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Patient Rights

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A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Purpose/Goals

The purpose of this course is to prepare healthcare professionals to incorporate patient's rights into their practice and into their patient education.

Objectives

Upon completion of this self-study module, the participant will be able to:

  1. Education patients that they have a right to know.
  2. Accept the right of the patient to accept or refuse treatment.
  3. Discuss how healthcare personnel protect the right of patients to participate in their own care.
  4. Discuss Living Will, Durable Power of Attorney for Healthcare and DNR Order.
  5. Discuss the impact of the Affordable Care Acts impact on patient rights.

Introduction

Patient's have both rights and responsibilities when it comes to their health and the health care services they receive. On March 26, 1997, President Bill Clinton appointed an Advisory Commission on Consumer Protection and Quality in Health Care Industry. The Commission issued its final report, Quality First: Better Health Care for All Americans, in March 1998. As part of its work, the Commission issued a Consumer Bill of Rights and Responsibilities. This document was intended to serve as a blueprint for how systems and procedures that aim to protect consumers and ensure quality of care could be improved. In particular, this Consumer Bill of Rights and Responsibilities expressed three goals:

  • To strengthen consumer confidence by assuring that the health care system is fair and responsive to consumer's needs, provides consumers with credible and effective mechanisms to address their concerns and encourages consumer to take an active role in improving and assuring their health.
  • To reaffirm the importance of a strong relationship between patients and their health care professionals.
  • To reaffirm the critical role consumers play in safeguarding their health by establishing rights and responsibilities for all participants in improving their health.

Patients have the right to care, treatment, and services that safeguards their personal dignity and respect their cultural, psychosocial and spiritual values. These values often affect the patient's treatment needs and preferences. By understanding and respecting patients and their values, providers can help meet the patient's needs for treatment and services and protect the patient's rights. Many health plans, including all of the plans sponsored by the Federal government, have adopted these general principles. The Consumer Bill of Rights and Responsibilities also lists specific rights and responsibilities that Federal health plans and others have adopted. Under the Conditions of Participation - CMS (Centers for Medicaid and Medicare Services) requires participating hospitals to protect and promote the rights of patients. This means that patients must be informed of their rights before they accept or refuse treatment. Sometimes, a patient is not able to communicate directly. In this case, patient rights should be discussed with the patient's legal representative. Patients must be able to understand information about their rights. Some patients need special help to understand. For example, patients who do not speak English have the right to a medical translator or translated materials. They have this right by law. Patient rights fall into seven general areas:

  1. Information disclosures
  2. Participation in treatment decisions
  3. Respect, safety, and nondiscrimination
  4. Confidentiality of health information
  5. Grievances, complaints, and appeals
  6. Access to emergency service
  7. Choice of providers and plans

Information Disclosure

Patients in health care facilities have the right to accurate and easily understand information about their health plan, health care professionals and health care facilities. If they speak another language, have physical or mental disabilities appropriate information must be provided to make informed health care decisions. They have the right to know about:

  1. The facility itself this information can cover a wide range like how to file a complaint.
    1. The facility's position on withholding and withdrawing life-sustaining care and treatment
    2. Experience with specific procedures and services
    3. Accreditation status
    4. Quality and consumer satisfaction ratings this information is being made available through the internet
  2. Their health care team who is responsible for their care names and professional status
    1. Education and board certification status
    2. Years of practice
    3. Experience
    4. Quality and consumer satisfaction ratings
  3. Their rights and responsibilities as patients. Remember they must understand the information they are given about their rights.

Regulatory agencies require proof that facilities provide this to patients by both direct observation and facility policies. Each facility has its own methods for making sure patients know and understand their rights. Most facilities display the patient rights at intake points in the facility. Many facilities also provide patients with a written form of patient rights at intake during the admission process in patient handbooks. Rights and responsibilities may also be posted in waiting areas for patients, families, and visitors to review; however, a written list of rights may not be enough. The facility must make sure that all patients understand their rights well enough to exercise them. In fact, this is true of all information. All information must be presented so that the patient can understand it. This means that patients may need special help if they do not speak English, cannot hear well, or have other mental or physical barriers to understanding. Examples of special help include:

  • Translators
  • Sign-language interpreters
  • Social workers or case managers
  • Large print or Braille materials
  • Magnifying glass or large print document

Participation in Treatment Decisions

Patients have the right to participate in decisions about their care and to set the course of their treatment. This means that patients must be given accurate information. Patients have the right to know their diagnosis, prognosis and treatment options. Health care professional must discuss all treatment options with their patients, which includes the option of no treatment. Further, they need to know the risks, benefits and potential medical consequences for each treatment option.

