Chapter II

REVIEW OF LITERATURE

Human rights are those inalienable rights which transcend

political boundaries, ideologies and faiths. Patient’s rights on the other

hand are a reflection of these rights. It is where the needs of the people

for prompt and just healthcare are met without being constrained by

socio-economic, cultural, physical, emotional status and the like. The

principle of achieving and attaining the fundamental dignity to achieve

equality of all human beings guides the fulfillment of these rights.

The patient’s interest and welfare is the core of the healing

relationship. It is fundamental to medical practice. The Hippocratic

principle which states that the healer shall act to promote the patient’s

interest and well-being and never to do harm are the long-standing

guiding rules of the health care profession. To put this fundamental

credo into the working language of the health professionals, ethical codes

have been articulated over the centuries by differing religious and

cultural traditions. (Dunn, 1994)

Both have at their heart certain understandings of the value of the

human individual and of his or her right to be treated with dignity and

respect. Amnesty International believes that the ethics of the health

professions shall reinforce human rights and make health professionals

 17

allies in its campaign for the promotion and protection of basic rights

(Dunn, 1994). To achieve this, the medical profession shall have an

understanding of the value of the human individual and knowledge of

their rights for them to be able to treat these patients with utmost

respect and dignity.

The Universal Declaration of Human Rights has been instrumental

in enshrining the notion of patients’ rights in international law. This

provides a legal and moral ground for the improvement of the standards

of care on the basis of the mutual responsibilities of the medical

practitioner and the patient towards each other as members of the

“human family.” This is also important in giving guidance on critical

social, legal and ethical issues. But there remains a great deal of work to

be done to clarify the relationship between human rights and right to

health which includes patients’ rights. The United Nations Commission

on Human Rights (UNHCR) has designated a Special Rapporteur to

provide the organization with reports that examine and clarify the

broader relationship between human rights and right to health in

recognition of this challenge. This report has been of great importance to

the World Health Organization, whose mission is to ensure “health for

all”. Grounding the mission into a fundamental human right which is the

right to health is an important milestone, and a great step forward in

realizing the organization’s goal (Rosenbaum, 1997).

 18

"Patients have needs, not rights" is a commonly heard response to

increased patient rights. In fact, they have both. "Health" and "life" has

been the primary values expressed by health care professionals.

However, in the wake of rapid development in terms of care and

treatment comes reports and alarm signals from hospitals and nursing

homes bearing witness to violations of the rights of individuals.

Therefore, the need to strengthen and safeguard patient's rights is

greater than ever before. (Medicare Center Rights, 1996)

These violations prompt the emergence of patient rights’

legislation. Patient rights legislation has several important functions. To

the legally inexperienced, it may be difficult to get an overview of one's

rights when it comes to placing demands on the health care system.

Bringing over the legislation makes it easier for both patients and health

care personnel to do the deed. In addition, since rights are aimed among

other things, at promoting equal treatment, they may reduce the scope of

the doctor's discretion, thus, safeguarding the patients’ legal security

(Medicare Center Rights, 1996).

Effective health care requires collaboration between patients and

physicians and other health care professionals. Relationships between

patients and health care professionals are most rewarding and likely to

result in positive outcomes when they are characterized by open

communication, active participation of patients in the treatment process,

respect for personal and professional values, and sensitivity to

 19

differences. These results to patient participation in treatment which is

very important if health care professionals want compliance. The benefits

of patient participation go beyond just the anticipated therapeutic effect

of the intervention (Czajkowski and Chesney, 1990). Patient participation

in treatment, their compliance also leads to improved satisfaction with

care and better quality of life.

As the primary setting and primary persons for the provision of

health services; hospitals and health care professionals shall provide a

foundation for understanding the rights of patients and their families by

living up with the health care ethics that respects the role of patients and

their significant others in decision-making about treatment choices and

other aspects of their care.

In the Philippines, where health care institutions recognize each

patient as an individual with unique health care needs, authorities

stresses the importance of respecting each patient's personal dignity, and

the provision of considerate care focus upon each patient's individual

needs.

The patients’ rights are first established by the American Hospital

Association (AHA) in 1973 and are revised sometime in October 1992. It

is developed with the expectation that hospitals and health care

institutions will support these rights to be able to deliver effective patient

care. The AHA encourages institutions to translate and/or simplify the

bill of rights to meet the needs of their specific patient populations and to
 20

make patient rights and responsibilities understandable to patients and

their families (Kozier, 2004).

