Review article: Patients who leave before care is completed: What does the legal duty to warn mean for emergency department clinicians?

Patients leave ED for a variety of reasons and at all stages of care. In Australian law, clinicians and health services owe a duty of care to people presenting to the ED for care, even if they have not yet entered a treatment space. There is also a positive duty to warn patients of material risks associated with their condition, proposed treatment(s), reasonable alternative treatment options and the likely effect of their healthcare decisions, including refusing treatment. This extends to a decision to leave the ED before care is completed. The form of that warning may vary based on what is known about the patient's condition and the associated risks at the time. Specific documentation of warnings given is essential.

Problemática de los medicamentos empleados fuera de la ficha técnica (uso off-label): Análisis de sus exigencias, con especial consideración a la obligación de información y consentimiento informado / Problems of off-label use of drugs: Analysis of the requirements, with special consideration to the obligation of information and informed consent

El médico siempre debe perseguir el mayor beneficio para su paciente, intentando provocar el mínimo perjuicio a la hora de prescribirle un fármaco. Ante dicha tesitura, cuando no existe una alternativa terapéutica autorizada, es relativamente frecuente administrar medicamentos fuera de la ficha técnica (off-label) en ciertas especialidades. Bajo tales premisas, el objeto de este trabajo es analizar los requisitos legales, la forma de articular la obligación de información y el consentimiento informado del paciente, situación esta última especialmente compleja en el caso de la emisión por parte del menor de edad. (AU)

When prescribing a medication, a physician makes a benefit-risk evaluation based on the drug’s potential benefits outweighing the potential risks. Faced with this situation, when there is no authorized therapeutic alternative, it is relatively common to administer drugs off-label in certain specialties. The aim of this paper is to analyze the legal requirements, the way to articulate the obligation of information and the informed consent of the patient, a particularly complex situation in the case of minors. (AU)

Florida Law Enforcement Policies for and Experience With Tarasoff-Like Reporting.

Mandatory duty to warn law enforcement for mental health professionals in Florida took effect on July 1, 2019, as part of the recommendations from the Marjory Stoneman Douglas School (Parkland) Shooting Commission's report. Prior to this, Florida had been a permissive Tarasoff state. Although this change was intended to promote public safety, there is scant literature on the interactions between mental health providers and law enforcement related to Tarasoff situations. The objective of this study is to determine the degree to which Florida law enforcement agencies have knowledge, experience, and policies dealing with a serious threat made by a patient. An invitation to participate in a survey was distributed to police departments, sheriffs' offices, and 911 stations using email and traditional paper mail. The response rate was 11 percent (47 of 416) to an emailed questionnaire and 22 percent (82 of 369) to a paper-based follow-up survey. The surveys were completed by 31 percent (129 of 416) of potential respondents. Between 80 and 90 percent of all agencies have policies and procedures on what to do if a warning call from a mental health provider is received, which, for the majority of respondents, was the same policy as if notified about a suicidal individual.

Disclosing genetic information to family members without consent: Five Australian case studies.

Genetic risk information is relevant to individual patients and also their blood relatives. Health practitioners (HPs) routinely advise patients of the importance of sharing genetic information with family members, especially for clinically actionable conditions where prevention is possible. However, some patients refuse to share genetic results with at-risk relatives, and HPs must choose whether to use or disclose genetic information without consent. This requires an understanding of their legal and ethical obligations, which research shows many HPs do not have. A recent UK case held that HPs have a duty to a patient's relatives where there is a proximate relationship, to conduct a balancing exercise of the benefit of disclosure of the genetic risk information to the relative against the interest of the patient in maintaining confidentiality. In Australia, there is currently no legal duty to disclose genetic information to a patient's at-risk relatives, but there are laws and guidelines governing unconsented use/disclosure of genetic information. These laws are inconsistent across different Australian states and health contexts, requiring greater harmonisation. Here we provide an up-to-date and clinically accessible resource summarising the laws applying to HPs across Australia, and outline five Australian case studies which have arisen in clinical genetics services, regarding the disclosure of genetic results to relatives without consent. The issues addressed here are relevant to any Australian HP with access to genetic information, as well as HPs and policy-makers in other jurisdictions considering these issues.