Discussing clinical information with a patient is part of informed consent. Informed consent is an ongoing process of communication between a health care provider and his or her patient. It allows the patient to make intelligent decisions about a proposed course of treatment. Information is useful to a patient only if he or she can understand it. When discussing diagnosis and treatment options with the patient avoid the use of medical jargon and terminology; seek the services of a translator or interpreter if necessary; and assist the patient in obtaining a second opinion if requested. The informed consent process should include a full discussion of the following:

  • The nature of proposed treatment
  • Potential benefits and risks
  • Recuperation time
  • Likelihood of success or possible outcomes
  • Possible side effects of medication and treatment
  • Costs including what insurance may and may not cover
  • Complete information about diagnosis and treatment
  • Reasonable alternatives to the proposed treatment (plus risks, benefits and side effects of these alternatives)
  • Any limitations on confidentiality

After receiving all pertinent information, a patient may give informed consent for treatment or refuse treatment. Except in an emergency, a patient must give his or her informed consent prior to the start of any procedure or treatment. Informed consent or the reason for a patient's inability to provide informed consent must be documented in the medical record. Patients also have the right to refuse treatment. Even after giving informed consent, patients may change their mind at any time. If the patient decides to withdraw consent, the treatment must be stopped. When a patient refuses treatment, he or she has the right to know what will happen. The patient should receive information on the possible medical and other consequences of refusing treatment. Parents, guardians, family members or other individuals that are designated as the representative of the patient if he cannot make his/her own decisions must be provided the same information.

Advanced Directives

The Patient Self Determination Act became effective December 1991. This law requires that all hospitals receiving Medicare or Medicaid funding provide information to all adult patients upon admission about advanced directives and to ask whether the patient has an advanced directive. In accordance with Federal and State regulations, patients should receive information regarding advanced directives if they do not present with this information at admission. Advanced directives can be used from admission to admission; however, they should be reviewed with the patient at each admission to verify accuracy. If the patient is incompetent at the time of admission, the information should be provided to the surrogate or proxy. If the patient is temporarily incapacitated, the information should be provided when decisional capacity returns. A patient's right to make decisions about his/her care is true even after the patient is no longer able to communicate those decisions directly. Advance directives can protect people in extreme conditions. These people may be unable to communicate due to a condition such as irreversible brain damage or brain disease that affects the ability to think as well as communicate.

Advanced directives can limit life-prolonging measures when there is little or no chance of recovery. For example, advanced directives may enable patients to make their feelings known about cardiopulmonary resuscitation (CPR), intravenous (IV) therapy, feeding tubes, ventilators and dialysis. Advanced directives can address pain relief either requesting or refusing it.

An advanced directive is a legal document that allows a patient to participate in future health care decisions. There are two forms of advanced directives:

  • Living Will a patient documents his/her wishes for future treatment in the event of terminal illness. A living will goes into effect when a patient develops a terminal condition that makes it impossible to communicate health care decisions directly. They are called living wills because they take effect while a patient is still alive.
  • Durable Power of Attorney for Health Care in this document, the patient appoints a representative to make health care decisions. The power of attorney goes into effect when the patient loses the ability to communicate his/her own decisions. The patient names a person called a proxy to make decisions.

An additional tool for participating in future health care decisions is the do-not-resuscitate (DNR) order. A DNR order states that a patient does not want CPR if he/she goes into cardiac or respiratory arrest. A patient may request a DNR order; however, only a physician can approve and give the order.

