دانش پرستاری: از کلاس درس تا جامعه

کلیک کنید

The unsolicited ominous diagnosis

Case scenario

سناریو

یک پزشک مورد احترام، وابسته به یک مرکز پزشکی آموزشی در یک فروشگاه مشغول خرید برای همسرش است. صاحب فروشگاه او را برای خرید یک لباس زنانه مناسب چهل سالگی کمک می کند. در حین تعامل پزشک نمی تواند کمک کند اما متوجه ضایعه ای غیرقرینه با پیگمانتاسیون در بازوی راست خانم فروشنده می شود  اگرچه او درماتولوژیست نیست یک جراح عمومی است ولی تجربه  کار با ملانومای بدخیم  و بیوپسی غدد  لمفاوی را دارد. او به وجود ملانوما در این خانم مشکوک می شود.

این جراح باید موارد زیر را در نظر بگیرد

    A.  Ignore the lesion because he is not “on duty

    B.  Advise the patient that the lesion is a melanoma

    C.  Alert the patient to the lesion and suggest that she submit to an examination by her primary care provider

    D.  Alert the patient to the lesion’s potential implications and arrange for her to be seen by a dermatologist for a thorough evaluation

    E.  Alert the patient and arrange for her to be seen by him for an excision

    F.  Ask the patient to remove her shirt in the back room so that he can perform a more thorough examination and palpate her axillary and cervical lymph nodes

 کامنت
It is not uncommon for dermatologists to identify significant clinical pathology on casual visual inspection in a nonclinical environment.[1] While one may be able to observe skin lesions in this kind of scenario, such settings obviously do not afford the observer the same standards as a dermatologic medical office. Lighting is not standardized, and there are none of the usual diagnostic instruments found in the typical dermatology office (microscope, dermatoscope, Wood’s light, biopsy equipment, etc). Given these limitations, any advice rendered is arguably substandard but may be viewed as a true consult by the individual to whom it is offered. We as dermatologists are not the lone specialty who faces this dilemma. For example, neurologists often find themselves in a similar circumstance after noting the movement or speech pattern of someone during casual observation.[2]

قانونی
Legally, we have no duty to individuals we encounter outside of a clinical setting as was noted in St. John v. Pope: “Professionals do not owe a duty to exercise their particular talents, knowledge, and skill on behalf of every person they encounter in the course of a day.”[3] However, we are, as medical professionals, committed to the ethical principle of beneficence, which implies that one should promote health and try to do whatever is in the best interest of an individual. Medical associations have established that physicians have an ethical responsibility to provide assistance in an emergency situation. [4] , [5] Moseley[6] wrote that he considered it more ethically irresponsible for a physician to refrain from volunteering aid in an emergency than it is for the untrained bystander. Beyond ethics, it is possible that there could be a legal and moral obligation to help in an emergency situation as well, if duty can be established.[7] Several Good Samaritan laws have been put in place in various states to protect those who do choose to help in an emergency situation. However, the absence of an emergency does not preclude the risk of increased mortality or morbidity. An untreated melanoma can certainly lead to death. Failing to notify an individual who would otherwise be unaware of a suspected melanoma on their skin can be as deleterious as passing by an emergency situation without offering aid. By this reasoning, many feel it is truly a physician’s ethical and possibly legal duty to inform an individual of a potentially fatal condition.

In our increasingly litigious society, however, physicians are often less inclined to intervene in the care of individuals when the physician’s legal duty is unclear. While making an individual aware of a condition and recommending that they seek evaluation is not rendering a professional diagnosis, it may be interpreted as such by the individual. Does the disclosing physician assume some legal responsibility? Even though melanoma typically may not be considered an emergency, one would hope that a physician disclosing medical risks would be legally protected in a similar way that the Good Samaritan laws protect individuals responding to an emergency. However, such disclosure is most likely not legally protected. Although to the best of our knowledge there is no legal precedent that such disclosure is unprotected, who amongst us would like to become the test case?

