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  1. DUTIES OF MEDICAL PRACTITIONER • Duties of Medical Practitioners Towards Patient • 1. Duty to exercise a reasonable degree of skill and knowledge. • 2. Duties with regard to attendance and examination: • 3. Duty to furnish proper and suitable medicines: • 4. Duty to give instruction: • 5. Duty to control and warn: • 6. Duty to third party:
  2. DUTIES OF MEDICAL PRACTITIONER 7. Duty towards children and adults incapable of taking care of themselves: 8. Duty to inform patient of risks: 9. Duty with regard to poison: 10. Duties in connection with administration of anesthetic agents: 11. Duty in connection with X-ray examination. 12. Duty to maintain secrecy:
  3. DUTIES OF MEDICAL PRACTITIONER 13. Duties with regards to operation: 14. Duty with regards to take consent: Duties of Medical Practitioners Towards Professional Colleague. 15
  4. Duties of Medical Practitioners Towards Professional Colleague. 15. Not to criticize colleague 16. Never take fees 17. Duties with regard to consultation 18. Duty to notify certain diseases
  5. Duty of care • Duty of care arises simply by examining someone for signs of illness or trauma or even accepting a patient on to a list of existing patients. As soon as a doctor gives advice and counseling over telephone, a legal duty to the patient arises.
  6. A DOCTOR CAN DISCONTINUE THE TREATMENT: • a. When the doctor patient relationship is terminated by notice from either side (When the pt. wants to change the doctor). • b. When another doctor has been consulted without the knowledge of the first doctor. • c. When remedies other than those prescribed by the doctor are being used.
  7. A DOCTOR CAN DISCONTINUE THE TREATMENT: • d. When the advice of the doctor is not properly followed. • e. When the doctor is not paid his due fees for attending the patient. • f. When the doctor himself has fallen sick. • g. When the doctor understand that the patient is malingering.
  8. Duties under Geneva Conventions • In Geneva, in 1949, four conventions were agreed : • 1. Wounded or sick armed forces • 2.Ship-wrecked persons • 3.Prisoners of war • 4. Civilians of enemy nationality • Are to be treated without any adverse distinction based on sex, race,nationality,political opinions.
  9. Duties with Regard to Consultation: • Consultation should be done following circumstances : • 1. When an operation or treatment involving danger to life. • 2. When an operation affecting generative functions • 3. When an operation is to be performed on a patient who received serious injuries in a criminal assault. • 4. When an operation of mutilating or destructive nature to be performed on an unborn child. • 5. When a therapeutic abortion is to be procured. • 6. When a women on whom criminal abortion has already been performed.
  10. PRIVILEGED COMMUNICATION • It may be defined as a bonafied information to a concerned person or authority given by a doctor to protect the interest of the community or the public towards whom he has a legal, social or moral duty; although such communication under normal condition contravenes the general rules of professional secrecy.
  11. The following are the examples of privileged communication: • 1. Information about Infectious disease:- When a person suffering from or is a carrier of some infectious disease which is known to contaminate through food and drink, is employed in a hotel to prepare food or serve food to the customers, then his doctor should first advise him to abstain from working till he is free from the disease.
  12. • If he does not listen to the advice of the doctor then the doctor should inform the employer about the danger from the particular employee.
  13. • 2. Information about non-infectious disease of some specific categories of employees:- • Person suffering from defective colour vision, if he engaged in jobs like driving.
  14. • 3. Information about the risk of contamination to public in general with infectious disease:- When a person suffering from a contagious disease takes birth in a public bath like a bathing pool,
  15. • 4. Information about a patient suffering from sexually transmitted disease:- • When a doctor finds that one of his patients, who is suffering from sexually transmitted disease is planning to marry, he should first advice the patient not to marry until he is cured of his disease.
  16. • If the patient does not listen to the advice of the doctor than the doctor can inform the person about his illness, whom the patient going to marry.
