Ann Alpers

Criminal act or palliative care? Prosecutions involving the care of the dying.

Author examines criminal investigations and prosecutions of physicians and nurses in connection with their care of dying patients and concludes that the criminal law has failed to protect patients and families and has significant power to deter appropriate pain management for dying patients.

Key legal principles for hospitalists

In a hospitalist system, when a patient leaves the hospital, he or she will return to a primary care provider (PCP) for follow-up and continuing care. The hand-off after discharge can compromise communication with the PCP. Physicians have a legal duty to provide follow-up care to patients with whom they have a relationship. The obligation to provide follow-up care endures even when the patient misses a scheduled appointment or does not adhere to the follow-up regimen. In general, the physician who began the care must fulfill that obligation. An essential component of follow-up care includes educating the patient about what symptoms require follow-up care and why it is important. The duty to provide adequate follow-up care is shared by the hospitalist and the PCP. Virtually no malpractice case law considers the obligations and practices of hospitalists. This article uses cases involving follow-up care for patients treated in an emergency department and general cases regarding liability for follow-up care to examine the potential legal obligations of both hospitalists and PCPs for follow-up care, including circumstances involving pending test results and incidental findings.

Avoiding Family Feuds: Responding to Surrogate Demands for Life-Sustaining Interventions

he laws and ethical guidelines governing decision making for incompetent patients evolved from conT troversies in which family members refused life-sustaining interventions.’ These cases led to a consensus that advance directives to limit interventions should be respected and that a surrogate designated by the patient or specified by statute could refuse interventions, even when other relatives disagreed.* Surrogate decision-making statutes and ethical principles about respect for delegated autonomy promote an active role for family members or other surrogates in medical decisions for incompetent patients. Inviting surrogates to participate actively in medical decisions recognizes the importance of the patient’s personal community and assures that decisions will reflect the patient’s own preferences and values. The standard approach to decisions for incompetent adults gives advance directives priority over a surrogate’s substituted judgment, which in turn has priority over assessments of the patient’s best interest^.^ A patient may express advance directives by appointing a proxy, stating specific preferences, or articulating general values. We use case examples to illustrate the limitations of all three types of advance directives. Another standard encourages patients to designate a single proxy and gives that individual priority over other friends and relatives. Such proxy designation makes particular sense for gay men with acquired immune deficiency syndrome, who want their partners or friends to make decisions for them.4 A single designated surrogate can also resolve a case in which several relatives di~agree.~ However, our cases illustrate how surrogates often make decisions as members of a family unit whose relationships will

A Middle Ground on Physician-Assisted Suicide

“[A] murder prosecution is a poor way to design an ethical and moral code for doctors,” observed the California Court of Appeal in 1983. Yet, physicians who have chosen to help terminally ill patients to commit suicide have trespassed on illegal ground. When skilled medical care fails to relieve the pain of terminally ill patients, some people believe that physicians may assist in these suicides. Others reject any kind of physician involvement. The debate on assisted suiczide and active euthanasia has focused on whether these acts can ever be acceptable. We propose to shift the debate to a less divisive issue: whether a caring physician who provides a suffering and ill patient with a prescription for a lethal dose of medication should be prosecuted as a felon. Even assisted suicides opponents may object to such criminal prosecution. We propose to modify existing criminal laws to give physicians who assist their terminally ill patients in suicide, under carefully defined circumstances, a legal defense against criminal charges.

Health care financing administration’s new regulations for financial incentives in medicaid and medicare managed care: one step forward?

Because financial incentives for managed care physicians may create conflicts of interests, new regulations have been instituted that will result in disclosure of certain financial incentives to the Federal Government and to some patients. Given the limitations of these regulations, health plans and physicians should take the lead in addressing concerns about the harmful effects of financial incentives. For example, public disclosure may deter unusually strong financial incentives. Purchasing coalitions, advocacy groups, and journalists should have increased access to information about physician-level incentives. These nonregulatory measures might reassure patients that managed care physicians are committed to their best interests.