Health care personnel play a critical role in protecting patient rights related to advance directives. Health care personnel must empower patients to complete advanced directives. They must offer information about advanced directives to all adult patients in a language/manner they can understand and they must help patients who wish to complete an advance directive. Health care personnel must respect the decisions in a patients advanced directive. They must place a copy of the directive in the patients chart. If a copy is not available, the important points of the directive should be documented in the medical record. Health care providers then must follow the directive, after it has taken effect.

An advanced directive takes effect only after the patient is no longer able to communicate directly. Until that time, the patient's direct communication is the only thing that matters. A competent patient may change his/her advanced directive at any time. If a patient wishes to change a directive, the health care provider must make it possible. Patient care must NEVER be based on whether or not the patient has an advanced directive and the decisions in the directive. All patients must be treated fairly and equally, regardless of advanced directives.

When a patient loses the ability to communicate directly, often he/she does not have an advanced directive. In this situation, treatment wishes must still be respected as much as possible. Florida State Status 765.401 provides for the appointment of health care representatives. To make decisions about the patient's treatment, the representative should talk to the physician in charge of the patients care and consider what the patient would want. The hierarchy of health care decision makers for a patient without an advance directive depends upon state law.

Power of attorney means one person authorizes another person to act on their behalf. Some important points regarding a power of attorney include signatures of the principal party, two adult witnesses, and the notary public. It may be use immediately. A power of attorney does not need to be filed in court except for real estate transactions. The power of attorney is in effect until revoked by the principal, participant's death, or revoked by the court. A power of attorney may have more than one agent all agents must concur when making decisions. There are several types of power of attorney.

  • General: an agent acts on behalf of the person in a variety of situations.
  • Limited: limited to a specific transaction.
  • Health care: to make decisions when incapacitated
  • Springing: in effect at some future time illness, disability of principal.
  • Durable: all of the above can be made durable by adding text enables agent to act when the principle is incompetent and physically unable to make decisions.

A health care surrogate is any competent adult expressly designated in writing by a patient to make health care decisions on his or her behalf when incapacitated. This surrogate has no authority to act until the primary care physician determines that the principal lacks capacity to make informed health care decisions. A proxy is a competent adult, who has not been expressly designated to make health care decisions for a particular incapacitated individual but who is authorized to make health care decisions. A health care proxy is appointed by the hospital when there is no power of attorney or surrogate and health care decisions need to be made. Potential representatives for an incapacitated patient may include:

  • Guardian
  • Spouse
  • Adult child
  • Parent
  • Domestic partner
  • Brother or sister
  • Close friend

Research Participation

Patients have the right to refuse treatment. They also have the right to be part of research studies or educational activities. If a patient refuses experimental treatment, this should not have any effect on his/her regular care. If the patient wants to be part of a research study, he/she must sign a written consent that explains that the proposed treatment is experimental. Consent form for participation in experimental treatment must include the nature of experimental treatment, procedures involved, risks and benefits, other available options, and confirmation of interrupted patient care.

Organ Donation

Patients have the right to choose about organ donation. They must give informed consent if they want to donate their organs. If the patient is unable to give informed consent, the representative of the patient may make this decision.

Respect and Nondiscrimination

Patients have the right to considerate, respectful, nondiscriminatory, and compassionate care from doctors, health plan representatives, and other health care providers. Respect means valuing the patient's needs, desires, feelings, and ideas. Treat patients with common courtesy. For example, knock and wait before entering a patient's room; respond politely to patients; listen to patients; and remain compassionate. All patients have the right to fair and equal health care services regardless of:

  • Race
  • Ethnicity
  • National origin
  • Religion
  • Political affiliation
  • Level of education
  • Place of residence or business
  • Age
  • Gender
  • Marital status
  • Personal appearance
  • Mental or physical disability
  • Sexual orientation
  • Genetic information
  • Source of payment

Patient Safety and Security

Patients have the right to safety and security. They have the right to a choice of health care providers that is sufficient to provide him/her with access to appropriate high-quality care. All caregivers must do their part to ensure a safe environment of care for patients. All employees are responsible for knowing facility policies regarding environmental safety, infection control and security. JCAHO has been concerned about patient safety over the past few years to issue its Patient Safety Goals.

