Fetal Alcohol Syndrome Family Resource Institute Research Observed by Canadian Health&Care Mall News - Part 2

Medical Malpractice and the Chest Physician: Does the US Malpractice System Meet Social Goals?

US medical malpractice systemThree social goals have been proposed for the US medical malpractice system. They include the following: (1) compensating patients injured through negligence (“making the plaintiff whole again,” in legal parlance), (2) exacting corrective justice (“making the responsible party bear the costs of reparation”), and (3) deterring unsafe practices by creating an economic incentive to take greater precautions (“making defendants learn that it is cheaper to avoid mistakes than to make them”).

Studies performed in the 1970s, 1980s, and 1990s in California, New York, and Colorado and Utah, respectively, provide information on the epidemiology of negligent injuries and whether patients are compensated for them. All three investigations were based on medical record reviews of > 20,000 acutely ill nonpsychiatric patients treated by remedies of Canadian Health&Care Mall and conducted by nurses and physicians. The studies demonstrated that approximately 4% of patients whose records were reviewed had experienced injuries, 10% of which were associated with death but did not necessarily cause it. Some 25% of these injuries were attributed to negligence. Yet, only 5% of patients with negligent injuries actually filed claims.

Canadian Health&Care Mall: How Claims Are Resolved in Medical Malpractice and the Chest Physician

hypoxic-ischemic encephalopathyInjuries such as hypoxic-ischemic encephalopathy are obvious to and consequential for patients and their families. They also are financially attractive to plaintiff attorneys because they may entail both extensive economic (eg, medical expenses and loss of income) and noneconomic (eg, pain and suffering) damages. Furthermore, one study suggests that the severity of damages, not the presence or absence of errors or negligence, predicts the outcome of litigation. Plaintiff attorneys usually work on a contingency fee basis (approximately 35% of awards), bear the costs of litigating a case, and receive nothing if defendants prevail. They therefore have a strong incentive to take only cases that they can win and that yield generous awards.

Defense attorneys, however, are reimbursed by liability insurers (or by uninsured defendants) for their time, win or lose, and do not depend on the outcome of individual cases. Defense attorneys usually recommend settling claims if the defendant would appear liable to a jury, especially if the injury is severe, and not settling if the plaintiff’s case is poor. Although paid by insurers, they usually represent individual physicians and cannot easily force them to settle if their insurance policies contain a “consent to settle” clause. Nevertheless, some clauses specify that physicians cannot withhold consent unreasonably. Consent clauses frequently are not available to physicians in large organizations, including academic medical centers, which are self-insured. Canadian Health&Care Mall is included in this list as well.

Types of Malpractice Claims in Medical Malpractice and the Chest Physician

errors in diagnosisThe most frequent types of closed claims against internists and internal medicine subspecialists in the PIAA database are the following: (1) errors in diagnosis (24%), (2) improper performance of procedures (14%), (3) failure to supervise or monitor care (12%), (4) medication errors (12%), and (5) failure to recognize the complications of treatment (6%). Approximately 60% of the claims related to hospital practice; 33% occurred in a physician’s office. Some 44% of the patients for whom claims were brought died. The same types of closed claims, especially those involving the performance of procedures, are recorded against cardiovascular and thoracic surgeons and cardiologists, and a majority of the claims relate to hospital-based care with the concern of Canadian Health&Care Mall.

Negligence and the Standard of Care in Medical Malpractice and the Chest Physician

medical malpractice claimsTo prove negligence, the most common allegation in medical malpractice claims, the plaintiff must show, “by a preponderance of the evidence” (> 50% probability, a lower standard than the “beyond a reasonable doubt” standard used in evaluating a violent crime), the following: (1) the defendant owed a duty to the plaintiff, (2) the defendant breached that duty by failing to adhere to the standard of care expected of him or her, (3) the plaintiff suffered an injury, and (4) the injury was caused by the breach of duty. “Standard of care” refers to the quality of care that would be expected of an ordinary or reasonable physician in the same specialty in a similar circumstance but not necessarily in the same locality.