  17. The following are the examples of privileged communication: • 1. Information about Infectious disease:- • 2. Information about non-infectious disease of some specific categories of employees:- • 3. Information about the risk of contamination to public in general with infectious disease:- • 4. Information about a patient suffering from sexually transmitted disease:-
  18. Privileged communication: • 5. Information about the outbreak of a communicable disease:- • 6. Information about commission of some crime:- • 7. Information disclosed in the interest of the patient:- • 8. Disclosure in the interest of the doctor himself:- • 9. Disclosure in a court of law:-
  19. • 9. Disclosure in a court of law:- • Though a doctor is not ordinarily expected to divulge any secret information about his patient which he learns in course of treating the patient, in a Court of Law he does not exercise the privilege of professional secrecy,
  20. • As a lawyer does. Whatever information is required by the court, for the interest of justice, the doctor is legally bound to narrate the same before the court as per knowledge.
  21. RIGHTS AND PRIVILEGES ENJOYED BY A REGISTERED MEDICAL PRACTITIONER • 1. Right to choose his patient. • 2. Right to practice medicine. • 3. Right to dispense medicine. • 4. Right to posses and supply dangerous drugs to his patients.
  22. RIGHTS AND PRIVILEGES ENJOYED BY A REGISTERED MEDICAL PRACTITIONER • 5. Right to use title and description of the qualification which he actually possess. • 6. Right to realize fee and other expenses for attending his patient • 7. Right for appointment in public and local hospital. • 8. Right to issue medical certificates and medico legal reports.
  23. RIGHTS AND PRIVILEGES ENJOYED BY A REGISTERED MEDICAL PRACTITIONER • 9. Right to give evidence in a court of law as an expert witness. • 10. Right to be exempted from acting as a juror in course of holding an inquest. • 11. Removal of organs from a dead body for transplantation purposes. • 12. Right to use the Red Cross emblem.
  24. CONSENT • Definition: Consent means voluntary agreement, approval or permission for compliance of some act. Consent is valid only it is given after knowing the nature and consequences of the consent and those of the act for which consent is given.
  25. Types of Consent • Consent Implied Expressed or Informed Verbal Written
  26. IMPLIED CONSENT: • When the conduct of a person is very much indicative that he is agreeable to some act, or he desire that the act to be done, then it is implied that he has given consent for the act, even though he has not expressed his consent in words or in letters.
  27. Informed consent: • When consent has been given after knowing all the pros and cons of the act for which consent has been given. (i.e., the nature and quality of the act, the risk involved in it, whether he has any other choice for the act in question) it is termed as Informed Consent.
  28. Informed consent implies an understanding by the patient of. • 1. The nature of his condition. • 2. The nature of the proposed treatment or procedure. • 3. The alternative procedure. • 4. The risk and benefits involved in the proposed and alternative procedure.
  29. • 5. The potential risk of not receiving treatment. • 6. The relative chances of success or failure of both procedures, so that he may accept and reject either of the procedure.
  30. RULES OF CONSENT: • 1. A consent given by a person under fear of injury, or due to misunderstanding of a fact is not valid. • 2. The consent given by an insane or intoxicated person, who is unable to understand the nature and consequences of that to which he gives his consent is invalid. • 3. Consent given for committing a crime or an illegal act such as criminal abortion is invalid.
  31. RULES OF CONSENT: • 4. A child under 12 years of age and an insane person cannot give valid consent to suffer any harm which may result from an act done in good faith and for its benefit. • 5. Oral consent should be obtained in the presence of disinterested third party i.e. nurse.
  32. RULES OF CONSENT: • 6. The consent should be free, voluntary, clear, intelligent, informed, direct and personal. There should be no undue influence, fraud misrepresentation of facts, compulsion, and threat of physical injury, death or other consequences. • 7. For the greater interest of the community a person may be subjected to forceful treatment without his consent, when there is a danger of spreading the disease.
  33. Circumstances where consent of the patient is necessary in medical practice: 1. Consent is required in all cases of medical examination and treatment. 2. When the method of treatment or investigation extends beyond usual procedure and involves risk. 3. Written informed consent should be taken before examining a person with the purpose to prepare a m/l report.
  34. Circumstances where consent of the patient is necessary in medical practice: 4. While examining a victim of a criminal case (victim of rape, assault etc) 5. Ordinarily, consent should be sought for examination of an accused person. 6. Except in circumstances of privileged communication, the secret information about the patient should not be disclosed, without his consent.