All patients should be screened for abuse. Facilities must have procedures for identifying, reporting, and treating victims of abuse. They have the right to expect access to protective services in the case of abuse. Sometimes patients need to be kept safe from themselves. They may need to be restrained. The decision to use restraints is a medical decision. Restraints must never be used for discipline or convenience. When a patient must be restrained, it is important to protect the patient's rights, safety, comfort, and dignity.

Confidentiality of Health Information

Patients have the right to reasonable visual and auditory privacy and confidentiality. A private place should be used for case discussion, consultation, examination, and treatment. The patient has the right to review and receive copies of their own medical record and request that the physician amend the record if it is not accurate, relevant or complete. The medical records should only be shared with clinicians who are directly involved in the patients case, regulatory personnel who are looking into a facility's quality of care, and other people who have a legal or regulatory right to see the records. Protected health care information should not be share with anyone else. Only authorized employees should have access where medical records are stored. The patient should receive an accounting of disclosures of personal health information. Patients may not be allowed to see certain information only if that information could harm the patient or someone else or that information is being inspected by an oversight committee.

HIPAA Health Insurance Portability and Accountability Act privacy rule is a federal regulation. The rule sets standards for patient privacy and confidentiality. It also sets severe civil and criminal penalties for people who violate a patient's privacy. To comply with HIPAA protected patient information must only be shared with people who are directly involved in the patient care. The patients case must only be discussed with people who are directly involved in the case. This is especially important when talking in public areas (elevators, restrooms, hallways, or cafeteria etc.). Patient charts should not be left out where they might be seen or accessed by unauthorized persons. It is important to observe surroundings when discussing patient care.

Complaints/Grievances/Appeals

The patient has the right to a fair, fast, and objective review of any complaint that they have against the health plan, doctors, hospitals, or other health care personnel. This includes complaints about waiting times, operating hours, the conduct of health care personnel and the adequacy of health care facilities. Many facilities have a Patient Care Representative to deal specifically with complaints or grievances. Many patient complaints can be addressed quickly. For example, if a patient complains about getting the wrong items on her lunch tray, make sure she gets the right items next time. The sooner the issue is resolved at the facility level the better the patient compliance and satisfaction with health care provided. The patient may need to have access to the ethics committee for issues regarding his/her care. They should expect that issues related to end-of-life care be treated with respect and sensitivity. The patient should be able to examine and receive an explanation of his/her bill regardless of source of payment.

More than 50% of patients sue because of miscommunications, anger, and lack of information between physicians, hospital staff, and patients/families. Grievance management is everyone's responsibility. Handling grievances effectively from the start benefits everyone involved, and it helps keep small grievances from becoming big ones and reduce the risk of liability. When complaints cannot be resolved quickly and easily, patients have the right to file a grievance. A grievance is a formal written or verbal complaint. If a patient wants to file a grievance, the health care provider must:

  • Explain the grievance process at the facility. This includes the name of the staff person the patient should contact.
  • Explain that grievances may be filed with state agencies. This is true whether the patient has already used the facility's internal grievance process.
  • Give the patient the phone number and address for filing a grievance with the state.

Health care facilities must review, investigate, and resolve all grievances within a reasonable period. If the grievance has to do with the patient's safety, it should be reviewed immediately. Examples include grievances about abuse or neglect. To complete the grievance process, the facility must give the patient a written report. This report should explain: how the facility investigated the grievance and the facility's decision about the grievance.

Access to Emergency Services

Patients and insurance companies often disagree about the need for emergency care. For example, if an individual has severe chest pains and goes to the Emergency Department because they think they are having a heart attack. Tests show that the problem is heartburn and the managed care plan refuses to cover the cost of the ER service. They argue that they do not have to pay for emergency services when an event was not life threatening. In the past, this type of conflict has led health care facilities to reject patients, refuse to treat patients, and to transfer patients to other hospitals. To solve this problem, insurance companies now must use a standard definition for the need for ER services. This definition uses the idea of a prudent layperson. Under this definition, a person has need for ER services if he or she has signs or symptoms that a reasonable non-medical person would consider an emergency.

