Tuesday, July 13, 2010

CHARTER OF PATIENTS’ RIGHTS AND RESPONSIBILITIES

Charter of
PATIENTS’ RIGHTS AND RESPONSIBILITIES
(Jointly prepared by Rugna Hakka Samiti-Pune, Jan Aarogya Abhiyan, Indian Medical Association-Pune(IMA) and Federation of Obsteric and Gynaecological Societies of India-FOGSI)


Doctor-patient relations have to be healthy if patients are to get good care and doctors are to work satisfactorily. For this to happen doctors should respect patients’ rights and patients should observe their responsibilities.
Doctor-patient relations are not merely that of seller and buyer. Secondly the specificities of medicine, of medical service have to be borne in mind and a system needs to be created to ensure observance of patients’ rights and responsibilities. Representatives of patients (e.g. Rugna Hakka Samiti-Pune, Jan Aarogya Abhiyan) and doctor’s representatives (Indian Medical Association (IMA), Pune and Federation of Obstetricians and Gynecologists (FOGSI)) have decided to work towards this end. This brochure is part of that joint endeavor.
Firstly, specificities of medical science and technology make medical profession a distinct one. Unlike physical sciences and engineering where things are reasonably certain, unexpected medical complications cannot be predicted. Sometimes the doctors may not be able to avoid such complications. But they need to be detected in time, treated promptly and good communication needs to be established with the patients/relatives. If the doctor-patient relations are healthy, a good rapport can be established in such delicate situations.
Any professional is some kind of expert. But doctors are not just experts. The patient’s immediate need is relief from pain, illness. He /she may be in hurry to become fit and join work at the earliest. Doctors fulfill this delicate, immediate need. Secondly, the process of opening up one’s body and mind to the doctor, so necessary for proper diagnosis and treatment, inevitably leads to doctors having a kind of authority. Medical ethics demands that doctors should always use this ‘medical power’ for patient’s benefit. That is why medicine is regarded as a ‘noble profession’. After receiving a service, a customer merely thanks the service provider whereas the patient remains indebted to the doctor. Patients’ rights have to be respected keeping in mind this inherent vulnerability of patients vis a vis doctors. Patients too should follow their responsibilities so that doctors can do their work satisfactorily.
Keeping in mind above-mentioned characteristics of medical profession and doctor-patient relationship, let us see what doctors, patients ought to do. Let us first understand patient’s rights as a human being without any discrimination on the basis of income, gender, caste, religion, location etc.

PATIENTS’ RIGHTS
1) Right to Emergency Medical Care –
All doctors are duty bound to provide basic Emergency Medical Care and injured persons have a right to get Emergency Medical Care. It includes any of the essential measures like removing obstruction in the respiratory tract, stopping blood loss, intravenous fluids, analgesic medicines as per requirement, stabilising patient’s vital parameters (by using life saving medicines when necessary), preparation for referral to appropriate hospital if required etc. Only after providing this emergency care, hospitals can demand fees or can inform police.

2. Right to information-
All patients should be given the adequate relevant information about the nature, severity and likely outcome of the present illness; provisional diagnosis or confirmed diagnosis; relevant information about the proposed care, the expected results, risks and advantages/disadvantages of various alternative procedures, treatment options and the possible effects of the non-use of medical treatment should be communicated. It should be noted that sometimes-precise diagnosis might not be initially possible. Secondly, there are no set standards about how much information is to be given. Hence what minimum information is to be provided has to be based on practical experience. In case of further doubts, patients/relatives should ask doctors about these. Doctors may take help of informative booklets written in simple language comprehensible to patients, or any educational material, or take help of assistant doctor to provide such information. Any queries beyond this should be asked to concerned main doctor.
Patients/person authorised by patient should be informed about the likely cost of the treatment. Patients and family should be informed about the financial implications when there is a change in the patient’s condition or line of treatment. (Doctor would communicate, in this regard, to one person authorised by patient. It is difficult for the doctor to communicate with a number of different persons.)
Patient or person authorised by patient has a right to have an access to his / her indoor case paper’s photocopy (during admission-within 24 hours and after discharge-within 72 hours) after paying appropriate fees for photocopying.
Hospital should provide Indicative Rates (like daily visit fee, bed charges, main diagnostic tests charges) to each patient. Some of these Indicative Rates should be displayed prominently on the board in the hospital. Secondly, rates of concerned services relevant to the patient like - relevant rates for a woman coming for delivery, specialist’s fee for each visit should be provided to each patient. This will help the patients to figure out the likely expenditure from all these displayed charges. On request, the hospital should provide written expenditure estimation to patients according to his/her illness. Patient/person authorised by the patient should be informed about the financial implications when there is a change in the patient condition or treatment setting.
At the time of discharge, patient should get a discharge card, which should contain: condition of patient at time of admission; important clinical findings; summarized results of laboratory tests; diagnosis and, treatment during hospitalisation; condition of patient at discharge; date of follow-up visit if required; medicines and precautions to be taken after discharge, medicines to be avoided,(especially in case of any allergy to any medicines). Clear instructions should be given in cases where medicines that should not be stopped without doctor’s consultation (e.g. medicines for hypertension, diabetes) and instructions should be given regarding emergency situations. This follow up advice should be written in a language and manner, which can be easily understood by a common person.
In case of death of the patient, the death summary should be provided to deceased’s relatives. It should include all-important medical points, ranging from condition of patient at time of admission to the cause of death.

