Untitled

Ethics of truth telling in medical practice

• Veracity, or truth telling, is a basic moral principle believed by patients to be standard practice by their healthcare providers regarding diagnoses, test results, and treatment options.
• Attitudes toward truth telling have changed but remain controversial, specifically on whether it is ethically permissible to hide information or deceive a patient.

Importance of truth telling

• Truth telling respects patient autonomy, allowing them to make informed decisions.
• Patients with terminal illnesses need to know their condition to prepare for death, manage finances, and spend time with loved ones.
• Truth telling maintains a trusting doctor-patient relationship.
• Truth telling avoids malpractice and medico-legal claims, which can be caused by withholding information that hinders valid informed consent.
• Physicians have a legal obligation to obtain valid informed consent by providing important information to patients.

Situations where truth telling may not be routinely applied

• Patient wishes: If a patient has expressed a desire not to know the truth if it is bad, and would be too upsetting.
• A physician should ask the patient to assign a responsible guardian.
• Patient's condition: When revealing information would cause significantly more harm than benefit, such as severe depression or suicide risk.
• Physicians should deliver the truth gradually while providing support.
• Decision-making capacity: When the patient is unable to consent to treatment due to being incompetent or incapacitated and emergency treatment is required.
• Physicians should inform the patient's relatives and obtain their consent if available.

SPIKES protocol for breaking bad news

• Has four objectives: gathering information, giving complete medical information, providing support, and encouraging patient collaboration in developing a future strategy for treatment.

Components of "SPIKES" protocol

• Setting: Arrange for privacy and involve important persons.
• Perception: Determine what the patient knows about their condition and accept denial without confrontation.
• Invitation: Ask if the patient wants to know the details of their condition and/or treatment, respecting their right not to know, but offer to answer questions later.
• Knowledge: Give medical facts using understandable language, considering educational level, socio-cultural background, and emotional state, gradually providing information. Check patient understanding and respond to reactions, starting with positive facts. Give accurate facts about treatment options, prognosis, costs, etc.
• Explore emotions: Allow the patient time to express feelings and then respond empathically.
• Strategy and summary: Ask if they want to clarify anything and offer an agenda for the next meeting.

Ethical issues in mental illness

• Mental illness is characterized by abnormal thoughts, emotions, behavior, and relationships.
• Patients in neuropsychiatric practice may suffer from significant mental and physical symptoms, leading to an imbalance in the physician-patient relationship.
• Physicians have a special ethical obligation to place the unique needs of mentally ill patients above their own interests.
• Vulnerable groups: Mentally ill people are considered among this, and may suffer from ethical problems such as invalid informed consent, breaking confidentiality, and conflict of interest.
• Physicians must be cautious of situations that may cause physical, sexual, psychological, or financial harm to patients.

Important ethical and professional practices in neuropsychiatric care:

• Informed Consent: Is an ethically and legally important process.
• Important points include:
  • Assessing decision-making capacity according to clinical and legal standards.
  • Providing all necessary information for accurate decision-making.
  • Protecting the patient from internal or external pressures.
  • Modifying the method of giving information if it is damaging to the patient, but should follow protocols.
  • It is unacceptable to hide information about side effects of medication.
• Assessing decision-making capacity: Is the ability to reach an informed, reasoned, and free choice.
• Must Understand relevant information. Must Interpret information wisely. Must Appreciate the situation and its consequences. Must Make a constant choice with reasoning
• Required if patients Exhibit cognitive impairment, impaired judgment, or Manifest irrational behaviors and decisions.
• Involuntary neuropsychiatric treatment: Obligatory treatment against patients' wishes, often hospitalization, indicated by imminent dangerousness to themselves or others, or inability to meet basic needs.
• Involuntary treatment should be decided according to legal rules, must show dangerousness criteria, including:
  • Suffering from a severe mental disorder.
  • Likely to cause harm to self or substantial deterioration, or likely to cause harm to others.
  • Refusal or inability to consent to voluntary admission.
  • Lacking the capacity to make an informed decision.
• Confidentiality: Is an ethical and legal right, especially important for the mentally ill due to the personal nature of information shared.
• Important confidentiality considerations:
  • Patients should be informed about the limits of confidentiality at the start of the relationship.
  • Disclosure of confidential information should only occur with informed consent or to protect from imminent harm.
  • Disclosure should be limited to the minimum required.
  • Psychotherapy notes should be separate from the medical record.
  • Electronic patient records require additional protection.
• Honesty and Trust: Neurologists and psychiatrists should maintain a trusting relationship and avoid any act of fraud or exploitation.
• Specific examples of fraud in neuropsychiatric practice:
  • Making false or misleading statements.
  • Recommending unnecessary treatment or admission.
  • Fabricating records or false bills.
  • Supporting false sick leaves.
  • Falsifying qualifications.
  • Practicing outside one's area of competence.

Ethical aspects of organ transplantation

• Organ transplantation is the surgical replacement of a failing or damaged organ with a healthy one.

Types of transplantation

• Auto transplantation: transplanting organs and/or tissues within the same person's body.
• Has no legal or ethical limitations.
• Allotransplantation: transplanting organs and/or tissues between two different people.
• Depends on the degree of similarity between tissue antigens of the donor and recipient.
• Rejection remains a main cause of failure.
• Transfusion: the most common form of transplantation.