Congress passed the prudent layperson definition of emergency for Medicare and Medicaid in 1997. The prudent layperson definition appears in the Consumer Bill of Rights and Responsibilities:

Consumers have the right to access emergency health care services when and where the need arises. Health plans should provide payment when a consumer presents to an emergency department with acute symptoms of sufficient severity that a prudent layperson could reasonably expect the absence of medical attention to result in placing the consumer's health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.

If the patient has severe pain, an injury, or sudden illness that convinces him/her that their health is in serious jeopardy, they have the right to receive screening and stabilization emergency services whenever and wherever needed without prior authorization or financial penalty. The patient has the right to request transferal to another institution providing it is medically permissible and that the other facility will accept the transfer.

Another tool for protecting the right to emergency medical treatment is the Emergency Medical Treatment and Active Labor Act (EMTALA), which helps prevent patient dumping. Therefore, it is often called the anti-dumping law. EMTALA was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA). Consider this scenario: A patient goes to the emergency room and asks for medical service. Under EMTALA, the hospital must screen this patient. Screening must be complete enough to find out whether the patient has an emergency medical condition. The medical screening exam must be performed by a physician or qualified individual who is designated by the facility to provide medical screening exam. It must be clearly stated that triage exam does not constitute a medical screening exam. If the patient does not have an emergency condition, the hospital has no further obligation under EMTALA. If the patient does have an emergency condition, the hospital must provide stabilizing treatment. This treatment must be provided without considering the patients ability to pay. Before the patient is stabilized, the hospital may transfer the patient ONLY if another facility is better equipped to treat the patient. The hospital may not transfer an unstable patient for economic reasons.

Bills and Bill Examination

Patients have the right to question their bills. They have the right to request and receive a detailed explanation of every item on a bill.

Patient Responsibilities

As well as patient rights, the patient should be informed of his responsibilities. Patient responsibilities typically include:

  • Providing accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to his/her health.
  • Reporting unexpected changes in his/her condition to the responsible health care provider.
  • Reporting whether he/she clearly understands and comprehends the plan of action for his/her needs and what is expected of the patient.
  • Following treatment plans recommended by the practitioner primarily responsible for his/her care. This plan may include following instructions of nurses or other health care personnel who implement the physician's orders and enforces facility rules and regulations.
  • Keeping appointments and notifying the health care provider or facility when he/she is unable to do so for any reason.
  • Actions if he/she refuses treatment or does not follow the physician's instructions.
  • Assuring that the financial obligations of health care are fulfilled as promptly as possible
  • Being considerate of the rights of other patients and personnel and respectful of property of others.

Additional Pediatric Rights

Patients (and as applicable parents, guardians, foster parents, or other legal representatives) have the right to:

  • Have their developmental, cognitive, emotional, and social needs met while they are in the hospital in an environment that is supportive of infants, children, and adolescents
    • Play, educational and social activities essential to all children and adolescents
    • Information about what to expect prior to, during, and following procedure/experience and support in coping
    • Participation of children/families in decisions affecting their own medical treatment.
  • Have parents recognized as partners in decision making with medical professionals and in the care of their child as permitted.

Family Responsibilities

The family consists of those individuals responsible for physical and emotional care of the child on a continuous basis regardless of whether they are related. Parents and families have the responsibility for:

  1. Continuing their parenting role to the extent of their ability
  2. Being available to participate in decision-making and providing staff with knowledge of parents/family whereabouts

The Affordable Care Act

Insurance companies often leave patients without coverage when they need it the most, causing them to put off needed care, compromising their health and driving up the cost of care when they get it. Too often, insurance companies put insurance company bureaucrats between you and your doctor.

On June 22, 2010, President Obama announced new interim final regulations, the Patients Bill of Rights, that include a set of protections that apply to health coverage starting on or after September 23, 2010, six months after the enactment of the Affordable Care Act.

