Insight on medicolegal issues : proceedings of the conference

For the First time any conference was live posted on Facebook & Twitter

http://twitter.com/#%21/search/medicolegal

 https://www.facebook.com/pages/Insight-on-Medicolegal-Issues/247091668637671

Following are the excerpts posted on the wall

The inaugural lamp was lit by Hon'ble Mr Justice AK Sikri, Judge Delhi High Court; Hon'ble Justice Vipin Sanghi, Judge Delhi High Court; Dr K K Aggarwal Organising Chairman, Dr HS Rissam, Member Board of Directors MCI: Dr Ranjit Roy Chaudhury, Past President DMC; Dr AK Agarwal, President DMC. Dr Girish Tyagi, Registrar DM: Dr Vinod Khetarpal, President DMA: Dr P K Dave, Former Director, AIIMS, Dr Sanjiv Malik, Past National President, IMA, Dr Ashok Seth and Dr Prem Kakkar were also the part of inaugural ceremony.

    Dr K K Aggarwal

·         You are required to have only average degree of skill and knowledge

·         Difference of opinion is nit negligence

·         Error of judgment is not negligence

·         Mere deviation from medical practice is not negligence

Dr Ranjit Roy Chaudhary

• Role of hospital in a drug trial-when a clinical trial takes place, director or principal, signs that this trial is going to be held in this institute. Head should also be held responsible in case something goes wrong.
• ‎Clinician Trials should be carried out inntransparecy, equity, ethics and according to the rules of the country.
• ‎ Never start a clinical trial. Without approval of institute of ethics committee. ‎Controlled double blind multi centre trial is the goal to rule out bias.
• ‎ It is the clinical investigator who starts the trial and only he can stop the trial
• ‎ In a trial one must have no conflicts of intreats.
• ‎ In a trial one should be unbiased.
• ‎ One trial hundred million dollars on one trial
• ‎You can go to jail if the trial forms are not properly filled up
• ‎The patient must not be harmed  
• Autonomy, non malificence, beneficence & justice.
• Four cardinal principles in clinical trial

Ms Priya Hingorani

• Currently 21 pharmacovigilance centers in India:
• ‎ICMR plays a significant role in controlling and regulating clinical trials in India:
• ‎Informed consent is the most basic and complex part of conducting clinic research
• ‎ Amendment To schedule of drug regulatory act-India now permits concomitant phase 2 & phase 3 trials
• ‎ Statutory permits. Required for conducting trials-India has long hotspot considered for research due to large patient population, well educated investigators, lower cost, wide spectrum of diseases

Dr. Anoop Gupta

• IVF is the future for the country. Population will make us a superpower
• Must not use relatives as donors or surrogates.
• ‎In India IVF Success rates are 40-60%.
• ‎ Basic ethics of medical profession is to be honest to the patient
• ‎Ethics is system of moral issues you a have to really decide what is good or what is bad for the patient
• We have to be very instantaneous in our judgments whenever a patient comes
• ‎ Ethical issues in IVF practice

Dr N K Bhatia

• It is mandatory for the doctor to take consent from patient before transfusion: ‎39 countries have reached 100% voluntary blood donation
• ‎Key to recruiting donors-consent of donors and proper counselling
• ‎Compulsory blood test in donated blood HIV, Hepatitis B, Hepatitis C and Syphilis
• ‎In NCR Delhi, the only requirement of blood is 4.5 lakh units (3.5 lakh collection)
• ‎ Hardly less than .1% are regular blood donors
• WHO has advocated that Nation must adopt 100% voluntary blood donation
• ‎ The safest blood donors are voluntary, non-remunerated, repeated, regular, donors from low risk population

Dr Rajesh Chawla

·         Need for do not resuscitate laws in terminally ill patients in India: ‎ Ethical and legal status of withholding and withdrawal of life-sustaining therapy from critically ill patients in India is ambiguous.

·         ‎ There is a need for DNR laws in our country.

