PATIENT AND PHYSICIAN  RELATIONSHIP 

Both the physician and the patient must agree to form a  relationship if there is to be a contract for service and treatment. To receive proper treatment, the patient must confide  truthfully in the physician regarding all aspects of his or her  health. Failure to state all the facts may result in serious  consequences for the patient. The physician is not liable if  the patient has withheld critical information that directly  affects medical care. 

 

Physician Rights 

Physicians have the right to select the patients they wish to  treat. They also have the right to refuse service to patients.  From an ethical standpoint, most physicians do treat patients  who need their skills. This is particularly true in cases of  emergency.  Physicians also have the right to decide the type of services they provide, where their offices are located, and their  open hours of operation. The physician has the right to  expect payment for treatment given.  Physicians have a right to take vacations and time off  from their practices. Care must be taken to inform patients  if their physician will be unavailable. In most cases, another  physician will cover or take care of a colleague’s patients.

 

 

Patient Rights 

The patient has the right to give consent, or permission, for  all treatment. Consent is either expressed or implied. 

Expressed consent occurs when the patient consents to a  procedure or treatment either verbally or in writing, as with  the case of informed consent, which is discussed next.  Implied consent is based on the patient’s action and is not  expressed verbally or in writing. For example, when a  patient comes in for a routine examination for medical  treatment, there is implied consent that the physician will  touch the person during the examination. Generally, touching someone without the person’s consent is referred to as  battery. Therefore, the touching required for the examination would not be considered a crime of battery because  consent for the action is implied by the nature of the  appointment. 

In giving consent for treatment, the patient reasonably  expects that the physician will use the appropriate standard  of care in providing care and treatment. Patients also expect  that all information and records about their cases will be  kept confidential by the physician and staff. The patient’s  right to privacy prohibits the presence of unauthorized persons during physical examinations or treatments. 

In addition to these rights, the patient also has certain  obligations. For example, the patient is expected to follow  the instructions given by the physician. In addition, the  patient is expected to pay the physician for medical services. 

 

The Right to Refuse Treatment 

Patients have the right to refuse treatment. Different cultural and religious groups must be accommodated, if necessary. Members of some religious groups, such as Jehovah’s  Witnesses and Christian Scientists, do not wish to receive  blood transfusions or certain types of medical treatment. If  they are adults, they should not receive the treatment

against  their wishes. In the case of a minor child, the court may  appoint a guardian who can then give consent for the procedure if it is deemed to be in the child’s best interest.  A patient might also refuse a treatment because that  patient views the side effects associated with treatment to be  more harmful or worse to deal with than the condition that  requires treatment. It is not uncommon for some patients in  advanced stages of cancer with metastasis to refuse chemotherapy and radiation treatments because they believe the  quality of their remaining life would be diminished. A common belief is that the quality of one’s life is more valuable  than the quantity (length in years) of life.  Patients in hospital settings may often be discouraged  about their treatment or prognosis or may simply hate being  in the hospital. Those patients may choose to leave the hospital of their own free will. To hold someone against their  will is considered false imprisonment. If a patient leaves the  hospital against physician’s orders, the patient is considered  to be leaving AMA, against medical advice. Such patients  are required to sign a document stating that they are aware  of the risks associated with leaving and that they will not  hold the hospital or physicians liable for any repercussions  that may arise from their decision to leave. 

 

The Patient Care Partnership 

The Patient Care Partnership (formerly called the Patients’  Bill of Rights) is a concept that details what you, as a patient,  should expect during your hospital stay, principally: 

• High-quality hospital care
• A clean and safe environment
• Your involvement in your care (This includes involvement surrounding treatment options; you must understand that you have a right to choose your treatment options, the right to consent to treatment, and, as discussed earlier, the right to refuse treatment.)
• Protection of your privacy
• Help when leaving the hospital
• Help with your billing claims

Although the Patient Care Partnership concepts pertain specifically to hospitalization, physician offices should operate  on the understanding that their patients have similar rights.  In fact, most medical practices adopt these rights for their  patient population. As a medical assistant, you should be  able to discuss with a patient, before hospitalization, what  that patient has a right to expect during the hospital stay. 

 

Informed Consent 

The patient should expect to receive information concerning the advantages and potential risks of all treatments and procedures. Informed consent means that the  patient is instructed about the possible consequences  both of having and of not having certain procedures and  treatments. The physician must carefully explain that in  some cases, the treatment may even make the patient’s  condition worse. 

