Doctor Patient Relationship

Nakwagala Frederick Nelson

MARCH 03 2021
 Introduction
• This relationship is central to the practice of
medicine and is essential for the delivery of
high-quality health care in the diagnosis and
treatment of disease.

• It emphasizes the primacy of patient autonomy

in the context of a power differential, conflict
of values, obligation to maximize benefit, and
proscription against deliberate harm issues of
justice.
 AUTONOMY
• This is the moral right to choose and follow
ones own plan of life and action
• Clinicians are morally obliged to refrain from
interference with autonomous beliefs of
others
• The only exception is when ones choices and
actions infringe on the welfare and freedoms
of others
• Your freedom ends where harm to others
starts
 Patients rights 1
• To know the name, identity and professional status
of all persons providing services to you and to know
the physician who is primarily responsible for your
care.
•  To receive complete and current information
concerning your diagnosis, treatment and prognosis
in terms that you can understand.
• To access to all information contained in your
medical record.
• SHOULD PATIENTS DEMAND DOCTORS’ HIV STATUS
 Patients rights 2
• To an explanation in terms you can understand of any
proposed procedure, drug or treatment. The explanation
should include a description of the nature and purpose of
procedure, drug or treatment; the possible benefits; the
serious side effects, risks or drawbacks which are known;
potential costs; problems related to recovery; and, the
likelihood of success. The explanation should also include
discussion of alternative procedures or treatments.

SHOULD THIS BE DONE IN CONTEXT OF LIMITED RESOURCES

ESPECIALLY HUMAN RESOURCE?
 Patients rights 3
• To accept or refuse any procedure, drug or treatment and to be informed
of the consequences of any such refusal.

• To formulate advance treatment directives and to expect that these

directives will be honored.

• To appoint surrogate decision-maker to make heath care decision on your

behalf in the event you lose the capacity to make decisions.

• WHO SHOULD MAKE DECISIONS FOR INCAPACITATED PATIENTS IN OUR

SETTINGS?

 
 Patients rights 4
• To personal privacy. Care discussion, consultation,
examination and treatment will be conducted discreetly.
 
• To expect that all communications and records related to
your care will be treated confidentially.
 
• To supportive care including appropriate management of
pain, treatment of uncomfortable symptoms and support of
your psychological and spiritual needs even if you are dying or
have a terminal illness.

• HOW CAN WE ACHIEVE THIS IN CONGESTED WARDS?

 Patients rights 5
• To know about the option of organ, tissue or eye donation, when
relevant. 
• To have access to protective services.

• To assistance in obtaining consultation with another physician regarding

your care. This consultation may result in additional cost to you.

• To be transferred to another facility at your request or when medically

appropriate and legally permissible. You have a right to be given a
complete explanation concerning the need for and alternatives to such a
transfer. The facility to which you will be transferred must first accept
you as a patient.

• WHAT ARE THE DANGERS OF ORGAN DONATION IN OUR SETTINGS?

 Patients rights 6
• To know if your care involves research or experimental methods of
treatment. You have the right to consent or refuse to participate.

• To voice complaints regarding your care, to have those complaints

reviewed, and, when possible, resolved without fear of recrimination or
penalty to yourself. You have the right to be informed of the response to
your complaint.

• To expect reasonable continuity of care and to be informed by care givers

of realistic patient care options when hospital care is not appropriate.
You have the right to participate in this discharge planning process.
 Patients rights 7
• To examine your bill and receive an explanation of the charges regardless
of the source of payment for your care.
 
• To ask about the ownership interests the hospital may have in
organizations to which it may refer you.
 
• To be informed of any hospital policies, procedures, rules or regulations
applicable to your care.
•  If you are unable to exercise these rights, your legal guardian, next of kin
or legally Authorized surrogate has the right to exercise these rights listed
above on your behalf.