Legal rules before blood transfusion

• Voluntary informed consent from the patient.
• No risk to the health of the donor.
• Donor must be free from transmissible diseases.
• Donor information should be kept confidential.
• Payment to the donor is ethically unacceptable.

Living organ donation

• Living people who wish to donate can donate one of a set of paired organs (kidney), or a portion of an organ (liver).
• Living donors may be:
  • Living Related Donors (LRDs): blood relatives of the recipient.
  • Living Non-Related Donors (LNRDs): not related by blood, can include a husband, wife, or a friend.
  • Living Non-directed donors (LNDDs): unknown to the recipient, donation out of humanitarian motives.

Rules before living organ donation

• Voluntary informed consent from a competent donor.
• There should be no harm to the donor.
• The operation should be in a well-equipped hospital.
• Organ donation from children and mentally disabled persons violates their body integrity due to lack of giving consent.

Living donor complications

• Health problems: postoperative and future health complications are possible.
• Psychological problems: family members may feel pressured to donate if there is a sick relative.
• Medical follow up: Donors may face future complications without adequate care.
• Cadaveric organ donation: Donation from a dead person, needing support from medical, legal, and the public.

Ethical and legal problems of cadaveric organ donation

• Brain death of the person should be declared before donation.
• Wishes of the dead person should be respected.
• Consent of the family should be obtained.

Brain death

• Irreversible loss of brain function, including the brain stem frequently from traumatic brain injury in adults.

Brain death diagnosis criteria

• Deep uninterrupted coma with no response to stimuli.
• At least six hours post coma onset.
• Coma cause confirmed by diagnostic measures (extensive damage to the brain).
• Complete absence of brain stem reflexes (pupillary, corneal, gag, cough reflexes).
• No spontaneous respiration.

Rules before cadaveric organ donation

• Transplant team should be different from the team providing care for the potential donor to avoid potential conflict of interest.
• Organs removed and the donor's death has been declared by a competent medical team.
• No payment for organs - buying and selling is unethical. Doctors involved in paid donation - medical malpractice.
• Once a person dies; his or her organs may be donated if the person has consented to do so before death. With an unknown status, the hospital may request from a family member to give consent to remove for organs.
• Physicians caring for a patient should not be involved for donation after patient's death, including obtaining consent, as it is against the law. Defer to the hospital.

How to write medical/medico-legal reports

• Physicians provide these reports about their patients for different purposes.
• A medico-legal report is usually read by non-medical personnel (prosecutor, judge).
• The report may be used in court proceedings and subjected to scrutiny (review, analysis).
• A structured, comprehensive report may minimize the chances of giving testimony in court and avoid shifting a physician's status from witness to accused.
• Treating doctor has a professional and ethical obligation to assist by providing an expert report.

Parties that may Request medical/medico-legal reports

Patients, Lawyers, Insurance companies, Employers, Legal authorities (prosecution, court). Physicians will be asked to present a report about their patients' conditions/management lines if there is accusation (in two versions; English and Arabic).

Before preparing a medical/medico-legal report

• Take patient permission unless the court asks for it.
• Understand the intention and objective of the report.
• Utilize medical records to write reports and provide clarity on request from court.
• Write factually accurate information in the report.

Format for a medical/medico-legal report

• Don't write report as a paragraph/story but as a bullet point list.
• Report sections:
  • Name of requesting party, date of request and purpose of report.
  • Patient information (name, age).
  • Date of admission/interview.
  • Credentials, Address and Qualifications.
  • Medical Facts in Chronological Order.
  • Clinical presentation (history and symptoms)
  • Examination findings.
  • Investigations.
  • Provisional diagnosis.
  • Treatment/management.
  • Patient Informed Consent
  • Current Patient Condition.
  • Response to Questions.
  • Signature and Date of Report.
  • References.
• Honest and Accurate Obligation:
  • Honesty and be transparent, use truth and facts, be 100% certain before signature.
  • Check all important information Before Signature.
  • Justifiable Time Frame.
  • No Expectations should be written.
  • Do not accuse colleague.

Tips

• Always say facts truthfully under oath.
• Always Use Medical Records.
• Add a second report if there's a mistake.
• Use clear concise abbreviations, terms and concepts.
• Don't use legal language.
• Facts and opinions should have clear borders.
• Dont opinions beyond knowledge.
• Don't avoid information.
• Don't avoid information Avoid Emotionally Loaded Language.
• Consult a Medical Defense Organisation.

Role of medical expert witness:

• Court can request the treating and/or expert witness to provide opinions of the case/management.
• Must define the Standard of Care in medical care claims.
• No involvement with patient in case but should have skills/expertise.
• Well Prepared Expert Report with revised details.
• Must competent for an effective action.
• Inexperience witnesses are misleading.
• Expert Signature with Delivery and Responsibility from statements by Witness.

Medical expert report must include:

• Experts Qualifications.
• All Important Facts.
• Reason for Expressed Opinions.
• Indicating Outside area of Expertise on areas outside the question.
• Include Reference Support with Examinations/Qualifications/Tests.
• State Lack if Information.