Legal and Ethics issues are difficult topics on the PRITE and ABPN Psychiatry Board exams, as well as the psychiatry shelf and Psychiatry MOC exams.
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Legal Aspects of End of Life Care in psychiatry – laws vary by state, when in doubt, seeking legal counsel and/or assistance from ethics committees is very helpful. Remember, psychiatry patients must give consent for most care except in specific instances where there is implied consent (patient comes into the ER unconscious, for example). They can refuse psychiatric or medical care, even if refusal results in their death. This is based on the right to be free of bodily invasion. Continuing psychiatric or medical care without consent can be an assault/battery charge. All interventions (inc. nutrition, hydration, antibiotics, etc) can be discontinued at patient’s request.
This being said, the psychiatry patient must have the capacity to make decisions. This is defined as the ability to express his/her goals and values, and can justify their choice in conjunction with these goals/values. If the patient does not have the capacity to make decisions for themselves, a surrogate decision maker must be found (medical power of attorney, closest living relative, etc).
IF they have the capacity to make decisions, they have the exclusive right to refuse any and all medical interventions, even if this goes contrary to the wishes of their family members. If they are mentally incapacitated, but have advance directives, the instructions in the directives must be followed. These decisions become much more difficult when a psychiatric patient is unable to make decisions, and has not left any advance directive
Mentally incapacitated patients who are in a persistent vegetative state, comatose, or terminally ill, then family members (even if not appointed as decision makers) can withdraw medical interventions based on prior conversations with the patient or their understanding of the patients goals and values. This is not universal across all states however, so legal counsel must be obtained.
Confidentiality in psychiatry in adolescent health care – Again, laws very by state. Adolescents are much more likely to seek health care and confide in their psychiatrist if they believe the information discussed will be kept private. Confidentiality is defined as privileged and private nature of information provided during the health care transaction. This can and should be discussed with the patient and any caregivers (parents or legal guardians) at the initial psychiatry adolescent visit.
Confidentiality is a fine line – it is important for providers to respect their younger patient’s privacy, but it is also important to encourage an open dialogue with the patient’s parents about issues that may affect their health.
Conditional confidentiality – Exceptions to confidentiality also vary by state and laws, but these typically include mandated reporting of issues such as child abuse, violent injuries, or sexually transmitted infections, and some mandatory parental notification. Some areas of the country also allow parental notification for specific services if the provider feels that it is in the best interest of the patient (for example, suicidal ideation).
One of the largest threats to confidentiality is laws that grant parents explicit access to minors’ complete medical records, financial obligations, etc.
Child Abuse – physicians, including psychiatrists, in most states are mandated to report suspected child abuse and neglect. Parents should be informed that the report is being made. This should focus on the provider’s concern for the child’s well-being, and the legal mandate to report. The parents should also be given information on what will occur next (CPS, police, social worker, etc)
The most important thing in a case of suspected child abuse is the medical record. It must provide as much detail about the event as possible, including direct quotes from caregivers and sketches or photos of the injuries. This documentation may help to refresh the provider’s memory, as a hearing in court may occur months or years after the alleged abuse. Testifying in court can be very difficult, so it is suggested that a pretrial interview with the attorney for whom the testimony will be given (prosecutor, usually) will give an understanding of the entire case, provide an opportunity to review the medical record and photographs, and get information on questions that may be asked during examination in the courtroom.
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Emanuel, Ezekiel M.D., PhD. (03/2011). Legal aspects of end of life care. UpToDate, Inc. Retrieved from http://www.uptodate.com/home/index.html.
Endom, Erin M.D. (02/2012). Child abuse: Social and medicolegal issues. UpToDate, Inc. Retrieved from http://www.uptodate.com/home/index.html.
Middleman, Amy M.D., MPH, MS Ed., and Kelly Olson, M.D.. M.A. (09/2010). Confidentiality in adolescent health care. UpToDate, Inc. Retrieved from http://www.uptodate.com/home/index.html.
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