  35. Circumstances where consent of the patient is necessary in medical practice: 7. For the purpose of treatment of either the husband or the wife, consent of the person to be treated is necessary and no consent from the other spouse is necessary.
  36. • Substituted consent : If a person in need of treatment is incapable of giving informed consent, consent(proxy consent) must be obtained from next of kin. The order of succession is generally spouse, adult child, parent and sibling.
  37. Blanket(open)consent : The consent practiced in most hospitals that cover almost everything a doctor might do to a patient without mentioning anything specific. It is of questionable legal validity.
  38. Informed Refusal • The physician has a duty to disclose adequately and appropriately to the patient, the risk or possible consequences of refusal to undergo a test or treatment. After understanding all the facts, the patient can refuse to submit to treatment or an operation.
  39. The informed refusal should be recorded in writing which also may be helpful for the doctor if he is later charged for negligence for not doing the needful for the cure of the patient.
  40. Malpractice
  41. Malpractice or Malpraxis • Malpractice or Malpraxis may be defined as absence of reasonable care and skill in a doctor in course of treating his patient or his willful negligence in the treatment of a patient, causing some damage, bodily injury or death of the patient.
  42. • Malpractice can be conveniently divided into two broad types: • Medical Negligence - Where the standard of medical care given to a patient is considered to be inadequate. • Professional misconduct- Where the personal, professional behavior falls below that which is expected of a doctor. • Ref :Simpson’s Forensic Medicine – 12th ed.2003;15.
  43. • Malpractice or Malpraxis Medical Professional negligence misconduct Civil Criminal Negligence Negligence
  44. Types of Medical Negligence: • Civil Negligence. • Criminal Negligence.
  45. Civil Negligence • Civil negligence indicates such act of negligence. On the part of the treating physician which causes some suffering, harm or damage to the patient which can be compensated by paying money and which does not come under the purview of the Criminal Procedure Code (Cr.P.C) and Bangladesh Penal Code (BPC) and does not demand legal punishment of the doctor.
  46. Criminal negligence: • Criminal negligence indicate such act of negligence on the part of the treating physician which causes irreversible bodily harm or death of the patient, and which results from gross carelessness and unskillful ness of the doctor which can not be compensated by paying money and the erring doctor is liable to be punished as per Criminal Procedure Code (Cr.P.C.) and Bangladesh Penal Code (BPC).
  47. • Medical negligence may be committed in the following ways: • 1. Nonfeasance --- act of omission. • 2. Misfeasance --- act of • 3. Malfeasance --- commission
  48. NONFEASANCE: • Omission of an obligatory act when something has to be done by the doctor but the erring doctor fails to do it. • Examples:(1) A wounded person has to be immunized by tetanus toxoid, but the doctor did not do it. • (11) X-ray should be taken in bony injury to diagnose fracture or dislocation, but the doctor fail to do it. • (111) X-ray should be taken in head injury whether any skull fracture or intracranial hemorrhage. But doctor fails to do it.
  49. MALFEASANCE • To do a bad thing, when something should not have to be done but the doctor did it. • Examples:(1) knowing the patient a peptic ulcer, administering aspirin or NSAID, which lead to perforation of peptic ulcer. • (11) A patient of 60 yrs having enlarged prostate or glaucoma if a doctor prescribed anticholinergics, which will cause urinary retention, or aggravating glaucoma.
  50. MISFEASANCE • Doing of a lawful act in a wrongful manner. In other wards a right thing is done in a wrong way. • Example : (i) Wrong bottle of blood has been transfused Which may cause death. • ii) Indication of amputation right leg but the surgeon amputed left one. • (iii) A patient has severe pain to the 2nd molar tooth but the dentists extracted the 1st one.
  51. The burden of proof of negligence of the doctor lays on the plaintiff i, e, the complainant. • To proof negligence on the part of the doctor the following ingredients must be present, • Duty. • Dereliction. • Direct causation. 4 D’s • Damage
  52. 1. DUTY: That the doctor owed a duty of care to the patient. • DUTY OF CARE: A doctor who undertakes to treat a patient has a duty to take all the due care necessary for the well being of the patient e.g., standard medical care, management after care, advice and referral.