Moseley[6] suggested five criteria that should be met before considering proffering unsolicited medical advice. First, the recipient must have a serious impending risk to their health. A suspected melanoma in our opinion meets this criterion. Second, the physician should feel relatively certain of the diagnosis. Third, the condition could potentially remain untreated, either by the individual being unaware of the condition or unable for various reasons to treat it. Fourth, a reasonable person would want to be made aware of this condition. Lastly, treatment is available for the condition, either to cure the condition or for palliation. Moseley[6] qualifies the second criterion by stating that if the condition is significantly dangerous, the physician could be less certain about the diagnosis and notification would still be warranted. He concluded that if these criteria are met, the physician would be under strict obligation to notify the individual. He also states that physicians belong to a morally defined vocation, dedicated to helping the sick, which translates in these situations into a moral obligation of notifying an individual with a potential health risk. Even in ambiguous settings, where the safest course of action legally would be to remain uninvolved, the ethical considerations for best care of the individual may outweigh the legal risks.[8]

Of note is that the Good Samaritan laws require that a physician attending to an emergency situation receive no reimbursement for their act.[9] Monetary exchanges or even a small token gift that is given as a gesture of thanks or gratitude should therefore be avoided.

Assuming that a physician has decided to disclose a possible medical condition, one must also ponder the manner in which the individual is informed. Sensitivity is paramount in these extracurricular settings—not only to avoid a potentially upset or angry patient, but also because this may impact potential legal liability for the physician. A physician does not need to see someone in their clinical practice or consider someone a patient for duty to be established,[10] and once established, this duty can raise the specter of legal ramifications. Given that a physician may not be covered by his/her malpractice insurance for a claim based upon an encounter that occurred outside of their practice, it is best in these scenarios not to offer a diagnosis but to alert the patient to what they have observed and recommend that the person seek the care of a specialist in an appropriate medical setting.



انالیز سناریو

Of the choices offered at the inception of this article, we do not feel it would be ethical to ignore a potentially life-threatening lesion because one is “off duty.” In view of the setting, we also do not feel it would be appropriate to tell the patient that she definitively has a melanoma. Closer inspection with proper lighting and with a dermatoscope and then, if indicated, a biopsy specimen would be the best course of action. Until the lesion is properly evaluated, it is our opinion that it would be presumptive to arrange for the owner of the shop to be seen by a surgeon for an excision. Asking the patient to remove her shirt in the back room so that you can perform a more thorough examination and palpate her axillary and cervical lymph nodes would clearly be inappropriate.

Alerting the patient to the lesion and suggesting that she have it examined by her primary care doctor is a viable option, but because of the level of concern, we would opt for arranging for her to be seen by a dermatologist for a thorough evaluation as the ideal choice.

This case scenario is not fictional. The physician performed exactly as he should have. When the store became less crowded, he asked to speak to the owner in private. We believe this sensitivity to an individual’s privacy is paramount in disclosing news such as this. He also introduced himself and identified who he was professionally and that he was “concerned” about the lesion. He then gave the store owner the name of one of the dermatologists at the university (J.G-K.). Upon arriving home, the surgeon e-mailed this dermatologist about this encounter so that when the patient called she would get a prompt appointment for evaluation and a biopsy. The patient called the office on Monday and was seen on Tuesday, at which time the surgeon’s concerns were substantiated and the lesion was excised. Dermatopathologic evaluation identified a malignant melanoma, superficial spreading type, level II, measuring 0.38 mm at it greatest depth. The owner of the store had no idea that this lesion was present or was potentially dangerous, and was extremely grateful to the surgeon for alerting her. She remains a patient of the university dermatologist and has subsequently been diagnosed over the years with several basal cell carcinomas, dysplastic melanocytic nevi, and an in situ melanoma

آدرس

The unsolicited ominous diagnosis

Journal of the American Academy of Dermatology - Volume 66, Issue 6  June 2012