INTRODUCTION
The Unknown patient can be defined as
the patient whose identity cannot be ascertained at the time of arrival to the
Hospital. It is synonymous with unnamed patient, nameless patient and
unidentified patient.
In the USA, they are popularly referred to as
John Doe (Male) or Jane Doe (Female).
Care: The Cambridge dictionary defines care as the
process of protecting someone or something and providing what that person or
thing needs OR the process of providing for the needs of someone or something.
Fortunately for me: Overview refers to
a short description of something but “no details”. So pardon me if details are
not given in this manuscript.
This literature was to include the care of
the Unknown Patient, Policy Overview and Review. However, there are paucity of information with respect to the Policies of
the unknown patient, underscoring the point that there may not be Policies in
our country regarding the care of the Unknown Patients.
The
Unknown Patient poses major challenges to
- Attending
Physician
- The
Institution
- The
Society/Public
These challenges are further compounded by
inadequate and lack of appropriate Health care financing and legal frame work.
The Unknown Patient therefore represents a unique burden in the context of
Patient Safety, Legal, Humanitarian and Treatment issues because of Medical
Decision Making.
INCIDENCE/BURDEN OF THE UNKOWN PATIENT
The Unknown Patient is of global Medical
concern.
A Los Angeles County
Hospital recorded 1,131 Unknown Patients in 2016. This increased to 1,176 in
2018.
In a 10 year
retrospective study in an Indian metropolitan Neurology Hospital, of 151
Unknown Patients seen over the period:
- 88.7% were Males
- Mean age 43.8 years
•
83.6% were brought by the Police
•
49.7%
were registered as Medical Legal Cases (MLC)
•
66.9%
had loss of consciousness
•
9.3%
deaths were recorded
Ø Seizures, metabolic encephalopathy, stroke Neuro-infection and head injury were the primary reasons
for admission of Unknown patients to Neuro-emergency
service.
Other known presentations of the Unknown
Patients,
Ø Trauma
Ø Severe
cognitive impairment eg.
Alzheimer's Disease
Ø Drug Abuse/Overdose
Ø Psychotic Patients.
In
RSUTH: From January 2018 – July 2019
Ø A
total of 4328 Admissions (2850 in 2018)
**13 Unknown Patients were Admitted
12 (92.3%) were Males
11 (84%) ;Road Traffic Injuries
1 (8%) ; Gun Shot Wounds
1 (8%) ; Substance Abuse
4 (31%) were later Identified and 6(46%) Died
6 (46%) had documented Pathway to care (Police and Good Samaritans)
Ø Documentation
was a critical factor as most of the Unknown Patients had no folders opened for
them until they were identified.
PATIENT
IDENTIFICATION AND SAFETY
Ø Failure
to correctly identify patient constitutes serious risk to the patient’s safety.
Ø Adequate identification is the ability of the
patient, their escort or medical staff to identify the patient by name and one
of the following.
- Date of Birth (DoB)
- Address
- Social
Security Number
OR
The patient has written identification that
contains that information. Example; (a) Driver’s License (b) Non-driver
ID and Birth Certificate (c) Passport etc.
Patient Safety is the absence of preventable
harm to a patient during the process of healthcare and reduction of risk of
unnecessary harm associated with healthcare to an acceptable minimum.
Unknown patients are at higher risk of unsafe
medication practices and medication errors especially in poor resource
hospitals.
EXISTING LEGAL FRAMEWORK
a. Code of Medical Ethics
- Duties
of Physician to the Sick
Ø Physician
shall preserve absolute confidentiality on all he knows about his patient even
after the patient has died.
Ø A
Physician shall give Emergency care as a Humanitarian duty unless
he is assured that others are willing and able to give such care.
Ø A
Physician shall act in the patients best interest when
providing medical care.
Ø Practitioners
shall provide appropriate privacy to their patients.
•
The Code of Ethics does not permit the doctor
to give any treatment against the patient’s wishes even as it recognizes the
individual’s right to accept or refuse medical treatment.
•
Priority remains to save life by any
available means.
Ø Disclosure
of information on a patient by the doctor can only be made following an
informed consent of the patient in writing.
Ø For
discretionary breach, the doctor is required to inform the patient even though
disclosure is minimized.
