Emergency department administration, legal matters and quality care

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Chapter 47 Emergency department administration, legal matters and quality care

HOW THE LAW AFFECTS THE PRACTICE OF EMERGENCY MEDICINE

(S Lesley Forster)

There have been a number of recent changes in society and in the law which greatly affect the practice of medicine in general, and emergency medicine in particular. Those practising emergency medicine need to be aware of these changes and to ensure that their practice conforms to the legal requirements. In court, ignorance of the law is no excuse.

This chapter also considers ways of decreasing the likelihood of legal action, and what to do if you are sued.

Confidentiality

The overriding ethical maxim in the treatment of patients is that the doctor must keep secret anything he or she hears about the patient. There are, of course, exceptions; for example, where a patient consents to the disclosure of information, or when giving evidence in court.

When faced with requests from police officers for information regarding a patient’s condition, ideally the written consent of the patient should be obtained first. It is the doctor’s duty to ensure that information is given only to those who are entitled to it.

It is accepted that, in some instances, public interest can override a doctor’s duty of confidentiality. If, for example, a patient confides to a doctor an intention to commit a serious criminal offence such as homicide or sexual assault, then it would be in order for the doctor to provide a relevant third party with that information.

There are other circumstances where the situation is not quite so clear, and judgement must be made according to the circumstances at the time as to what constitutes a serious criminal offence. It seems to be fairly well accepted among the medical profession, for example, that a doctor should not notify police of a patient’s involvement in minor criminal activities, such as personal use of illicit drugs or property offences.

Some occasions arise where there is no absolute answer to the problem; for example, if a patient who is known to be involved in drug trafficking presents to the emergency department. In such a case, where doubt may exist, the advice of colleagues, medical administration and, even better, the advice of a medical defence organisation should be sought in order to assist the doctor to make the very serious decision as to whether to override the duty of confidentiality.

For guidance, the St Vincent’s Hospital policy regarding internally concealed drugs is shown in Box 47.1.

Box 47.1 St Vincent’s Hospital policy and procedure for management of patients with internally concealed drugs

These patients may present of their own accord or may be brought in by the police.

Some drugs, e.g. heroin and cocaine, may cause death if leakage occurs. This is much less likely with hashish. Mechanical problems such as obstruction may occur with any ingested packets.

Medical management should proceed as appropriate. Drug screens and other investigations are performed if medically indicated. Abdominal and chest X-rays, CT may be required. Close observation and supportive therapy are indicated. Specific antidotes such as naloxone may be required. Decontamination may be needed if packet rupture and toxicity have occurred (toxicity may occur by diffusion without packet rupture). Glycoprep (or similar) may be used to hasten transit. Laparotomy may be indicated to relieve mechanical obstruction or to urgently remove leaking packets which cannot be otherwise retrieved.

If, in the judgement of the treating doctor, the amount of substance is small, i.e. unlikely to be intended for large-scale trafficking but rather intended for individual use, and the patient was not brought in by the police, then it is not mandatory that the police be contacted. Where large quantities are involved, the following steps should be taken:

(Reproduced with permission.)

By phone or mail

Under the Public Health Act 1991 and Regulation, hospital CEOs (or their delegates) are required to notify the following diseases to the local public health unit.

More legal obligations