3. Right to informed consent
In case of any potentially hazardous treatment (like surgery, blood transfusion, potentially hazardous tests etc.), patient should get adequate information (in a manner comprehensible to common person) related to the treatment or operation to be undergone, including the associated risks and discomforts, side effects and alternatives. Patients have a right to give written consent to the treatment and have a right to refuse treatment. If patient refuses the treatment or invasive investigation, consequences of such refusal are patient’s responsibility.
In the case of an unconscious patient or when a patient is not able to take decision, then the written consent of a relative/ patient authorised person should be taken.
(In case of surgery or similarly potentially hazardous treatment (e.g. Chemotherapy for cancer), consent should not be taken immediately before the surgery or potentially hazardous treatment. It should be taken when decision of such treatment is finalised.)

4. Right to confidentiality
All the data and information related to an individual’s state of health, and concerning the medical/surgical treatments to which he or she is subjected, must be stored and used in such a manner to maintain the anonymity of the patient/informant. This is especially necessary in cases of conditions, which carry a stigma. (There are some exceptions to this - If a person has HIV infection, then it is a human right of his/her partner to know this. Similarly in case of some communicable diseases, such information needs to be provided to public health authorities. Information must be provided if any court demands it. Barring such exceptions, patient’s identity, condition, disease, diagnosis etc. should be limited to doctors and medical staff.)


5. Right to second opinion
Patients/persons authorised by patients have the right to seek a second opinion from an expert in the concerned field by inviting him/her in the same hospital. All medical information must be made available to the second doctor; whereas the latter should meet the first doctor.
(Of course, patient would pay the second doctor’s fees. Secondly, patient and the first doctor has a right to get the opinion, including due rationale, from the second doctor in writing so that second opinion would not be given irresponsibly or with ulterior intentions. The second doctor’s opinion will not be binding on first doctor. If the second doctor gives a different opinion about diagnosis, treatment and if patient wants that treatment, then patient should take treatment from second doctor on his/her own responsibility. The first hospital has responsibility to continue the ongoing treatment till the patient is transferred out. It is not responsibility of first hospital to take care of the patient while transporting him/her to second hospital. Such a discharge would be ‘discharge against medical advice’ (AMA) and it would be noted as such on the discharge card. From all this, it becomes clear that patient’s responsibility increases while seeking second opinion. e.g. if delays occur, due to the process of seeking second opinion, in getting tests done or receiving treatment then, the first doctor is not responsible . Despite of all this, patients have a right to seek second opinion.)

6. Right to respect human dignity and privacy of the patient
Keeping in mind the patient’s vulnerability, doctors and hospital staff should respect his/her human dignity. Each patient has the right to receive respectful care and communication at all times and under all circumstances, as recognition of his/her personal dignity.
During physical examination of female patients, a female caregiver or female staff member must be present.


7. Non-discrimination on the basis of HIV status –
No person suffering from HIV may be denied care on the basis of the HIV status if the hospital can provide necessary services. E.g. HIV positive pregnant women seeking hospital delivery care should receive delivery care. Treatments of other illnesses (diabetes, high blood pressure, malaria etc.) of HIV positive patients do not require special knowledge, skills. Special knowledge, skills are required only for the treatment of AIDS patients.