Patients’ rights are intended to accomplish three major goals. First,

to strengthen patient’s confidence by assuming that the health care

system is fair and responsive to the patient’s needs; to provide patient’s

with credible and effective mechanisms to address their concerns and to

encourage patients to take an active role in improving and assuring their

health. Second, is to reaffirm the importance of a strong relationship

between patients and their health care professionals. Third, is to reaffirm

the critical role patients play in safeguarding their own health by

establishing both rights and responsibilities for all participants in

improving health status.

According to the AHA, a patient's rights can be exercised on his or

her behalf by parents, guardians, family members, other conservators

designated surrogate or proxy decision-maker if the patient lacks

decision-making capacity, is legally incompetent, or is a minor. And

below are the Rights of Patients as published by the AHA and are

honored by both the international health care system and the

Philippines, particularly at Ilocos Training and Regional Medical Center

(ITRMC), City of San Fernando, La Union according to its applicability in

the institution which is the locale of the study.

 21

Patient’s Rights

Patients have the right to considerate and respectful care.

Patients have the right to considerate, respectful care from all members

of the health care system at all times and under all circumstances

because an environment of mutual respect is essential to maintain a

quality health care system. Patients want to be treated with respect and

they want to be treated fairly.

Respect has been defined as recognizing a "person's capacities and

perspectives, including his or her right to hold certain views, to make

certain choices, and to take certain actions based on personal values and

beliefs" (Faden and Beauchamp, 1986). Conversely, patients defined

respectful treatment as that which takes into consideration the values,

preferences, and expressed needs of the patient. In addition, patients

wanted health care providers to communicate well, to be respectful of the

patient's time, and to give emotional support to alleviate the patient's

fear and anxiety.

In ITRMC, patients are treated fairly regardless of their socio-

economic status. To achieve this, social workers are assigned to have

rounds on every ward to be able to assess the financial capabilities of the

patient. They then categorize the patients on the following criteria. A -can

afford. B- with Health Management Organization (HMO). C1- 25%

discount. C2 - 50% discount. C3- 75% discount. D - indigent for the

 22

patients to receive equal attention during admission or during

confinement.

Medical cases are prioritized according to who really needs urgent

treatment. Medical management is first given to those who suffer from

conditions that have to do with airway, breathing and circulation (ABC’s).

Other less severe cases after will then receive the same attention.

Patients are greeted and called on by name during administration

of medications or during the signing of consent for therapeutic

management. Their decisions are always sought in every aspect of their

care for them to fully participate with the realization of their plan of care.

Sometimes, patients are also placed on isolation or treated with

utmost precaution for them not to suffer from cross-contamination which

is a big possibility because of the diseases that surround him in the

hospital environment.

Patients have the right to obtain from physicians and other

direct caregivers relevant, current and understandable information

about their diagnosis, treatment and prognosis. Physicians, medical

practitioners and nurses at ITRMC always provide the patient

information regarding the flow of their treatment. Records are updated

every now and then. And for as long as the patient demands to have him

or her information of his or her condition; medical records pertaining to

his or her treatment, prognosis and findings are readily available.

 23

Patients have the right to know the identity of physicians,

nurses and as well as students and other trainees involved in their

care. Introducing oneself before participating in the patient’s plan of care

or before talking to them is a standard operating procedure (SOP) of the

hospital. Wearing of institutionalized uniforms, identification cards (ID’s),

and nameplates are also observed in such a way that students and

medical professionals alike are recognized as partners in the delivery of

the patient’s health care.

Patients have the right to know the immediate and long -term

financial significance of treatment choices in so far as they are

known. Patients have the right to receive accurate, easily understood

information regarding their health. Value-based purchasing allows

patients to obtain greater value for their health care by seeking higher

quality care at the best price. Patients in ITRMC are being informed of

the corresponding expenses to be incurred in every treatment that they

will avail from the hospital. The importance of the medical procedures

and their alternatives are made known to the patient. If the patient can’t

afford the said treatments, it is only then that referrals are made.

Patients have the right to make decisions about the plan of

care before and during the course of their treatment. Patients are

given the privilege to make choices about their plan of care. To push

through or not to push through with the treatments solely depend on the

patients’ decision. To consider the treatment offered such as in blood

 24

transfusion (BT) or to resort to other options depends on what the

patient thinks is best for his condition.