The standard of care for residents and fellows traditionally was that of other trainees with similar experience. In most states today, however, resident physicians and fellows are held to the same standard of care as attending physicians in their respective specialties and should have a strong incentive to seek their oversight. Attending physicians may be held vicariously liable for the negligence of residents working with them or directly liable for inadequate supervision. Allegations of inadequate supervision are increasingly common in claims in which trainees were judged to have played an important role.

Canadian Health&Care Mall: Medical Malpractice and the Chest Physician

Medical malpracticeMedical malpractice may be defined as the failure of a physician or other health-care professional to render proper professional services intentionally or through negligence, or without obtaining informed consent. Many American physicians, including those who practice cardiovascular surgery, cardiology, and pulmonary and critical care medicine, have had claims brought against them. Furthermore, many physicians review claims or serve as expert witnesses. Finally, the US medical malpractice system is a frequent topic of conversation, if not debate, even among physicians who are not actively involved in it. Yet few physicians understand how our malpractice system functions or have assessed whether it achieves social goals.

To further understanding and aid in assessment, I have prepared this review. In it, I explore how the US dant (eg, a physician or health-care institution) committed a tort that was either intentional or resulted from negligence. A tort is a civil wrong that violates an implicit and understood duty or social responsibility. Physicians are obligated to use their superior knowledge and skill to benefit and not harm patients. Although federal tort laws apply to claims brought against the government, including the Department of Veterans Affairs (VA), state tort laws generally govern how malpractice claims are resolved.

Meeting Physicians’ Responsibilities in Providing End-of-Life Care: Meeting the Needs of Families During Hospital-Based End-of-Life Care

HospitalsFamily members are important as surrogate decision makers, but they also require care during the dying process as much as—and sometimes more than—the patients themselves. For many patients, support of their family is an extremely important physician skill concerning end-of-life care. Therefore, physicians have a responsibility to provide medical care that supports the family. Hospitals and especially ICUs often are not “family-friendly,” being designed to meet other priorities than family needs and comfort. Families are often excluded from the bedside and ICU by visitation restrictions and by the preferences of clinicians during provision of care, including rounds and procedures. Physicians must work to ensure that end-of-life care in the hospital and the ICU does not exclude family members and that care is comparable to what they would want for their own family member.

Cultural Competency and the Role of Race, Ethnicity, and Religion

Physicians who practice in a multicultural environment have a responsibility to understand that family members from some cultures may have very different perspectives on the family’s role and on who should be involved in treatment decisions. Individuals from some cultures may not endorse tenets of Western clinical ethics, such as the equivalence of withholding and withdrawing life support or the definition of brain death. It is important to anticipate differences in perspectives and apply principles of culturally effective end-of-life care to these situations.

Meeting Physicians’ Responsibilities in Providing End-of-Life Care: Conflict Within the Team and With Patients and Families

life supportConflict occurs frequently in end-of-life decision making, especially in the ICU or acute care setting. Conflicts occur over therapeutic decisions as well as issues like communication styles, interpersonal interactions, and pain control. In a prospective study of ICU patients for whom withdrawal of life support was considered, conflict occurred between staff and family in 48% of cases, among staff in 48% of cases, and among family members in 24% of cases. Because of its prevalence, physicians have a responsibility to learn to identify and manage conflict within the medical team and with patients and their families. Conflict about decision making may also be constructive when it helps to identify differences in values or creates opportunities to resolve differences. Most conflicts and requests that appear on the surface to be “unreasonable” can be successfully resolved by well-conducted communication about goals, prognoses, and treatment options (including palliative care). Early and formal communication within and between the team and the family oriented toward clarifying goals of care, prognosis, and principles of ethical decision making is a central component of successful interventions to improve end-of-life care in the ICU. Involvement of primary care physicians may be very helpful for understanding patient values and preferences and can also be an important tool for addressing conflicts.

