Patient’s Rights: What are they and how can we meet them?

OBJECTIVES:

The patient’s we serve have become savvy healthcare consumers. They have rights and privileges under both a legal and moral standard. We are obligated to treat our patients with dignity, understanding and respect. What are their rights, what are our rights and how do we serve both masters?

PATIENT RIGHTS:

• To participate in developing their plan of treatment in your care.
• To receive an explanation of services in accordance with the treatment plan.
• To participate voluntarily in and to consent to treatment.
• To object to, or terminate, treatment.
• To have records protected by confidentiality and not be revealed to anyone other than designated medical personnel without written authorization.

• Confidentiality may only be broken under the following conditions (state laws will vary):

1. If the therapist has knowledge of child or elder abuse.
2. If the therapist has knowledge of the client's intent to harm oneself or others.
3. If the therapist receives a court order to the contrary.
4. If the client enters into litigation against the therapist.

• To have access to their records.
• To receive clinically appropriate care and treatment that is suited to their needs and skillfully, safely, and humanely administered with full respect for their dignity and personal integrity.
• To be treated in an ethical manner free from abuse, discrimination, mistreatment, and/or exploitation.
• To be treated by staff who are sensitive to one's cultural background.
• To be afforded privacy.
• To be free to report grievances regarding services or staff to a supervisor.
• To be informed of expected results of all therapies prescribed, including their possible adverse effects (e.g. – radiation, compression etc).
• To request a change in therapist.
• To request that another clinician review the individual treatment plan for a second opinion.

CONFIDENTIALITY:

Confidentiality is a fundamental tenet of medical care. It is a matter of respecting the privacy of patients, encouraging them to seek medical care and discuss their problems candidly, and preventing discrimination on the basis of their medical conditions. The technologist must not release information without the patient's consent to anyone but designated healthcare professionals involved in their care. However, confidentiality, like other ethical duties, is not absolute. It may have to be overridden to protect individual persons or the public (if the therapist has knowledge of child or elder abuse, if the therapist has knowledge of the client's intent to harm him/her self or others, if the therapist receives a court order to the contrary, if the client enters into litigation against the therapist). Before breaching confidentiality, the technologist should make every effort to discuss the issues with the patient’s primary healthcare provider and healthcare team. If breaching confidentiality is necessary, it should be done in a way that minimizes harm to the patient and that heeds applicable legislation.

Confidentiality is increasingly difficult to maintain in this era of computerized record keeping and electronic data processing, faxing of patient information, third-party payment for medical services, and sharing of patient care among numerous medical professionals and institutions. All healthcare personnel should be aware of the increased risk for invasion of patients' privacy and should help ensure confidentiality. Within our own institutions, we all must advocate policies and procedures to secure the confidentiality of patient records.

Discussion of the problems of an identified patient by professional staff in public places (for example, in elevators or in cafeterias) violates confidentiality and is unethical. Outside of an educational setting, discussions of a potentially identifiable patient in front of persons who are not involved in that patient's care are unwise and impair the public's confidence in the medical profession. When caring for patients who are well known to the public we should take extra care to remember that we are not free to discuss or disclose information about a patient's health without the explicit consent of the patient.

In the care of the adolescent patient, family support is important. However, this support must be balanced with confidentiality and respect for the adolescent's autonomy in health care decisions and in relationships with health care providers. We should poll our facilities to assure ourselves of the laws governing the right of adolescent patients to confidentiality and the adolescent's legal right to consent to treatment.

Occasionally, during the performance of our duties we receive information from a patient's friends or relatives and are asked to withhold the source of that information from the patient. We are not obliged to keep such secrets from the patient. The informant should be told this and discouraged from sharing this information with us and strongly urged to address the patient directly and to encourage the patient to discuss the information with the physician. We MUST use sensitivity and judgment in deciding whether to use the information and to reveal its content and source to the patient’s referring physician. We are always obligated to act in the best interests of the patient’s care.