• TO WHAT EXTENT SHOULD PATIENTS KNOW ABOUT A HOSPITALS

BUSINESS SECRETS?
 AUTONOMY IS NOT ABSOLUTE
• Compromised competence of patient
• Huge power and knowledge differential
btn patient and clinician
• Legal limitations (statutes of limitations)
• Stress of illness
• Cultural aspects
• Conflict of interest on patients part
especially in resource limited settings
 LEGAL ASPECTS
• Most legal systems deem that all persons have
a fundamental right to control what is done in
their body = SELF DETERMINATION
• This means that a person with sound mind can
prohibit life saving surgery!
• The requirement for explicit consent before
medical treatment is hence a binding legal
issue
• Documentation of this consent is legal
requirement
 PATERNALISM
• This is the practice of overriding or ignoring
patients preferences to benefit them or
enhance their welfare
• The practice of medicine grew in this line
• In modern times, this has been relegated but
others argue that it still has a role
• We need to discuss to what extent
paternalism may still need to be practiced in
low resource settings
 PREFERENCES OF CHILDREN
• Sliding scale of respect depending on age and
development
• Children may not be rational since
interpretation of risks, consequences,
alternatives and relative values may be under
developed.
• Childs preferences maybe overridden when
they conflict with welfare.
 IDEAL INFORMED CONSENT PROCESS
• Clinician makes diagnosis and recommends
treatment giving:
– Reasons for the treatment
– Alternatives to the treatment
– Benefits and burdens of all options
• Patients should:
– Understand the information
– Assess the treatment choices
– Express an option or one of the choices
 VITAL ASPECTS OF INFORMED
CONSENT
• Should exhibit:
– Mutual participation
– Good communication
– Shared decision making
• Should not be:
– Mechanical recitation of facts
– Mere signature on a paper
• Should have a dialogue btn client and clinician
• Is not only initial but continuing till discharge
 SCOPE OF DISCLOSURE
• Candid disclosure of bad news is the norm in western
societies
• Components:
– Patients current medical status
– Likely course if no treatment is given
– Interventions that might improve prognosis
– Risks and benefits of procedures
– Probabilities and uncertainties of the procedures
– Professional opinion about alternatives
– Recommendation based on clinicians best clinical
judgment
• Avoid technical jargon
• Translate complicated statistics into every day simple
probabilities
 COMPREHENSION
• Most patients don’t understand what doctors
communicate to them
• Give clear explanations
• Consider language issues
• Allow questions and assess understanding
• Use audio-visual aids
• Use culturally accepted methods and
approaches
 Documentation of IC
• A signed consent form is legally required
before initiating a therapeutic relationship

• This should be on an Institutional form

standardized for that purpose

• We are very poor at this aspect in Uganda!

 PITFALLS IN IC
• Technical language
• Uncertainty in all medical interventions
• Worry about harming or alarming the patient
• Being hurried by being busy
• Inadequate time
• Patients limited understanding
• Clients thinking clinicians should decide for
them
• Clinicians deeming the IC as mere bureaucracy
• HMO’S limiting time spent with patient
 DECISIONAL CAPACITY
• Competence is a legal term referring to legal
authority to make choices like finances.
• Legally competent individuals may have their
decisional capacity compromised by illness,
anxiety, pain or hospital settings.
• Adequate decisional capacity means an
individual understands pertinent information
to deliberate rationally about one values in
relation to clinicians recommendations.
• In cases of inadequacy consider using
surrogate decision makers
RELIGIOUS AND CULTURAL DIVERSITY
• Some beliefs and cultural values may make
clients make dangerous decisions.
• However in some cases clinicians unfamiliarity
with clients culture and values may be the
issue.
• Some cases require reconciling of clinicians
and clients views.
 Euthanasia
• Has two forms
– Active like Mercy Killing
– Passive or Physician Assisted Suicide

• Legalized in nations like Netherlands but fast

losing its appeal.

• It requires stringent steps and policies to

avoid abuse
 Truthful communication
• Deception whether by commission or
omission to be avoided.
• Others argue for benevolent deception in
cases where truth may cause harm
• Most in western models argue against
deception as truth telling is higher moral duty.
• Harms of knowing truth have not been
verified or proven
• Concealment of truth undermines physician
patient relationship
• What is the best approach for Uganda?
 DISCLOSURE OF MEDICAL ERROR
• They are very frequent
• Patients require apologies as a fundamental
respect of their rights.
• Reporting mistakes helps risk management
and quality control measures
• Give compensation including out of court
settlements
• When harm occurs, disclosure is obligatory
• When no harm occurs, disclosure is not
obligatory but helps control measures
 PLACEBO’S
• Refers to substances given well knowing they
lack the intended therapeutic effect.
• This is a form of deception!
• Use in clinical trials is justified as subjects are
aware they may be receiving placebo.
• In Uganda it is common to give placebo’s to
patients who agitate for medicines even when
clinicians think otherwise . This is unethical
unless patient is told!
 REFUSAL OF CARE
• If he is competent and informed, respect his
choices even if the refusal leads to serious
harm.
• This disturbs many clinicians though it is
supported by law.
• Jehovah witnesses of age who have no
incapacity should be allowed to refuse blood
but not for their children
•THANKS