8. Right to choose alternative treatment if options are available
The patient has the right to choose alternative line of treatment if such options are available. Doctors should inform about all benefits and risks of such options, preferably in written form. However, consequences of choosing a particular alternative become patient’s responsibility. In the case of an unconscious patient or when patient is not able to take decision, then written consent of a relative/ patient authorised person should be taken.

9. Right to make suggestions/complaints and to seek redressal-
Patients have the right to complain/make suggestions about any aspect of hospital service or non-adherence to any patient’s rights. Every hospital should display information prominently in the hospital about the existence of grievance redressal system along with the name, address and telephone number of persons to be contacted.
In order to avoid unnecessary court cases, conflicts and tensions in hospital premises it is desirable that a committee or body independent of the hospital management would organise periodical dialogue between the hospital and patients/citizens with the objective to informally address patient’s complaints.
According to section (7) of ‘Maharashtra Medicare Service Persons and Medicare Service Institutions (Prevention of Violence and Damage or Loss of Property) Act, 2009’, Maharashtra state government shall establish Authority to hear grievances of victims of medical negligence or mismanagement and to aid and advice such victims to take recourse to an appropriate forum for suitable relief.

10. Compliance with ICMR guidelines for clinical trials on patients-
In case of conducting Clinical trials involving patients, documented policies and procedures should guide all research activities in compliance with ICMR guidelines. Some important points, in this context, are as below:
a) Adequate information about the research should be given in a simple and easily understandable unambiguous language about the nature, duration and purpose of study, procedures to be followed, benefits to participant, foreseeable risks and discomforts, availability of medical treatment for injuries or side effects, compensation, alternative treatments if available etc.
b) The investigator must obtain the informed consent of the participant. Patient has right to deny participation at any stage during the clinical trial.
c) Re-consent should be taken when there is change in treatment modality, procedures and site visits.
d) Compensation should be provided to the patient if there is economic loss of the patient as a result of the inconvenience and time spent.
e) As a general rule, pregnant or nursing women should not be participants of any clinical trial except if there is special requirement to do so.

11. Free beds in Trust Hospital for poor patients-
As per the Mumbai High Court directive, Trust Hospitals should reserve 10% beds for free treatment to poor patients and another 10% beds for economically weaker sections at concessional rates.
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PATIENTS’ RESPONSIBILITIES
Patients should follow their responsibilities so that doctors can perform their work satisfactorily.
1) The patient should provide his/her health related information to the doctor and should provide full information in response to doctor’s questions without concealing any relevant information so that diagnosis of the disease and treatment can be done properly. (Patients/relatives should read carefully, informative pamphlets, brochures given by doctors. Patients need not insist that all information should be given by main doctor only. If further clarification is needed then before going to doctor, patients may write down all points/queries for their own convenience. This will help in asking precise questions.)
2) The patient should cooperate with the doctors during examination, diagnostic tests and treatment, and should follow doctor’s advice. Doctors can deny treatment to the patient if patient is not taking treatment as per doctor’s advice.
3) Patients should follow all instructions regarding appointment time, cooperate with hospital staff and fellow patients, observing silence and maintaining hygiene in the hospital.
4) Patients should not expect free services in private hospitals (with exception of particular categories of patients in Trust hospitals). Patients should pay doctor’s agreed fees, hospital charges in time.
5) Patients should respect the dignity of the doctor and other hospital staff as human beings and as professionals.
Patients should remember that doctors need rest, private life like any other human being. Doctors should fulfill their responsibility towards patients once consulted. However, keeping in mind above factors, at certain time doctors may decline to consult any new patients. However this denial should not be a discrimination against any patient (e.g. people living with HIV)
6)
Whatever the grievance may be, patient/accompanying persons should not resort to violence (verbal or physical). Violence against hospital and healthcare personnel is a cognizable and non-bailable offence. Offenders may be punished with imprisonment up to 3 years and fine up to Rs. 50,000/- and liable for compensation twice the amount of damage or loss to the property.
7) Patients’ relatives, friends etc should not bring any undue pressure on doctors by invoking any other identity based on caste, politics. religion, language, community or any such factor

All citizens should help to create greater awareness about Patient’s Rights and Responsibilities in society.

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