·         ‎ Do not resuscitate (DNR) order is another kind of advance directive. A DNR is request not to have CPR in case of cardiac arrest.

Dr. Neelam Mohan

·         Consent for organ transplant should consist of adequate information and should be unforced

·         ‎ Organ transplant law does not allow exchange of money between donor and recipient

·         ‎ According to the Indian Law, organ sales are banned and, therefore, and no foreigner can get local donor

·         ‎ Donor must be completely informed about risks and need of follow up

·         ‎ Hindu, Muslim and Christian support act of donation, Judaism and Gypsies condemn act of donation

·         Most organ donation for organ transplantation is done in the setting of brain death

Dr Gk Sharma

·         Regarding opinion on post mortem, the opinion should be clear & unambiguous In Medicolegal autopsy, request from police along with inquest papers are pre requisites

·         While conducting autopsy religious sentiments should be respected

·         Autopsy information should always be clear and unambiguous

·         ‎Indian law does not permit partial autopsy

·         Autopsy always done in the day time as some of the injuries and colour changes can be better appreciated in day light

·         ‎ Medicolegal autopsy can only be conducted by civil surgeons or medical officer authorized by State Government by an gazette notification

Dr. S.C. Tiwari

• You can encourage healing presence by being appreciative, forgiving, humble & kind
• ‎Healing presence in medical care - healing presence is the condition of being present consciously and compassionately in the present moment with another, during all crisis believing in and affirming their potential for and wholeness of life: ‎Curing is alleviating symptoms; healing is more often a gradual awakening of self
• ‎Spirituality in medical care - these domains, quality indicators and interventions or behaviours were generated in a modified Delphi approach
• ‎Spiritual care is not optional it is necessary
• Every hospital should have a prayer room
• The spiritual needs of a patient and relations should be taken care of.
• ‎Every dead body should be respected
• ‎ Spirituality should be included in the care of the terminal patients
• ‎ Spiritual care is not optional, it is necessary

Mr S K Saggar

Prayer room should be sarv dharm:

• Steps for being a healing presence -
• Open Yourself
• Intend to be a healing presence
• Prepare a space for healing presence to take place
• honor the one in your care
• offer what you have to give
• receive gifts that come from compassion
• live a life of wholeness and balance:

Ms Maninder Acharya

• Criminal liability under section 304A in Mathews case, Supreme Court has ruled in favour of doctors that the doctor would not be arrested on the basis of complaint of the patient
• ‎ Decisions of National Commission can be challenged before the Supreme Court
•  Deposition of expert witness is very important in medical negligence cases
• Medical negligence may arise from a doctor when he failed to do what he was required to do
• ‎In case of a complaint, doctor gets 30 days time to file his reply
• In the consumer court, there are three levels - District Forum, State Commission and National Commission
• ‎Various fora where civil cases are fought
• ‎Civil liability arise from tortuous liability i.e. duty under law
• Court procedures are required to be understood by medical fraternity
•  Understanding court procedures

Dr. H.K. Chopra

• That is the only way to defend against charges and practice ethically ‎ 
• Doctor's confidence to practice is greatly increased if he has indemnity insurance

    
Dr. Sudhir Gupta

• An error occurs when someone is trying to do the right thing but actually it is a wrong thing
• ‎Doctors’ negligence is decided by Bolam’s’ test
• ‎ Elements of medical negligence – legal duty to exercise due care, breach of the said duty, consequent damage
• ‎Identity of examined person; photograph/thumb impression/name of witnesses
• ‎Failure to take due care as a result of which an injury ensues is negligence
• ‎In MLC the medical and surgical care is the foremost priority and mandatory duty of doctor
• In MLC case, the medical and surgical care is the foremost priority and mandatory duty of doctors
• ‎In MLC case, one cannot say no to report
• ‎ Checklist of Medicolegal case