INFORMED CONSENT:

Any unauthorized touching of a person is battery, even in the medical setting. The patient's consent allows all healthcare professionals to provide the care we offer. Consent may be either expressed or implied. Expressed consent most often occurs in the hospital setting, where written or oral consent is given for a particular procedure. In many medical encounters, when the patient presents for evaluation and care, consent can be presumed. The underlying condition and treatment options are explained to the patient, and treatment is rendered or refused. In medical emergencies, consent to treatment that is necessary to maintain life or restore health is usually implied unless it is known that the patient would refuse the intervention.

The doctrine of informed consent goes beyond the question of whether consent was given for a treatment or intervention. Rather, it focuses on the content and process of consent. The healthcare provider is required to provide enough information to allow a patient to make an informed judgment about how to proceed. The presentation should be understandable to the patient, should be unbiased, and should include any medical recommendation. The patient's or surrogate's concurrence must be free and un-coerced.

The principle and practice of informed consent rely on patients to ask questions when they are uncertain about the information they receive; to think carefully about their choices; and to be forth-right about their values, concerns, and reservations about a particular recommendation. Once a course of action is decided on patients should make every reasonable effort to carry out the aspects of care that are in their control or to inform the medical team promptly if it is not possible to do so. We are obligated to ensure that the patient or the surrogate is adequately informed about the nature of the patient's medical condition and the objectives of, alternatives to, possible outcomes of, and risks involved with a proposed treatment.

COMPETENCY:

All adult patients are considered competent to make decisions about medical care unless a court declares them incompetent. In practice, however, physicians and family members usually make decisions without a formal competency hearing in the courts for patients who lack decision-making capacity. This clinical approach can be ethically justified if the physician and healthcare team has carefully determined that the patient is incapable of understanding the nature of the proposed treatment; the alternatives to it; and the risks, benefits, and consequences of it.

When a patient lacks decision-making capacity (that is, the ability to receive and express information and to make a choice consonant with that information and one's values), then, an appropriate surrogate should make decisions with the clinician. Ideally, surrogate decision makers should know the patient's preferences and act in the best interests of the patient. If the patient has designated a proxy, as through a durable power of attorney for health care, that choice should be respected. When patients have not selected surrogates, standard clinical practice is that family members serve as surrogates. Some jurisdictions designate the order in which family members will serve as surrogates. Medial professionals and facilities should be aware of all legal requirements for surrogate appointment and decision making. In some cases, all parties may agree that a close friend is a more appropriate surrogate than a relative.

Reasonable care must be taken to ensure that the surrogate's decisions are consistent with the patient's preferences and best interests. When possible, these decisions should be reached in the medical setting by physicians, surrogates, and other caregivers. Surrogates should understand that their decisions should be based on what the patient would want, not what surrogates would choose for themselves. If disagreements cannot be resolved, hospital ethics committees may be helpful. Courts should be used when doing so serves the patient, such as to establish guardianship for an unrepresented, incompetent patient; to resolve a problem when other processes fail; or to comply with the law.

Most adult patients can participate in, and thereby share responsibility for, their health care. Physicians cannot properly diagnose and treat conditions without full disclosure of patients' personal and family medical history, habits, ongoing treatments (medical and otherwise), and symptoms. The obligation to confidentiality exists in part to ensure that patients can be candid without fear of loss of privacy. All medical professionals and the facilities that serve the patient must try to create an environment in which honesty can thrive and all concerns and questions are elicited.

THE PATIENT AND THE MEDICAL RECORD:

Ethically and legally, patients have the right to know what is in their medical records. Legally, the actual chart and film record is the property of the physician or institution, although the information therein is the property of the patient. Most laws guarantee the patient personal access to the medical record. The physician must release information to the patient or to a third party at the request of the patient. The institution or physician should retain the original of the chart and radiographic studies and respond to a patient's request with copies unless the original record is required by law. To protect confidentiality, information should only be released with the written permission of the patient or the patient's legally authorized representative.

SUMMARY:
The patient is in our hands for a good deal of their treatment. We are obligated to act in a responsible manner toward them. We are entrusted with a great deal of sensitive information; the patient puts her faith in our professional behavior. Know your rights and responsibilities and understand your patient’s rights and obligations. Our job is getting more and more diverse with complicated medical legal implications. Ask your ethics department what your facility’s policies are. Protect yourself, your patient and your facility.