Disclosure to genetic relatives without consent - Australian genetic professionals' awareness of the health privacy law.

BACKGROUND: When a genetic mutation is identified in a family member (proband), internationally, it is usually the proband's or another responsible family member's role to disclose the information to at-risk relatives. However, both active and passive non-disclosure in families occurs: choosing not to communicate the information or failing to communicate the information despite intention to do so, respectively. The ethical obligations to prevent harm to at-risk relatives and promote the duty of care by genetic health professionals (GHPs) is in conflict with Privacy laws and professional regulations that prohibits disclosure of information to a third party without the consent of the proband (duty of confidentiality). In New South Wales (NSW), Australia, amendments to Privacy legislation permits such disclosure to living genetic relatives with the process defined under guidelines although there is no legal duty to warn. This study assessed NSW GHP's awareness and experience of the legislation and guidelines. METHODS: An online survey collected demographics; theoretical knowledge; clinical scenarios to assess application knowledge; attitudes; confidence; experience with active non-disclosure. A link to correct answers was provided after completion. Knowledge scores above the median for non-parametric data or above the mean for parametric data were classified as 'good' or 'poor'. Chi square tests assessed associations between confidence and knowledge scores. RESULTS: While many of the 37 participants reported reading the guidelines, there was limited awareness of their scope and clinical application; that there is no legal duty to warn; and that the threat does not need to be imminent to warrant disclosure. No association between confidence and 'good' theoretical or applied clinical knowledge was identified. Uncertainty of their professional responsibility was identified and in the several case examples of active non-disclosure that were reported this uncertainty reflected the need for further understanding of the guidelines in regard to the processes required before disclosure was initiated. CONCLUSIONS: There is a need for further education and training about the guidelines associated with the legislation that would be relevant to support disclosure. The findings may inform future strategies to support introduction of policy changes in other jurisdictions where similar regulatory regimes are introduced.

Legal Challenges in Genetics, Including Duty to Warn and Genetic Discrimination.

This review will explore two legal issues in genetic counseling: genetic discrimination and the duty to warn. It emphasizes the complexity and variability of federal and state genetic nondiscrimination protections in the United States and how the many gaps in such protections may affect people pursuing genetic testing. The limited law addressing legal obligations genetic counselors owe at-risk relatives likely does not require counselors to warn relatives directly about genetic risks. Whether it permits them to make such disclosures, however, is more uncertain and may depend on the jurisdiction.

HIV, confidentiality, and duty to protect: Considerations for psychotherapists in the age of treatment as prevention.

Confidentiality and duty to protect are complex issues for psychotherapists treating clients with HIV. The application of the Tarasoff ruling to situations involving HIV has long been debated with questions about how the Tarasoff principles of identifiability of the victim, foreseeability of harm, and necessary protective action apply to HIV within the context of psychotherapeutic relationships. The complexity of these debates is compounded by advances in HIV medicine including the availability of antiretroviral therapy and pre- and postexposure prophylaxis in addition to the current state of knowledge about treatment as prevention. The purpose of this article is to revisit Chenneville's (2000) decision-making model on HIV, confidentiality, and duty to protect in the age of pre- and postexposure prophylaxis and antiretroviral therapy. This revised model may serve as a critical framework for psychotherapists providing services to clients with HIV. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Teaching Forensic Concepts to Residents Using Interactive Online Modules.

Psychiatrists without specialty forensic training routinely encounter forensic questions and treat justice-involved patients, which underscores the importance of adequate forensic training in general psychiatry residency. Some programs may face challenges providing adequate forensic instruction due to a lack of local forensic psychiatrists or other forensic resources. Novel training approaches are needed to fill this gap. This article describes the development, dissemination, and preliminary impact of two online learning modules designed to teach general psychiatry residents about basic forensic psychiatry principles: confidentiality and the duty to third parties. The modules are based on adult learning theory and synthesize clinically relevant vignettes from historically significant legal cases. We disseminated the modules nationally with built-in pre-tests and post-tests. The module responses demonstrate three significant themes: the modules reached learners across the United States; even advanced residents had relatively low subject matter knowledge prior to module completion; and module completion was associated with a significant improvement in resident learners' knowledge of these two topics. This work shows one potential avenue for filling gaps in forensic education within general psychiatry training, although further studies are needed to appreciate the impact of such educational interventions on clinical practice.

