Legal Issues in Medical Practice

Contents
Section 1: Ethies in Healthcare: The Guiding Values!
1. The Ethics of Medical Practice
VP Singh, Parmod Goynt
Medical Ethics 3
Autonomy
Beneficence
Nonmaleficence 4
Conflict Between Autonomy and Beneficence/Nonmaleficence 5
Justice 5
Paternalism versus Autonomy: What Serves the Patient Best? 5
Does Paternalism Really Serve the Purpose? 6
Changing Ethos, Paternalism to Patient Autonomy 6
Should Physicians do Whatever Patients say? 7
What Serves the Patient Best? 7
Ethical Guidelines for Medical Practitioners B
Indian Medical Council (Professional conduct. Etiquette and Ethics) Regulations 8
Chapter 1: Code of Medical Ethics 8
Chapter 2: Duties of Physicians to their Patients. 9 Chapter 3: Duties of Physician in Consultation 10
Chapter 4: Responsibilities of Physicians to Each Other 10
Chapter 5: Duties of Physician to Public and Paramedical Profession 11
Chapter 6: Unethical Acts 11
Chapter 7: Misconduct 14
Chapter 8: Punishment and Disciplinary Action 16
2. Confidentiality and Disclosure in Medical Practice
VP Singh, Akashdeep Aggarwal
When Confidentiality may be Breached? 19
Legal Requirement/Administration of Justice 19
Guidelines on Medical Confidentiality 20
Medical Council of India Regulations 20
Right to Information Act and Medical Confidentiality 21
RTI and Medicolegal Cases 22
Medical Confidentiality and HIV Status 23
NACO Guidelines on Confidentiality in HIV-positive Individuals Operational Guidelines
for ICTCS: (July 2007)
Guidelines on HIV Testing (March 2007)
Judicial Decisions on Medical Confidentiality and HIV Status
Mandatory HIV Screening
HIV Testing of Patients Prior to Surgery
xx | Legal Issues in Medical Practice: Medicolegal Guidelines for Safe Practice
Section 2: Medicolegal Menace: Let's Face The Truth,
3. Disclosing Medical Errors: Why, When and How?
VP Singh, Gautam Biswas
Medical Emors 31
Disclosure of Medical Errors 32
How did it Start? 32
Ethics, Law and Policy 33
Consequences of Disclosing Medical Errors 33
Benefits of Disclesure to the Patient 33
Harms of Disclosure to the Patient 34
Harms of Disclosure to the Medical Practitioner 34
Benefits of Disclosure to the Medical Practitioner 34
Guidelines on Disclosing Medical Errors 34
How to Handle Medical Errors in Practice? 34
When Disclosure should Take Place? 35
Timing of Disclosure 35
Stages of Disclosure 35
What to Say? 36
4. End of Life Care Decisions: Ethical and Legal Issues Rashmi Datta, Pradeep Sreevastava, Arvind Kumar Singh
Palliative Care at the End of Life 40
Magnitude of the Problem 41
Medical Futility 41
Withholding or Withdrawal of Life Support 43
Advanced Directives and Do-not-resuscitate Orders 43
Euthanasia 44
Active Euthanasia 44
Passive Euthanasia 44
Voluntary Euthanasia 44
Nonvoluntary Euthanasia 44
Implications to Human Organ
Transplantation Act 45
Legal Aspects of End of Life Issues in India 45
5. Medicolegal Aspects of Discharge Against Medical Advice
Krishnadutt H Chavali, Swapnil S Agarwal, VP Singh
How Prevalent is Dama? 49
Causes and Predictors of Dama 50
Why Patients Leave Against Medical Advice? 50
Who is at Risk of DAMA? 50
Legal Status of DAMA 51
Dissolution of the Therapeutic Relationship 51
Is there any Protection Against Future Litigation? 51
Validity of DAMA 52
Duty of Doctor in DAMA
Consequences of DAMA
Risk to the Patient
Risk to the Doctor/Hospital
Contents xx
Managing DAMA A Practical Approach 54
Artess Decision-making Capacity 54
If Patient Lacks Capacity 54
6. Violence Against Doctors: Causes, Effects, and Solutions
Sundeep Mishrn
Definition 61
Factors Predisposing to Violence 61
Situation Unique to India 62
What Leads to Violence by Attendants/Relatives? 62
Physician Related Factors 62
Patient Related Factors 62
Hospital Related Factors 63
Role of Community 63
How to Anticipate Violence in Healthcare Setting? 64
Role of Media 64
Managing Violence in Healthcare Setting 65
At the Time of Violence 65
Preventing Violence in Healthcare Setting 65
Preventive Tips for the Physicians 65
Preventive Tips for the Hospital Administrators 67
Strong and Effective Laws: Essential in Fight Against Violence 67
Strengthening the Law Against Violence 67
implementation of Effective Laws 69
Role of Media in Preventing Violence 69
Health Related Literacy 69
Insurance Schemes 69
Section 3: Patient Safety Initiatives: A Key to Medicolegal Safety
7. Patient Safety and Risk Management
Sameer Mehta
Strategies for Safety in Healthcare 74
Emergency Care and Patient Safety 74