Patients have the right to refuse a recommended treatment or

plan of care. A more basic reason for providing patients with information

is an ethical one. Health care professionals have an ethical obligation to

inform patients about how their actions can affect the patient’s life and

health. Medical ethicists ground this obligation the principle of respect

for individual autonomy and individuals’ right to make choices about

how they receive medical care. (Beauchamp and Childress, 1994)

Individual differences or preferences are some factors which affect

the plan of treatment designated to each patient. Some of which are a.

religion – followers of Jehovah’s witnesses do not comply with blood

transfusion as based on their beliefs that blood is dirty. b. tradition-

patients sometimes refuse some recommended treatment due to their

superstitious beliefs. c. socio-economic status- patients sometimes

refuse surgeries because these procedures subject them to expenses that

they cannot afford.

In ITRMC, patients who refuse any recommended treatment or

plan of care such as in administration of medications or in blood

transfusions are obliged to sign on what is known in the hospital as

“blotter” which prevents the institution from being liable to any

consequences brought by the patient’s refusal to avail any recommended

service.
 25

Patients have the right to be informed of the medical

consequences of their refusal of the treatment or plan of care. There

are some instances where some proposals for treatment are being

refused like refusal for intravenous (IV) infusion or refusal for blood

transfusion (BT), and refusal for care or refusal for admission. In cases

like these, the nurse will let the patient sign just after the doctor’s order

which confirms the patient’s refusal of such. The nurse will then notify

the physician about the refusal thereby prompting the medical

practitioner to explain whatever consequences the situation may lead to.

Patients have the right to make a statement such as a “living

will” which should be followed by the hospital as permitted by law.

In ITRMC, making statements such as living will by the patient is

regarded as a personal matter. The only contribution of the healthcare

professionals is that they subject themselves as witnesses upon request

if guided by legal intents and purposes.

Patients have the right to be advised of their rights under the

hospital policy. Upon admission, the assigned personnel present and

likewise explain the different policies of the institution. Various points

that are raised are the time and the number of hours for visiting,

prohibition of watchers in occupying vacant beds in the ward and

prohibition of smoking within the hospital premises. The staff in

collaboration with non-government organizations like SINAG, and other

caregivers also conducts lectures regarding the hospital rules and

 26

regulations. The institution also makes it a point to place posters and

guide lists into conspicuous areas informing the patients and watchers

alike of the hospital’s rules and regulations.

Patients have the right to privacy. Facilities such as private

rooms and other equipments are available at the hospital in order for

patients to have privacy. Proper draping during skin preparations or

during obtaining specimens from a patient without bathroom privileges

are observed by nursing students, other trainees and medical

practitioners.

Patients have the right to confidentiality of all records and

communications regarding their care. The assurance that patient's

health information will remain confidential is "fundamental to effective

diagnosis, treatment and healing" (Shalala, 1997).

Patients have the right to communicate with health care providers

in confidence and to have the confidentiality of their individually

identifiable health care information protected. The legal right to

confidentiality of health care information and its essential role in the

delivery of quality health care has been recognized by the Philippine

laws.

Medical records of the patients in ITRMC are kept with strict

confidentiality. Only the doctors, nurses and other medical personnel

are allowed to view and study the charts of patients. Nursing students

are only allowed to open these charts if they’re supervised by both the
 27

staff nurse and the clinical instructor alike. The quality of the health care

system depends on the regular exchange of information between health

care providers. Watchers or other relatives of the patient can also view

these charts if and only if they are authorized by the patient himself to

do so.

Patients have the right to review all their medical records and

have them explained or interpreted. Obtaining the information and

making it available to patient’s will, by itself, equip patients with the

knowledge and abilities required to act on this information. Patients are

able to evaluate critical information about quality. However, research on

how patients use information to make decisions suggests that too much

information can be overwhelming (Edgman-Levitan and Clery, 1996). The

matter must be presented to them in a manner that they can really

understand.

In ITRMC, only the doctors have the right to interpret every single

detail or finding concerning the patient’s condition. Nurses offer

explanations also but only as support to what the physician has said or

to clarify or explain the importance of some aspects of the patient’s care

that he or she cannot understand.

Patients have the right to receive requested care and services

provided these are reasonable. Patients have the right to a choice of

health care providers that is sufficient to ensure access to appropriate

high-quality health care.

 28

The granting of any request or service for care is case-to-case

basis. If a patient from a ward requests for him or her to be transferred

in a private room, it can be provided if there are private rooms available.

