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5 The Physician–Patient Relationship Learning Objectives After completing this chapter, you will be able to: · 1. Define the key terms. · 2. Describe the rights a physician has when practicing medicine and when accepting a patient. · 3. Discuss the nine principles of medical ethics as designated by the American Medical Association (AMA). · 4. Summarize “A Patient’s Bill of Rights.” · 5. Understand standard of care and how it is applied to the practice of medicine. · 6. Discuss three patient self-determination acts. · 7. Describe the difference between implied consent and informed consent. Key Terms Abandonment Acquired immune deficiency syndrome (AIDS) Advance directive Against medical advice (AMA) Agent Consent Do not resuscitate (DNR) Durable power of attorney Human immunodeficiency virus (HIV) Implied consent Informed (or expressed) consent Incompetent patient In loco parentis Living will Minor Noncompliant patient Parens patriae authority Privileged communication Prognosis Proxy Uniform Anatomical Gift Act THE CASE OF DAVID Z. AND AMYOTROPHIC LATERAL SCLEROSIS (ALS) David, who has suffered with ALS for 20 years, is now hospitalized in a private religious hospital on a respirator. He spoke with his physician before he became incapacitated and asked that he be allowed to die if the suffering became too much for him. The physician agreed that, while he would not give David any drugs to assist a suicide, he would discontinue David’s respirator if asked to do so. David has now indicated through a prearranged code of blinking eye movements that he wants the respirator discontinued. David had signed his living will before he became ill, indicating that he did not want extraordinary means keeping him alive. The nursing staff has alerted the hospital administrator about the impending discontinuation of the respirator. The administrator tells the physician that this is against the hospital’s policy. She states that once a patient is placed on a respirator, the family must seek a court order to have him or her removed from this type of life support. In addition, it is against hospital policy to have any staff members present during such a procedure. After consulting with the family, the physician orders an ambulance to transport the patient back to his home, where the physician discontinues the life support. · 1. What were the primary concerns of the hospital? · 2. What was the physician’s primary concern? · 3. When should the discussion about the patient’s future plans have taken place with the hospital administrator? Introduction Few topics are as important as the physician–patient relationship. This relationship impacts the entire healthcare team. All healthcare professionals who interact with the patient must understand their responsibilities to both the patient and the physician. The patient’s right to confidentiality must always be paramount. The first physicians were “medicine men,” witch doctors, or sorcerers. The physician–pa.

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IL LU S T R A T IO N B Y E LI Z A B E T H L A D A W ith medical malpractice insurance premiums rising sharply across the nation and at least a dozen states facing an insurance crisis, physicians and policymakers are debating vigorously how best to respond. Tort reforms that would cap awards are among the proposals and have proven effective at moderat- ing premiums in several states. [See “Understanding the Physician Liability Insurance Crisis,” FPM, October 2002, page 47.] But while physicians await legislative action or an upturn in the economy to soften the impact of insurance hikes, there is something doctors can do: better manage risk. Risk management involves more than just reading a journal article, listening to a lecture or filling out a work- book. It is a style of practice that endeavors, first and foremost, to prevent patient injuries; second, to avoid malpractice claims; and third, when a claim does occur, to reduce malpractice claim losses. First prevent patient injury A while back, I was involved in the care of a four-year-old boy who was admitted with status asthmaticus. He was very ill, requiring intubation and ventilatory support. ➤ March 2003 ■ w w w. a a f p . or g / f pm ■ F A M I L Y P R A C T I C E M A N A G E M E N T ■ 2 9 Dr. Roberts is past president of the AAFP. He served for six years on the Board of Governors of the Wisconsin Patient Compensation Fund and for the past eight years has served on the Board of Directors of the Physician Insurance Company of Wisconsin. He is a professor of family medicine at the University of Wisconsin Medical School and practices in Belleville, Wis. Conflicts of interest: Dr. Roberts discloses that he is a member of the Board of Directors of the Physicians Insurance Company of Wisconsin. Seven Reasons Family Doctors Get Sued and How to Reduce Your Risk By adopting a risk-management mind-set, physicians can avert not only malpractice claims but also patient injury. Richard G. Roberts, MD, JD, FAAFP Downloaded from the Family Practice Management Web site at www.aafp.org /fpm. Copyright © 2003 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and /or permission requests. 3 0 ■ F A M I L Y P R A C T I C E M A N A G E M E N T ■ w w w. a a f p . or g / f pm ■ March 2003 We were at his bedside literally breath by breath through the night. The child bounced back, fortunately, as children often do, and within three days he was home. The following week at grand rounds, the senior resident presented the case. I opened the question and answer session that followed by asking the group, “How did we fail this boy?” A long silence ensued. One of the second-year residents responded, “I don’t understand what you’re talking about. You saved this kid’s life. At every turn you made exactly the right decision.” And I said, “Y ...

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