Possible Solutions 74
Radiology and Imaging 75
Counseling Rooms-Informed Consent 76
Isolation Rooms 77
Medical Records 77
Patient Accessibility 78
Patient Handling and Movement Assessment 79
Infection Control 79
Monitoring Differential Pressure 81
Medical Gases 82
Safety Measures Related to Medical Gases 82
Storage of Cylinders 83
Smart Hospitals 83
Risk Management 83
The Process of Risk Management 83
wall) Cegal fee in Medical Practice Mertolingaf Guidelines for Safe Practice
Heature axuntated Infections: A Threat to Patient Safety
What are the Sources of Healthcare associated com
Pace Related to Plealthcare associated infection m When are not Healthcare-errociated as
Common Healthcare associated Infertions 89 Veneta neociated Condition 90
Transmission of Infection 97
Source of Microorganisms
Surceptible Host 9) Means of Transmission 92
The Burden of Hospital-acquired Infection 92
Preventing Hospital-acquired Infection 92
Infection Prevention Initiatives 94
Recommendations by Agency for Healthcare
Research and Quality 94
Initiative by the World Health Organization 94
The Joint Commission's National Patient Safety Goals 94
Active Surveillance Culture 95
Indicators of Healthcare-associated Infections 96
Management of Healthcare-associated Infections 97
Strategies for Management of Healthcare-associated Infections 97
Principles of Empiric Therapy 97
Specific Empiric Situations 97
Initial Antibiotic Therapy 97
Therapeutic Strategies of Documented Healthcare-associated Infections 97
Gram-negative Organisms 98
Gram-positive Organisms 98
Newer Research Related to Healthcare-associated Infection 98
99
Medicolegal Aspects Related to Healthcare-associated Infection
All Healthcare-associated infections are not Preventable! 100
101
Medical Negligence Cases Related to Healthcare-associated Infection
Case 1: Patient Suffered Hepatitis Cinfection 101
Case 2: Patients Lost Vision due to Eye Infection 102
Legal Provisions Applicable to Healthcare-associated Infection 103
Section 304A IPC (Causing Death by Negligence) 103
Section 337 IPC (Causing Hurt by Act Endangering Life or Personal Safety of Others) 103 Section 338 IPC (Causing Grievous Hurt by Act Endangering Life or Personal Safety of Others)
Section 269 IPC (Negligent Act Likely to Spread Infection of Disease Dangerous to Life) 104
Section 270 IPC (Malignant Act Likely to Spread Infection of Disease Dangerous to Life) 104
9. Communication Skills in Healthcare: A Tool to Ensure Patient Satisfaction
Archana Kumari, Piyush Ranjan
What is Communication 108
Types of Communication 108
Communication in Healthcare 109
Importance of Communication Skills for Doctors 109
Basic Principles of Good Communication 110
Tips for Good Communication in OPD Setting 110
The Medical Interview with Patient
Cantenty xxx
Tips for Geisel Communication in an Indeer and Sating l
Commenting with the Atey
Barriers to Camermusic113
Comequences of ineffective Communication 111
How to Access the Communication Skills of Healthcare Workers (14
Breaking Raid News18 Teaching Communication Skills and Medical Curriculum 113
ALTCOM An miliative try Medical Council of tree 115
Section 4: Medical Records: A Double-edged Sword
10. Medicolegal Aspects of Informed Consent
VP Singh, Dasan Hansh
Judicial Decisions Introducing the Concept of Informed Consent 122
Objectives 123
Meaning 123
Evolution 122
Implied Consent 124
What makes the Consent Legally Acceptable? 124
Express Consent 124
Conditions for a Valid Consent 125
Age for Consent 125
Duty to Warn a 'Material Risk 127
Exceptions 128
Obtaining Consent: The Procedure 128
Documentation of Informed Consent 128
Judicial Decision on Informed Consent 129
Samira Kohli Case: Landmark Judgment on Informed Consent 129 Extracts from the Supreme Court's Judgment (Samira Kohli's Case) 129
11. Medicolegal Aspects of Medical Records
Joseph Thomas, Arun Mavaji Seetharam, Rajesh Kumar Sinha
Ownership of Data 134
Data Access and Confidentiality 134
Electronic Health Records Preservation 134
Data Privacy and Security 134
Categories of Medical Records 135
Guidelines on Medical Record 136
NABH Guidelines 136
Medicolegal Aspects of Medical Records 141
Preservation of Records 141
Ownership of Medical Records 142 Summoning Medical Records by Courts 142
Judicial Decisions Related to Medical Records 143
121
132
Component of Medical Records 132 Electronic Health Records: An Emerging Trend In India 133
Confidentiality of Medical Records 135