Mr Sidharth Luthra

• Paramedical and nursing staff should also be trained in proper maintenance of patient records:
• ‎ MCI Guidelines- maintain indoor records in standard Performa for 3 years from commencement of treatment
• ‎ Destruction of records can lead to a charge of destruction of evidence
•  A doctor need not go, records can be sent
• ‎ Paper records-legally more acceptable since they are difficult to tamper with.
•  Best document is the continuous record of treatment. It is the best possible defense against claims.
•  Electronic medical recording is in the process of evolution and is being increasingly used. Total avoidance of paper is ideal aim but certain issues need to be sorted out, e.g. electronic signature of doctor, patient etc.
•  Records should be comprehensive, properly planned, economical and accurate ‎   Records should be such which can be easily understood when retrieved back for planning, policy making and decision making
• Consent is critical issue in medical treatment
• Medicolegal record keeping

Hon’ble Justice A K Sikri

• ‎Function of court is to do justice. In all Medicolegal issues, justice cannot be done without the help of medical science
• ‎Inputs given by Medical experts has led to changes in laws pertaining to Rape, pornography etc.
• ‎In Medical Jurisprudence assistance of a Doctor is very important. In issues like determination of Age, DNA, Post mortem examination, examining cases of Sexual offences etc.
• ‎This issue can only be decided in assistance with medical science
• ‎Moral issue surrounding death - legal definition of death
• ‎ Juvenile Justice Act- Age determination very important, because if any crime is committed by a person under 18 years of age is dealt differently. He cannot be sent to jail
• ‎Euthanasia raises a moral debate. Should it be allowed? 3 aspects of euthanasia on which only medical science can provide answer on the basis of which laws can be made
• Likewise, doctors need the assistance of lawyers as to how much to speak and what is important to the case
• ‎Lawyers need the doctor's assistance even while cross examining other doctor
• ‎ Issues where doctors are not relevant to the outcome of the case but expert opinion is required to understand issues of medical negligence where the doctor himself is the subject of issue
• ‎Issues concern medical jurisprudence (assistance of medical professional is required without this assistance, cases cannot be resolved)
• ‎It is the opinion of the expert, a medical doctor, which decides the outcome of a case
• ‎ Law is an interdisciplinary subject. Knowledge of other disciplines is very important law as stand alone cannot act
• ‎   Purpose of my address is to inspire you, enthuse you and tell you that this legal system in many cases cannot survive without your cooperation and assistance. law and medicine are inseparable twins

Ms Meenakshi Lekhi

• A constant interface between doctors and lawyers is needed

·         The best lawyer is someone who understands your point of view and also produces a counter point of view

• Engaging a lawyer

Ms Indu Malhotra

• ‎Consent given for a diagnostic procedure, cannot be considered as a Consent for a therapeutic surgery unless it is contemplated:
• ‎Consent given for a diagnostic procedure cannot be considered as consent for a therapeutic surgery unless it is contemplated
• ‎ Consent given by the patient should be countersigned by a close relative
• ‎ Ideally the patient must fill the name of the procedure, name of the doctor leading the team and sign the consent form in his own hand writing
• ‎Consent should not be obtained as mere formality by obtaining signatures on blank forms
• ‎ If there is no emergency, there is no question of someone else giving the consent on behalf of the patient
• ‎ The patient himself/herself must give the consent
• ‎ The extent and nature of information be disclosed to the patient in India is governed by Bolam’s test
• ‎Except where consent can be clearly implied, there should always be an express consent for every procedure
• Consent must be duly obtained for each procedure

Dr. Manoj Singh

• ‎Ideal consent - 30 second video clip, question answer session, written dialogue, most importantly optimum patient understanding
• Informed consent of the patient is very important. Patient should be explained properly what procedure he will be going through.
• ‎Problems with traditional informed consent - written consent is often technical and incompletely understood by the patient. Verbal explanations are dependent on the time, experience and communication skills of the explainer. In-office explanations do not allow the patient sufficient time to review and ask questions about their procedure.
• ‎ Ideal consent
• Consent for drug trial is entirely different from consent for treatment and procedure
• ‎ The patient should have an opportunity to ask questions

Dr. N.P. Singh

• This form of extended consent should only be done in case of life threatening situation:
• ‎Extended consent
• ‎When a patient consults a medical practitioner, consent given for diagnostic surgery, can be construed as consent for performing additional or further surgical procedure-either as conservative treatment or as radical treatment-without the specific consent for such additional or further

Dr Ashok Seth

·   Commercialization should be beneficial for the patients and not for the institutions alone.