Ø Consent
for procedures.
Where the patient is unconscious or in a
state of mind constituting a mental impairment, a next of kin should stand in.
In the absence of a next of kin, the most senior doctor in the institution can
give appropriate directive to preserve life.
•
In special situations a court order may need
to be procured to enable lifesaving procedures Be
carried out.
b. The National Health Act (NHA) 2014
(a) Section 20(1). A
health care provider, health worker or establishment shall not refuse a person
Emergency Medical Treatment for any reason.
Penalty on conviction: #100,000 fine or
imprisonment for a period not exceeding 6 months.
(b) Section 3e 5% of the fund (Basic Health
Care Provision Fund) shall be used for Emergency Medical Treatment. To be
administered by a committee appointed by the National Council on Health.
(c) Section 26 (i): All information
concerning a user, including information relating to his or her health status,
treatment or say in a health establishment is confidential.
Ø Disclosure conditions similar to those of Code
of Medical Ethics.
c.
Compulsory Treatment and Care for Victims of Gunshot Act 2017
This Act provides for the compulsory
treatment and care for victims of Gunshots by Hospitals in Nigeria and goes
further to impose on every citizen a civic duty to render every possible
assistance to any person with Gunshot wounds by ensuring that the person is
taken to the nearest Hospital for immediate treatment.
Of Note are the following Sections:
Ø Every Hospital is to receive and treat victims
of GSW with or without police clearance and or payment of an initial deposit
but are duty bound to report to the nearest police station within two hours of
commencing treatment on the victim.
Ø A
facility that receives any Gunshot victim is required to notify the family
members or relations of the victim as far as they may ascertain within 24 hours
of becoming aware of the victims identity.
Ø The police may only receive a Gun Shot Victim
upon certification of fitness by the Chief Medical Director of the Hospital
where he is receiving treatment.
d.
Privacy
and Data Law
Ø Currently
there is no comprehensive data privacy or personal information protection law
in Nigeria that sets out detailed provision on the protection of the privacy of
the individual and citizens.
Ø Under the law establishing the National
Identity Management Commission (NIMC), the agency is charged with establishing
a National Identity Database.
Ø The
NIMC may provide information about a person in the interest of National
Security or Public Interest.
Ø By December 2018 it was expected that NIMC
would have registered 78 million of over 186 million Nigerians.
MANAGEMENT OF THE UNKNOWN PATIENT
Not only multi-disciplinary but multi-sectorial
A. History, Physical Examination and
Treatment
Ø Usually
brought in dire conditions by
•
The
police
•
The
Federal Road Safety Corps
•
The
EMS
•
Good
Samaritans
•
Others
Ø Seen mostly in public Hospitals where they are
left.
Ø Generally present as unidentified pedestrians,
cyclist who left home without any form of identity and involved in Road Traffic
Crash.
Ø Psychotic patients, overdosed drug users, mass
casualty incidents.
Ø People
with severe cognitive impairment.
Ø Unconscious: following trauma, metabolic,
cerebrovascular and seizure disorders.
Ø It
is usually at the point of Registration that the unknown status is determined.
Ø It is important to get the following
information from the Escort: eg. Police or Good Samaritans(GS)
(a) Location of pick-up
(b) Nature of event
(c) Any
recovered personal belonging (Phones, I.D, etc)
(d) From
the EMS: Dispatcher’s record
•
Time of Call
•
Name of Caller
•
Other details from caller
Ø Identify and document details of the police
patrol team and Good Samaritan (GS)
•
Name
of Team leader
•
Station / Division
•
Phone
Number
Ø ACTIVATE
HOSPITAL PROTOCOL IF ANY
Ø In RSUTH: Registered as Unknown Unknown
Other
Centres.
(a) Unknown Male or Female
(b) John or Jane Doe
(c) Trauma
X etc.
In case of mass
casualty events, Unknown Male 1, 2,3……
•
Use of identification band
Ø Complete
Thorough General and Systemic Physical Examination
Ø For Trauma Patients: The ATLS approach remains
the Gold standard
Ø Estimate Age, look for tattoo, tribal and
other marks, jewelleries, clothes etc.,give
a leading.
