impact on therapeutic benefit-producing behavior by health care providers.

For love, legacy, or pay: legal and pecuniary aspects of family caregiving.

Most caregiving and companionship provided by family members and friends to older individuals in home environments occurs because of the caregiver's feelings of ethical and emotional obligation and attachment. From a legal perspective, though, it might be ill-advised for an informal caregiver to admit such a motivation. Building on a recently published study of relevant litigation, this essay discusses changing cultural and legal aspects of family caregiving when there is some expectation of pay, property, or fuiture financial legacy in return for the caregiver's present work and sacrifices.

Nursing home culture change: legal apprehensions and opportunities.

There continue to be serious deficiencies in the quality of life available to many nursing home residents in the United States. One significant response to this undesirable situation is the nursing home "Culture Change" movement, which attempts to improve the nursing home environment-and consequently residents' quality of life-by making facilities less institutional and more homelike. One of the impediments often interfering with the adoption and implementation of culture change in specific facilities is apprehension by staff, administrators, and governing boards about potential legal liability and regulatory exposure if residents suffer injuries that might arguably be attributed to facility conditions or policies that were inspired and encouraged by the culture change movement. This article addresses and responds to the provider liability and regulatory apprehensions that impede the progress of culture change in nursing homes, using proposed new dietary services standards as an example.

Medicine, law, ethics: teaching versus learning.

PURPOSE: Doctors' anxieties about the legal environment begin during medical school. The signals faculty members send to medical students contribute to this anxiety. A pilot study was conducted to examine signals sent by faculty members to students regarding the relationship of legal risk management and ethical patient care at one medical school. It was also intended to determine the agreement between the messages faculty staff believe they are transmitting and those that students think they are hearing from faculty mentors. METHODS: A survey with six multiple-choice questions was sent electronically to clinical faculty staff of one medical school to elicit the signals faculty members send students regarding the relationship of legal risk management and ethical patient care. A complementary survey instrument was sent to all 240 third- and fourth-year students to elicit their perceptions of what they were being taught by their mentors about the legal environment. Responses were tabulated, analysed, and interpreted. RESULTS: Faculty staff and student responses to six questions regarding teaching and learning about the relationship of legal risk management and ethical patient care revealed, for four of the six questions, statistically significantly different perspectives between what faculty members thought they were teaching and what students thought they were learning. CONCLUSIONS: Medical schools should be teaching patient-centered medicine, reconciling an awareness of the legal environment with the provision of ethically and clinically sound patient care. To improve performance, we must address the messages faculty members send students and reduce the disparity between perceived faculty teaching and claimed student learning in this context.

Long-term complication: Florida's death certification process and long-term care.

This article discusses the medical-legal aspects of death certification in Florida long-term care settings based on an examination of relevant Florida laws and federal guidelines and a comparison of those laws and guidelines to actual medical practice. A review of the health care literature and Florida law, supplemented by interviews with key informants, supports the conclusion that Florida statutes provide a clear protocol for efficient death certification, but do not ensure the accuracy of death certificates. The death certification process in Florida long term care settings could be improved through increased physician training, the development of quality controls, and the expanded use of electronic patient medical records.