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Trauma destination legislation

trauma-list@trauma.org trauma-list@trauma.org
Fri, 04 Apr 2003 09:57:25 -0500

In a message dated 4/3/2003 11:22:02 PM Eastern Standard Time, htaed_rd@123mail.org writes:

> I would think that in the patient described (GCS = 13, hemodynamically
> unstable) it would be much harder to show that any decision was made
> with the best interest of the patient in mind if you did not go to a
> trauma center.
> I go out of my way to honor the requests of competent patients and family
> members. Based on what you wrote, there does not appear to be an
> understanding of the risks in not going to a trauma center. Without that
> understanding how can the family make an informed decision?
> With the unstable patient how much time is available to discuss this with
> the family. You did not mention the age of the patient.
> You might ask police (on scene already?) to intervene.
> Given the circumstances I would be surprised if a District Attorney would
> prosecute (Guiliani would have, but he just doesn't like EMS). I expect
> the laws vary by state, but there may be something federal 
> that addresses
> this. I do not know about civil law suits.
> Tim Noonan.

I agree with what you say above.  One problem with trying in any way to fashion your medical practice around "what could happen to ME legally if I did this" is you tend to forget proper medicine,  This very question indicates one basic tenet of the physician's mission has been forgotten--that our ONLY duty and obligation is to the patient.  We have NO obligation to ANYONE else, be it family, friends, police, lawyers, accountants, insurance clerks, etc etc.  Naturally we always make every effort to accomodate the family, keep them informed and involved, etc, and normally this is no threat to the patient.  BUT--in the end, especially when the family's wishes are at odds with the patient's welfare, remember that the patient is our primary concern.  By even beginning to consider the family's "wishes" here indicates this concept has been forgotten--there should be no hesitation.
Why I always harangue my residents and colleagues about such concerns as to what the lawyers may think, and that this should NEVER be a consideration in any medical decision, is that if it makes you do anything, it will always be the WRONG thing.  The best defense against not only getting sued, but (more importantly) LOSING a suit (for those who just must consider this at all), is simply to PRACTICE GOOD MEDICINE, documenting the reasons why you do things as thoroughly as possible so as to make your mindset clear you are acting only with the patient's best interest in mind. Of course, communicating these lines of thought as much as possible to the patient and family is always important, but there are times when this is not possible, or it just does not work.  When the interests of the family are ever at odds with those of the patient, then the patient MUST always win out. 
In the example posted, if you must consider the possiblity of what the lawyers might do, then doing what the family wanted is the SUREST way of opening yourself to liability--because you would not have a leg to stand on, given what you KNOW, that you were acting in the best interests of the patient.  You could always make it easier, if you must, by letting the family know it is also a matter of state law that this patient must be transported to a trauma center, if you have a legislated trauma system in your state, as we do.