Ø Hospital
Staff must play “Detective”
Ø Smell of breath can help,
burns at finger tips of dominant hand can indicate inhalational use of
psychoactive substance.
Ø Biometric
finger prints and photographs
Investigations and
Treatment are based on findings / suspicion.
B. Special Consideration
1. When surgery is
indicated:
Ø Institutional protocol / code of ethics for
the unconscious may be applied.
2. Blood Transfusion:
Ø Sex and Approximate age should be indicated in
the request form.
Ø It is advisable to apply a wrist band with
unknown M or F and sex indicated.
Ø If patient becomes known, Grouping and cross
matching is done using the correct identity and wrist band removed or changed
to actual name.
Ø Code of Ethics applies concerning the Jehovah’s witness.
Role of Medical
Social Workers (MSW)
Ø Institutions
differ on how to trace identity and family of the Unknown.
Ø In our Hospital the Medical Social Workers:
- Assist in tracing the family
- Stand in as patient relation though not
involved in Medical Decision Making
C.
Relationship with Law Enforcement
Agencies and the Public.
- When
patient is brought by the Police
- When
the patient is brought by Others
- Is
this a Medical Legal Case (MLC)?
- Managing
the Public
- Hospital
Information Desk and Public Safety / Relations Unit.
- Limited
Disclosure.
IDENTIFICATION
OUTCOME
- Self Identification
- Proven Relations
- Biometrics
D.
Death:
- This can be a major event in the Hospital
- May be a Coroner’s case
- Availability of Mortuary Service
FUNDING OF CARE OF THE UNKNOWN PATIENT
Ø The NHA provides for funding of the EMS
system.
Ø Most Hospitals end-up bearing the cost of the
care of the Unknown.
Ø Good Samaritan’s (Including Foundations)
Ø Hospital Staff
Ø The Patient when he/she becomes identified.
RECOMMENDATIONS
1)
Every
Hospital should have a Policy or Standard Operating Procedure for the care of
the Unknown patient within the ambits of extant laws and ethics.
2)
Government
should pay for the care of the Unknown as provided for in the NHA regarding the
EMS system.
3)
There
should be a National Policy on the identification and care of the Unknown
Patient as well as on missing persons.
- This year’s Physicians’ Week lectures
should come-up with the NMA position.
- All the relevant stake-holders should
have a National round table on the Unknown Patient with the NMA taking the
lead.
- The
Compulsory treatment and care for the Gunshot victims Act 2017 should be
amended to include the care of the Unknown Patient and resolve other
nuances.
CONCLUSION
The Unknown Patient has the right to right
treatment, the right time and funding of care should be seen as an ethical and
legal matter.
Every Hospital should have a Policy on the
Unknown Patient backed by a National Policy and legislation.
REFERENCES
1)
WHO Patient Safety and Risk Management
Service Delivery and Safety September, 2019. - https://www.who.int/patientsafety/en
2)
Southern Health NHS Foundation Trust Patient
Identification Policy - http://www.southernhealth.nhs.uk/_resources/assets/inline/full/0/71283.pdf
3)
Identification of unidentified patients model
policy June, 2017, updated January, 2018 -
(New York
State Missing Person White House) https://www.health.ny.gov/professionals/hospital_administrator/letters/2017/docs/2017-01_id_of_unidentified_patients_model_policy.pdf
4) Medical
Decision Making for unknown and unpresented
patient
- A
report submitted to the Haranl Ethics Leadership
group by the community ethics committee March, 2016 - https://www.ochsner.org/services/palliative-care/legal-hierarchy-of-medical-decision-making
5)
Unknown patients and Neurology casualty
services in an Indian Metropolitan city. A decade experience. - https://www.ncbi.nlm.nih.gov/pubmed/28615894
6)
The code of Medical Ethics in Nigeria. - http://www.mdcnigeria.org/Downloads/CODE%20OF%20CONDUCTS.pdf
7)
National Health Act 2014 - https://nass.gov.ng/document/download/7990
8)
Compulsory treatment and care for the
Gunshot victim. Act. 2017 - https://www.naijalegaltalkng.com/article/113-criminal-law-and-rights/324-the-compulsory-treatment-and-care-for-victims-of-gunshot-act-2017