If one patient request for oxygen inhalation because he or she is having

difficulty of breathing, it can be granted also provided that the service

will not jeopardize the patient’s condition. But if the patient requests to

exchange beds with a fellow patient or insists that the chairs or electric

fans in the ward should only be for his or her sole use, it will not be

granted because these amenities are intended for the use of all. If the

patient requests for the physician to come at his or her aid immediately,

it maybe for the physician to do his wound dressing or re-insert an

intravenous infusion because she doesn’t trust the nursing staff or the

trainee to carry it out, this cannot be granted because the physician has

lot of patient’s to attend to. The request can only be granted if it is

already detrimental to the patient. In cases where a patient or his

relatives request the nursing staff to limit or prohibit student nurses

from carrying out the patient’s plan of care, the nursing staff will then

explain that ITRMC is a training center. But it is however, with the

reassurance that these trainees who will be performing some of the

interventions that are necessary for their care are also equipped with the

knowledge and skills as much as they do. This then gives a go-signal for

the student nurses to do their functions but if and only if under the

supervision of the licensed staff nurse or clinical instructor.

 29

Patients then need to exercise their rights to choice by using good

judgment and providing direct feedback to evaluate about their level of

satisfaction with the service provided for them.

Patients have the right to ask and be told of the existence of

any business arrangements among the hospital, educational

institutions and/or people involved and that may influence their

treatment and care. Whenever questions are raised about the presence

of student nurses or other trainees during the delivery of the patient’s

care, it is then explained to him or her that the institution serves as

training ground for the students of the educational centers that the

hospital is affiliated with. It is with reassurance; however, that these

trainees can not push through with the delivery or the performance of

the patient’s plan of care unless they are supervised by a licensed

nursing staff or clinical instructor.

Patients have the right to informed consent to any medical

and surgical procedures affecting their plan of care. Before patients

are subjected to any medical or surgical procedure, a consent form

secured by the surgeon, is always presented to them for signing. It is

only when the consent form is signed that the surgeons or the physicians

at that can push through with the procedures.

Patients have the right to refuse to participate in any research

studies or human experimentation. More often than not, research

studies are conducted in the institution. If the research studies dwell

 30

mostly on letting the patient answer a questionnaire or an interview, it

can be permitted if the patient wants to. But if he or she doesn’t want to

answer any of the sorts, it can also be because the institution respects

the patient’s autonomy. If instances occur in which the patient will be

subjected to any experiment or any extensive study to rule-out his or her

condition, it is still dependent on the patient if he wants or doesn’t want

to push through with the procedure.

Patients have the right to expect a reasonable continuity of

care. The patient’s plan of care does not end at the end of his or her

confinement. To facilitate continuity of care, patients are given

instructions regarding their medications. They are also reminded of their

schedule for their follow-up check-ups. Referrals are also made for these

patients to receive immediate care when his or her condition recurs.

Patients have the right to be informed of available and

realistic care options when hospital care is no longer appropriate. In

cases where the institution lacks resources like machines or equipments

required for extensive procedures that immediately need to be done to

support the patient’s condition, the patient or his relatives are informed

of other options. It may be in the form of transferring the patient to other

institution or letting the hospital to continue performing the procedure

with the resources that it can offer. If the patient agrees, it is then that

referrals are made.

 31

Patients have the right to be informed of the hospitals policies

and practices that relate to their care, treatment and

responsibilities. When questions are raised regarding the patient’s plan

of care, treatment and responsibilities; the nursing staff and the trainees

explain the hospital policies that best respond to their queries. Other

situations that support this right are also presented on the other rights.

Patients have the right to be informed of the resources that

can be used to resolve disputes, grievances or conflicts. Disputes,

grievances or conflicts are always solved within the hospital premises by

the concerned patient and the person to whom he or she have the

misunderstanding, the concerned staff nurse, and the hospital’s security

services. It is only when the conflict goes beyond the hospital’s

jurisdiction such as in theft, it is only then that the hospital’s right to

solve the matter are waived.

Patients have the right to be informed of hospital charges and

available payment methods. Upon discharge, patients’ charges must be

fully paid. Patients in private rooms are updated everyday on their bills

while partial billing is provided to those patients who are confined in the

wards.

Personal Services Rendered (PSR) is being implemented by the

hospital as one way of extending their personal assistance to patients

who cannot afford to pay their bills. Watchers or relatives of each patient

are allowed to do some utility woks in the hospital and they are being
 32

paid Php 22.50 per hour. Payments for services rendered are deducted

from their charges. Patients can even trade their goods such as

vegetables, rice and fruits to the Dietary department or products such as

brooms to the Social Welfare Section and these will be deducted also

from their charges.