Medical Council of India Guidelines
xxiv |
Legal Issues in Medical Practice: Medicolegal Guidelines for Safe Practice
12. Documentation in Healthcare: Standards and Guidelines
Utsav Parekh
Medical Documentation 145
Documentation not Directly Retoted to the Patient 146 Legal Importance of Documentation 146
Rey Role in Litigation Process 146
Standard of Continuum of Core 146
Regulation Governing Medical Recordi 147
Cases Compelling Medical Documents 147
Benefits of Good Quality Documentation 147
Errors in Documentation 148
Vacuum in Clinical Documentation 148
Falling to Write a Complete Note 148
Failing to be Concise 149
Illegible Medical Documentation 149 Medical Council of India Guidelines on Prescription Writing 150
Use of Unsafe Abbreviations 150
Clinical Documentation Guidelines 150
Guiding Principle 1: Comprehensive and Complete Record 151 Guiding Principle 2: Patient Centered and Collaborative 151
Guiding Principle 3: Ensure and Maintain Confidentiality 152
Key Points for Good Medical Documentation 152
Critical Issues in Medical Documentation 154
Discharge Notes 154
Written Feedback from Patient/Attendants 155
Issuing Medical Certificate 155
Documenting Adverse Events 155
Documenting Instructions to the Patient 157
Documenting Patient's Refusal 157
Section 5: Litigation Against Medical Practitioners:
Let's Take the Bull by the Horns
13. Medical Negligence: Meaning, Scope and Legal Interpretation
VP Singh, Vivekanshu Verma
What is Medical Negligence? 161
Essential Components of Medical Negligence 161
Duty of Care 162
Dereliction in Duty of Care 162
Damage 163
Direct Causation 163
Types of Medical Negligence 163
Medical Negligence as a Tort 163
Medical Negligence as a Crime 163
Negligence Per Se 164
Vital Issues in Medical Negligence 164
Burden of Proof of Medical Negligence 164
Reasonable Care 166
Criminal Liability of Medical Professionals 167
Guidelines: Prosecution of Doctors for Criminal Rashness or Criminal Negligence
34. How to Defends Medical Regi
Cantons Y
169
Pattere of Compli
Complains under Cолен
The Complaint
form the ence Ompany 1
the Written Statement 171
rand Amur Rejoindera 171
172
Exemetipo or Witnesses
Argumenth 172
The Order 172
Anal 172
Facing the Court: Medicolegal Tips and Advice 173
Avoid Talking to the Complainant or his Advocate 173
Avold Fingerpainting 173
Avoid Alteration or Destruction of Medical Records 173
Appearing in a Criminal Case 173
15. Compensation in Medical Negligence: How much is Justified?
VP Singh, Mukesh Yadav
Compensation in Medical Negligence 176
Multiplier Method: Can it be Used in Medical Negligence Cases? 177
Multiplier's Method is not Applicable in Medical Negligence Cases 178
How much Compensation is Just and Adequate? 179
Impact of High Quantum of Compensation 180
Medical Liability-A Future Crisis: Learning from the Other Countries 180
The Crisis 180
Crisis Reform Models 181
Caps on Noneconomic Damages 181
No-fault Compensation 182
Health Courts 182
6. Professional Indemnity Insurance: Better Safe than Sorry
Rajendra S Bangal
Professional Indemnity Insurance 185
What does it Cover? 186
What it does not Cover? 186
Factors Influencing the Amount of Insurance 187
Some Important Information 188
AOO: AOY Ratio 188
Premium Rates (Individuals) 189
Premium Rates (Clinical Establishments) 189
Retroactive Date 189
An Ideal Indemnity Insurance Policy: Proposed Components
Medical Emergencies in Dentistry 320
frihlatten/insgestion at Pareign je 370 Incidental Findings on Petreatment Screen 121
Dlagreich of Malignancy in Dentistry 321
Esthetic Dentistry 322
Naghigence in Dentchy 332
No Negligence Occaslom in Dental Practice 323
Protection Against Litigation 323
How to Avold Litigation? 324 Steps et Personal Level 324
Interpersonal Behavior 224
Academic and Technical Update 324
Awareness of Medical Laws 325
Reasonable Skills and Care 325
29. Medicolegal Issues in Anesthesiology
Manpreet Singh, Ajay Kumar, Lakesh Anand
Standard of Care 328
Duty of Care and Liability 329
Medicolegal Issues in Anesthesiology 329
Death on Operation Table 329
Witnessed Death on Operation Table: Recommendations for Doctors 329
Anesthesia Deaths 331
Awareness During Anesthesia 331
Error of Judgment 333
Mistake 333
Burden of Proof 334
Res Ipsa Loquitur 334
How to Decrease the Likelihood of a Lawsuit? 335
Accepted Practices and Procedures 336
Accidents, Misadventures, and Mishaps 336
Inherent Risks
Choice of Treatment
Keeping the Professional Knowledge and Skill up-to-date
Cases to Observe