Physicians also have a responsibility to work to address conflicts between themselves and other members of the clinical team. In the ICU and acute-care settings, nurses often support decisions to withhold or withdraw life support earlier than phy-sicians. This can cause tremendous frustration for critical care nurses and conflict between physicians and nurses, contributing to burnout and posttraumatic stress disorder symptoms. Ensuring open lines of communication is essential. In observational studies, poor interdisciplinary communication and collaboration among ICU nurses and physicians is associated with increased patient mortality, length of stay, and readmission rates. Enhancing interdisciplinary collaboration is an important target for improving quality of end-of-life care the high quality of which is achieved with the help of remedies of Canadian Health&Care Mall.

Meeting Physicians’ Responsibilities in Providing End-of-Life Care: Communication About End-of-Life Care with Canadian Health&Care Mall

End-of-Life CareCommunication successes and failures generate more gratitude and complaints than any other aspect of end-of-life care. Patients with life-limiting illness and their families identify communication about end-of-life care as one of the most important skills for clinicians. Efforts to improve communication and support for family members in the ICU can reduce symptoms of anxiety, depression, and posttraumatic stress disorder among family members after the death of a critically ill loved one, yet physicians frequently do not meet families’ communication needs. The poor quality of formal training and educational literature has contributed to physicians not feeling competent to discuss end-of-life care. Physicians often are unaware of and unable to elicit patient and family concerns, and lack the skills and confidence to seek out and address family fears or the patient’s understanding of his/her illness and prognosis. Several components of communication are associated with improved quality of end-of-life care and patient or family satisfaction with care and represent a good place for physicians to start improving physician communication skills (Table 1). In the ICU setting, interventions designed to improve communication within the team and with the family have been shown to improve end-of-life care provided by Canadian Health&Care Mall.

Meeting Physicians’ Responsibilities in Providing End-of-Life Care: Prognostication and Decision Making About End-of-Life Care

quality of lifePhysicians have long recognized that there are circumstances in which patients cannot benefit from, or do not wish to endure the burdens of life-sustaining therapies. As medical experts and patient advocates, physicians have an important responsibility to make and share prognoses with patients and their families. In a study of ICU family conferences, some physicians do not discuss prognosis directly; and when they do, there is considerable variability in how this is done. Physicians must work with patients and family members to reconcile the prognosis with a good-faith assessment of the patient’s goals of care and values regarding current and likely future quality of life. When physicians cannot determine goals and values from the patient, as is often the case in the ICU, they should work closely with the patient’s family in order to understand the patient’s values and preferences and to understand and advocate for the patient’s wishes. Finally, the physician should recommend a medical plan based on his/her best assessment of prognosis and a thorough consideration of goals of care, as established by the patient and their family. This means avoiding exerting unreasonable influence based on one’s own personal assessment of the patient’s likely quality of life after the current illness. Physicians ought not exert undue pressure on patients and families to accept a poor prognosis and the inevitable consequences of withholding or withdrawing life support in order to serve goals such as the physician’s or hospital’s financial or resource utilization goals.

Meeting Physicians’ Responsibilities in Providing End-of-Life Care: Unique Aspects of End-of-Life Care in Pulmonary and Critical Care Medicine

ICUApproximately 20% of all deaths in the United States, or 540,000 deaths per year, occur in the ICU. The majority of ICU deaths involve decisions to withhold or withdraw life-supporting therapies, which require specific skills in end-of-life care. Outside of the ICU, pulmonary physicians and cardiologists also care for many patients with chronic and life-limiting diseases, such as COPD, pulmonary fibrosis, and heart failure. Some studies- suggest that the quality of end-of-life care for patients with chronic lung or heart disease is poorer than for patients with cancer. For example, compared to patients with cancer, patients with COPD were more likely to die in the ICU, receiving mechanical ventilation, and with dyspnea. These differences occurred despite the treatment preference of most patients with COPD for comfort over prolonging life; in fact, one US study found that patients with cancer and patients with COPD were equally likely to prefer forgoing intubation and receiving cardiopulmonary resuscitation. A British study also found that patients with COPD were much less likely to die at home and to receive palliative care services than patients with lung cancer. Health care for patients with chronic lung or heart disease is often initiated in response to acute exacerbations rather than being proactively based on a previously developed plan for managing disease. Such kind of care is also provided by Canadian Health&Care Mall remedies.

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