Familial genetic risks: how can we better navigate patient confidentiality and appropriate risk disclosure to relatives?

This article investigates a high-profile and ongoing dilemma for healthcare professionals (HCPs), namely whether the existence of a (legal) duty of care to genetic relatives of a patient is a help or a hindrance in deciding what to do in cases where a patient's genetic information may have relevance to the health of the patient's family members. The English case ABC v St George's Healthcare NHS Trust and others considered if a duty of confidentiality owed to the patient and a putative duty of care to the patient's close relatives could coexist in this context. This article examines whether embracing the concept of coexisting duties could enable HCPs to respect duties in line with their clinical judgement, thereby providing legal support and clarity to professionals to allow them to provide the best possible genetics service to both the patient and their family. We argue that these dual duties, framed as a novel, composite duty to consider the interests of genetic relatives, could allow HCPs to exercise and act on their professional judgements about the relative value of information to family members, without fears of liability for negligence or breach of confidence.

The Responsibility to Recontact Research Participants after Reinterpretation of Genetic and Genomic Research Results.

The evidence base supporting genetic and genomic sequence-variant interpretations is continuously evolving. An inherent consequence is that a variant's clinical significance might be reinterpreted over time as new evidence emerges regarding its pathogenicity or lack thereof. This raises ethical, legal, and financial issues as to whether there is a responsibility to recontact research participants to provide updates on reinterpretations of variants after the initial analysis. There has been discussion concerning the extent of this obligation in the context of both research and clinical care. Although clinical recommendations have begun to emerge, guidance is lacking on the responsibilities of researchers to inform participants of reinterpreted results. To respond, an American Society of Human Genetics (ASHG) workgroup developed this position statement, which was approved by the ASHG Board in November 2018. The workgroup included representatives from the National Society of Genetic Counselors, the Canadian College of Medical Genetics, and the Canadian Association of Genetic Counsellors. The final statement includes twelve position statements that were endorsed or supported by the following organizations: Genetic Alliance, European Society of Human Genetics, Canadian Association of Genetic Counsellors, American Association of Anthropological Genetics, Executive Committee of the American Association of Physical Anthropologists, Canadian College of Medical Genetics, Human Genetics Society of Australasia, and National Society of Genetic Counselors.

Informed Consent to Medical Treatment Post-Montgomery: Causation and Coincidence.

If a patient suffers physical harm during medical treatment when a risk materialises which the doctor failed to warn the patient about, there are two key issues when a negligence claim is brought by the patient. First, it must be shown that the doctor was negligent in failing to warn the patient about the particular risk. Secondly, it must normally be shown that this failure to warn was a cause of the damage suffered, although courts also allow claims to succeed when a patient may still have undergone treatment even if adequately warned. The recent decision in Montgomery v Lanarkshire HA [2015] UKSC 11 changes the test for the first of these steps, by moving away from asking what a reasonable doctor would warn about and asking instead what a reasonable patient, or indeed the actual patient, would want to know. This article considers how that change ought to impact on the second step, causation. The first part of this article traces the development of the law on the standard of disclosure of risks, from Sidaway to Montgomery in order to expose the place that patient autonomy now occupies and the conception of autonomy that underlies the decisions. The second section addresses the causation issues arising in cases of medical non-disclosure of risk, and includes but is not limited to discussion of Chester. It first considers the modified objective approach to proof of causation adopted in Canada and argues that English law would be wise to reject such a development. The Chester problem is then addressed, and the analysis will focus primarily on what is actually meant by 'coincidence' since this term is often used but rarely explained. Finally, considering the situation that arises when the risk that materialises is different from the risk about which the doctor failed to warn the patient, it argues for a closer delineation of the relevant risks in English law.

Alcohol and the Law.

In the intersection of alcohol ingestion with the law, medical ethics, and public safety, physicians are often unsure about how to proceed. Physicians' primary focus should be on patient education with an ethical and legal duty to warn the patient of the adverse effects of alcohol. Warning third parties of potential harm related to alcohol-related impairment may involve a breach of patient confidentiality; therefore it should only be undertaken after careful analysis suggests that the risk for significant harm exceeds the burden that results to the patient from warning others. The law remains vague in this area.