  53. DUTY OF CARE • Where a senior doctor delegates a task to a junior, he must assure himself that this assistant is sufficiently competent and experienced to do the job. If damage occurs as a result of improper delegation, then senior doctor may have carry part, or even all the responsibility.
  54. 2. DERELICTION • The failure on the part of the doctor to maintain care and skill. A doctor is derelicts (breaches) his duty of care when he fails to reach the standard or proficiency expected to him. • This dereliction or breach of the duty by an act of omission or commission.
  55. DERELICTION • Examples: Carelessly tying off a ureter during a hysterectomy is an act of commission. • Whilst failing to give anti tetanus toxoid after a penetration injury would be act of omission.
  56. 3. DIRECT CAUSATION The patient must prove this was the proximate cause of the harm, damage or injury to the patient. The harm, damage or injury can be physical, mental financial.
  57. “RES IPSA LOQUITOR’ • To prove causal connection between negligence and damage is sometimes difficult and generally established by expert testimony.
  58. • Sometimes the maxim “RES IPSA LOQUITOR” (facts speak for itself) applies and proof is crystal clear, i, e, i. failure to remove a surgical instrument from abdomen following abdominal surgery. ii. Cutting the cheek of a baby during caesarian section etc.
  59. 4. DAMAGES • If the duty of care, dereliction and direct causation have proved by the patient an action of negligence cannot be succeed unless there has been some damage, harm or injury caused to the patient, by an act of commission or omission.
  60. Damages • Damages are: • a) Loss of earning : Either due to absence from work or prevention or impairment of his duty or inability to carryout his occupation. • Example: The impaired carrier of a fashion model with a scarred lip.
  61. Damages are: • (b) Expenses incurred : e.g.-Hospital expenses, special diet etc. • (c) Reduction in expectation of longevity. • (d) Reduce enjoyment of life, such as loss of function of limb or sense. • Example: An amateur sportsman crippled by a badly treated Achilles tendon lesion.
  62. Damages are: • (e) Pain and suffering, either physical or mental suffering includes fright, humiliation and embarrassment. • (f) Loss of potency. • (g) Death.
  63. Novus Actus Interveniens • A doctor will not be responsible for any harm caused to the patient due to interference or intervention during the course of treatment, by any person who is not related with the treatment of the person.
  64. Novus Actus Interveniens • In some circumstances, it happens the other way. For example, if the victim of an assault suffers from some harm due to negligence of the doctor during the course of treatment, which the original assault was not likely to cause, then the assailant will not be fully responsible for the total harm. The doctor will be held responsible for his negligent act which caused the ultimate harm.
  65. Contributory Negligence • Contributory negligence is any unreasonable conduct or absence of ordinary care on the part of the patient, or his personal attendant, which combined with the doctors negligence, contributed to the injury complained of, as direct proximate cause and without which the injury would not have occurred.
  66. These are • 1. Failure to give the doctor accurate medical history. • 2. Failure to carryout all reasonable and proper instruction given by the doctor. • 3. Refusal to take the suggested treatment. • 4. Leaving the hospital against doctors advice. • 5. Failure to seek further medical assistance if symptoms persist.
  67. Medical Maloccurence • Not in all diseases or in all persons, one medicine gives the same or expected result. Bio-physiological actions and reactions to different drugs are different and extremely variable. Thus individual may react differently to the same drug, in the same dose and in the same mood of application, inspite of good medical attention and care.
  68. Medical Maloccurence • Also it is to our knowledge that some individuals may be quite tolerant to some drugs due to which the usual dose of the drug may not give the desired effect. On the other hand some individuals may be idiosyncratic to some drugs while others are not. These are the medical maloccurences, which may cause extra suffering to the patient and the doctor is not actually responsible in these cases, as the doctor is not negligent in his act.