The Doctrine of Informed Consent (Figure 3-1) includes  the following: 

• Explanation of advantages and risks to the treatment
• Alternatives available to the patient
• Potential outcomes to the treatment
• What might occur without treatment
• The use of understandable language

 

It is very difficult to fully inform a patient about all the  things that can go wrong with a treatment. In an emergency  situation, during which the patient is not able to understand  the explanation or sign a consent form, a physician is protected by law to provide care. A physician cannot delegate  the duty of obtaining informed consent to another person  except in emergency situations. Even then, after the emergency is under control, it is important to find a responsible  party with whom to discuss patient issues if the patient is  unable to give consent. Sometimes consent for procedures is  given by relatives or those holding medical proxies, which  allow the person to act in the best interests of the patient if  the patient is unable to give an informed consent. (See  “Durable Power of Attorney” later in this chapter for more  information.) Frequently, patients are asked at office visits to  declare names of relatives or friends with whom the physician can discuss patient care. This is an important document not only for determining with whom the physician can share  information on an ongoing basis but also for identifying  whom to consult in an emergency situation (Figure 3-2).  Does a signed informed-consent form protect both the  physician and the staff from lawsuits? The answer generally  is yes. As long as the physician has carefully explained the  treatment or procedure and the patient acknowledges the  risks involved by signing the consent form, some protection  from lawsuits is usually in place. Here, the assumption-ofrisk defense is often applied. This means that if a patient  signs an informed-consent form but tries later to sue the  physician for something that was clearly discussed before the  procedure, the patient is considered to have assumed the risk  of something going wrong. This takes a lot of the burden  off the physician when making a case in court. However,  this doesn’t always win the case for the physician. There  have been instances when patients who had been presented

 

(FIGURE 3-1 Sample of an informed consent to perform an operation, sedation, anesthesia, and other medical services.

 

FIGURE 3-2 The patient’s signature on the informed consent form  indicates that the patient understands the limits and risks involved in  the treatment or surgical procedure as explained by the physician. )

 

the risks of a procedure and signed the form nevertheless  sued and won a case against the physician when the treatment failed. 

Informed-consent forms used in outpatient surgical and  procedural facilities may be shorter in length and content  than those used in physicians’ offices. However, each state  mandates unique exceptions to the informed consent doctrine. The following are the more general exceptions: 

• A physician does not have to inform a patient about risks that are commonly known—for example, that a patient could choke while swallowing a pill. 
• A physician who feels the disclosure of risks may be detrimental to the patient is not responsible for disclosing them. This might occur if a patient has a severe heart condition that may be worsened by an announcement of risks from a needed treatment. 
• If the patient requests the physician not to disclose the risks, then the physician is not responsible for failing to do so. 

 

Medical Assistant’s Responsibility  with Informed Consent 

The medical assistant has the following responsibilities with  regard to informed consent. 

• The physician must thoroughly explain all procedures to the patient. The medical assistant is responsible for making sure a signed consent form has been obtained  and placed in the patient chart. Never have the patient  sign a document that she does not understand. 
• Obtain a parent’s or guardian’s signature before any procedure is performed on a minor. The only exception is in a case of emergency, when the parent or guardian cannot be reached. File the signed consent form immediately.

 

Rights of Minors 

A minor is considered a person who has not reached the  age of majority. The age of majority varies from state to  state but usually is 18. In most states, minors are unable  to give consent for treatment. Exceptions are special cases  involving pregnancy, request for birth control information, abortion, testing and treatment for sexually transmitted diseases, problems with substance abuse, and a  need for psychiatric care. Two types of minors can give  consent for treatment: 

A mature minor is a young person, generally under the  age of 18, who possesses the maturity to understand the  nature and consequences of the treatment. Emancipated  minors are those who have the same legal capacity as an adult  under any of the following five conditions: 

• They live on their own.
• They are married.
• They are self-supporting.
• They are in the armed forces.
• Any combination of these conditions.

Because not all states recognize the categories of mature  minors and emancipated minors, it is wise to be familiar  with the laws of your state and to handle consent on a caseby-case basis. The following are some legal implications to  consider when treating a minor. 

• Right to confidentiality—A 16-year-old girl who is seeking birth control information has a right to have her records remain confidential. 
• Financial responsibility—The 16-year-old girl seeking birth control information may not be able to pay for the office visit. Contacting her parents for payment may breach confidentiality. 
• Minor’s legal guardian—Legal guardianship is sometimes difficult to determine if the child lives with the mother but the father is financially responsible for care and treatment, or vice versa. However, the legal guardian must always be determined and documented in the  patient’s medical record. In the case of divorce, the  legal guardian is the individual a court has declared to  be responsible. Sometimes both parents share custody  in a divorce; sometimes there is only one legal guardian. If there is one legal guardian, the other parent may  be informed of some kinds of information regarding  the patient but not others. The physician may choose  to speak with an attorney about how to handle complex issues that may arise when one parent has custody  and the other wants information.