·   ‎Every private institution now has responsibility to not look at numbers but at outcomes.

·   ‎   Commercialization has nothing to do with private medicine, not every thing is profit based.

·   ‎   We are governed by a code of conduct keeping in mind morality & laws of land

·   ‎ Kickbacks, touts and commercialization in medical practice

Dr. P.K. Dave

·       Informed consent - proper communication is very important, patient should be properly counseled. the basis is to be honest with the patient, to communicate with the patient in his own language

Dr Kaberi Banerjee

· For pregnancies less than 12 weeks RMP who has assisted 25 MTPs can perform a MTP

· ‎It prohibits advertisement of PNDT techniques for detection or determination of sex

· ‎PNDT Act - prohibits determination & disclosure of the sex of the fetus

· ‎Consent for MTP from the woman is necessary

· ‎ MTP Act - Failure of contraceptives is considered as a grave risk to mental health of the women but she has to be a married lady

· ‎ MTP Act, PNDT Act

·         Social obligation of all medical practitioners to discourage female feticide

Dr Sanjiv Malik

· Kickbacks are given by corporate hospitals to referring Doctors and payment is made by Cheques.

· ‎MCI Act says you can't accept hospitality from a pharmaceutical company

· ‎Doctor-pharma relationship is a subject of debate all over the world

· Doctor Pharma relationship

Dr OP Kalra

Government should form a policy for propagating generic drugs this way price of drugs will fall.

Dr. Navin Dang.

• If request is made for medical records by an authorized person, the same should be handed over within 72 hours
• ‎ Every physician is required to maintain medical records for three years from the date of commencement
• ‎Discontinuance of life can only be done by a High Court Order
• ‎Passive euthanasia is permitted in certain situations
• ‎Active euthanasia is illegal
• ‎ Every doctor has the professional obligation to extend medical attendance in emergency
• ‎Patient has the right to privacy
• ‎The patent has the right to be informed as to the nature and procedure of treatment, its purpose, benefits and affects, alternatives available, substantial risks and adverse consequences of refusing treatment

Dr. Girish Tyagi

• ‎Damages can be awarded under three heads - pain & suffering, loss of amenity and loss of future earnings
• ‎Standard of skill and care - Standard of proof required is balance of probabilities. More serious the allegation, higher the degree of probability (Lord Dennin in Homal Vs Neucare Products)
• ‎Breach of duty - doctor has failed below the standard of care prescribed
• ‎Duty of care owed by institution (Institutional liability)
• ‎Duty of care owned by Physician (Doctor Patient Relationship)

Dr. Vijay Agarwal

• All errors 90% are due to some system failure, failure of planning. Errors should be taken as learning
• ‎Health care workers have to learn to use checklist and not rely on their memory
• Work context makes the consequences of mistakes vastly different
• ‎ Personal errors – IMSAFE (Illness, Medicine, Stress, Alcohol, Fatigue, Emotions)
• ‎ HALT (Hungry, Aging, Late, Tired) causes of errors
• ‎ Slip, lapse and mistakes are all serious and can potentially harm patients
• ‎ Violations are errors caused by deliberate deviations from an accepted protocol and standard of care
• ‎ Rule based mistake – getting the diagnose wrong and embarking on inappropriate treatment
• ‎ Mistake – It is a failure of planning
• ‎ Lapse – failure to administer a drug
• ‎Slip, e.g. accidentally pushing the wrong button of an equipment
• ‎Errors can be slip, lapse or mistake
• ‎Errors may occur when doing the wrong thing (commission) or by failing to do the right thing (omission)
• ‎Medical Accidents

Conference ended with vote of thanks by Dr. Vinod Khetarpal