  69. Misadventure A misadventure is a mischance or accident or disaster. Misadventure is of three types:- • 1. Therapeutic • 2. Diagnostic • 3. Experimental
  70. Therapeutic Misadventure • Therapeutic Misadventure is a case in which an individual has been injured or had died due to some unintentional act by a doctor or an agent of the doctor or hospital.
  71. Some Examples of Therapeutic Misadventure • 1. Hypersensitivity reaction, sometimes serious or fatal, may caused by penicillin, aspirin, tetracycline, etc. • 2. Excessive administration of antidote to a poisoned patient may cause death. • 3. Prolong use of stilboesterol may cause breast cancer.
  72. Example Of diagnostic Misadventure • 1. Radiological procedures used for diagnostic purpose may be fatal; e.g. Anaphylactic reaction by dye used for IVP, poisoning by barium meal, traumatic rupture of the rectum and chemical peritonitis during barium enema.
  73. Vicarious Responsibility • This means responsibility of a person due to the act of another. In medical practice this means responsibility of a superior medical employee for the negligent act of his subordinate employees or persons under training who are expected to work under the guidance of the superior.
  74. • This working relationship also known as “Respondent Superior" (let the Master answer) because superior has to answer for the fault of his subordinate.
  75. Defenses of a doctor against charges of negligence: • When charged for negligence, a doctor may plead any or many of the following arguments as his defense. • 1. That, he had no duty to the patient. • 2. That, he discharged his duties according to the prevailing standard of medical practice. • 3. That, the damage caused to the patient is not due his negligence but could be due to the act of of any other person who also was concerned with his treatment.
  76. • 4. That, the damage was the result of a third party that interfered in the treatment without his knowledge or consent. • 5. That the patient did not follow his advice properly or it was a case of contributory negligence. • 6. That, the damage complained of is an expected outcome for the particular type of the disease the patient suffered from.
  77. • 7. That, it was a case of reasonable error of judgment. • 8. That, it was a case of therapeutic or diagnostic misadventure. • 9. That, it was a case of medical maloccurrence. • 10. That, the complain should not be entertained because it has already been tried once by a court of law (Res judicata.).
  78. • 11. That, the damage was the result of taking some unavoidable risk which was taken in good faith in the interest of the patient with his or his guardian’s consent. • 12. That, the patient persistently insisted on the specific line of treatment which has caused the damage inspite of the doctor’s warning about the risk involved in that method of treatment.
  79. • 13. That, the time line allowed by the law for lodging such a complaint is over and the complaint may not by entertained now. Complaints of negligence should be lodged within two years, counting from the alleged date of causation of the damage.
  80. Precautionary steps to avoid a charge of negligence • Never guarantee a cure • Keep professional knowledge updated. • Apply due care and skill in treating a patient. • Take written consent in all step of treatment if involves risk.
  81. • Take consent of both husband and wife in giving treatment that may result in sterility or impotency. • Advice laboratory investigation to confirm clinical diagnosis. • Record the patient’s conditions and treatment given regularly.
  82. • Take consent of both husband and wife in giving treatment that may result in sterility or impotency. • Advice laboratory investigation to confirm clinical diagnosis. • Record the patient’s conditions and treatment given regularly.
  83. • Do not venture a procedure beyond the skills / field of specialization. • Avoid experimental treatment with a patient. But if it is necessary, proceed with written consent. • Write prescription clearly, legibly and neatly with proper instruction to the patient. • Give optimum postoperative care.
  84. • A qualified and experienced doctor should administer anesthesia. • Do all needful check up and give proper premeditations prior to administration of anesthesia. • Do not leave the patient till he/ she recovered from anesthesia effects. • Recommend inquest in case of death from anesthesia on an operation table
  85. • Choose your assistant with due care. • Do not stop giving treatment unless the patient desires or agrees to it . • Do not leave an emergency case unattended.
  86. • Do not criticize a professional colleague.
  87. • Do not perform additional task for which consent is not taken.
  88. • Arrange a substitute doctor with prior information if going on leave during treatment. • Always examine a female patient in presence of another female. • Strictly maintain provisions of medical termination of pregnancy (MTP) Act.
  89. • Always issue medical certificates with due care. • Dot not makes statement admitting fault on your part.
  90. Thank you