The Affordable Care Act cracks down on the some of the most egregious practices of the insurance industry while providing the stability and the flexibility that families and businesses need to make the choices that work best for them.

he Departments of Health and Human Services, Labor and Treasury collaborated on the Patients Bill of Rights which will create an important foundation of patients rights in the private health insurance market that puts Americans in charge of their own health.

The following health insurance Patient's Bill of Rights has embedded website short cuts for more information (Healthcare.gov, 2012, pg. 1).

  • Provides Coverage to Americans with Pre-existing Conditions: You may be eligible for health coverage under the Pre-Existing Condition Insurance Plan.
  • Protects Your Choice of Doctors: Choose the primary care doctor you want from your plans network.
  • Keeps Young Adults Covered: If you are under 26, you may be eligible to be covered under your parents health plan.
  • Ends Lifetime Limits on Coverage: Lifetime limits on most benefits are banned for all new health insurance plans.
  • Ends Pre-Existing Condition Exclusions for Children: Health plans can no longer limit or deny benefits to children under 19 due to a pre-existing condition.
  • Ends Arbitrary Withdrawals of Insurance Coverage: Insurers can no longer cancel your coverage just because you made an honest mistake.
  • Reviews Premium Increases: Insurance companies must now publicly justify any unreasonable rate hikes.
  • Helps You Get the Most from Your Premium Dollars: Your premium dollars must be spent primarily on health care not administrative costs.
  • Restricts Annual Dollar Limits on Coverage: Annual limits on your health benefits will be phased out by 2014.
  • Removes Insurance Company Barriers to Emergency Services: You can seek emergency care at a hospital outside of your health plans network.
  • Since the Patients Bill of Rights was enacted, the Affordable Care Act has provided additional rights and protections.

The health care law:

  • Covers Preventive Care at No Cost to You: You may be eligible for recommended preventive health services. No copayment.
  • Guarantees Your Right to Appeal: You now have the right to ask that your plan reconsider its denial of payment.
  • In addition, the Affordable Care Act will achieve greater cost savings by (Healthcare.gov, 2012, pg. 1).
  • Reducing the hidden tax on insured Americans: By making sure insurance covers people who are most at risk, there will be less uncompensated care and the amount of cost shifting among those who have coverage today will be reduced by up to $1 billion in 2013.
  • Improving Americans health: By making sure that high-risk individuals have insurance, the rules will reduce premature deaths. Insured children are less likely to experience avoidable hospital stays than uninsured children7 and, when hospitalized, insured children are at less risk of dying.
  • Protecting Americans savings: High medical costs contribute to some degree to about half of the more than 500,000 personal bankruptcies in the U.S. in 2007.9 These costs borne by individuals might be assumed by insurance companies once rescissions are banned, annual limits are restricted, lifetime limits are prohibited, and most children have access to health insurance without pre-existing condition exclusions.
  • Enhancing workers productivity: Making sure that kids with health problems have coverage will reduce the number of days parents have to take off from work to care for family members. Parents will also be freed from job lock, which occurs when people are afraid to take a better job because they might lose coverage for themselves or their families.10

References

American College of Emergency Physicians, 2012. EMTALA. Retrieved 10/13/12 from (Visit Source).

Advisory Commission on Consumer Protection and Quality in Health Care Industry. Donna Shalala, Secretary of the Department of Health and Human Services, and Alexis Herman, Secretary of the Department of Labor. Quality First: Better Health Care for All Americans March 1998.

Centers for Medicare and Medicaid Services. 2/27/12. Health Insurance Reform for Consumers. Retrieved 10/13/12 from (Visit Source).

Consumer Bill of Rights and Responsibilities; Conditions of Participation Centers for Medicaid and Medicare Services. 1999.

Federal Register /Vol. 75, No. 223 / Friday, November 19, 2010 /Rules and Regulations. 2010. Retrieved 10/1/112 from (Visit Source).

Healthcare.gov. (2012) The Healthcare Law and you. 2/6/12. Retrieved 10/1/12 from (Visit Source).


This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Dietitian/Nutritionalist (RDN), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Physical Therapist (PT/PTA), Registered Nurse (RN), Respiratory Therapist (RT)

Topics:

CPD: Prioritize People, Legal & Regulatory


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