Citation
Life sustaining technologies and the elderly: legal issues: Yugoslavia

Material Information

Title:
Life sustaining technologies and the elderly: legal issues: Yugoslavia
Series Title:
Life-sustaining technologies and the elderly
Creator:
Haug, Christoph
Publisher:
U.S. Congress. Office of Technology Assessment
Publication Date:
Language:
English
Physical Description:
17 pages.

Subjects

Subjects / Keywords:
Older people --medical care -- Legal status, laws, etc -- Yugoslavia ( LCSH )
Patients -- Legal status, laws, etc -- Yugoslavia ( LCSH )
Medical laws and legislation -- Yugoslavia ( LCSH )
Capacity and disability -- Yugoslavia ( LCSH )
Critical caremedicine -- Law and legislation -- Yugoslavia ( LCSH )
Genre:
federal government publication ( marcgt )

Notes

General Note:
This report discusses different existing Federal laws at republic and provincial level in Yugoslavia with regard to health insurance. it talks about the allocation of resources, the method of payments, patient rights,and ethical issues.

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Source Institution:
University of North Texas
Holding Location:
University of North Texas
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Classification:
Y 3.T 22/2:2 L 62/v.4/Yugosl. ( sudocs )

Aggregation Information

IUF:
University of Florida
OTA:
Office of Technology Assessment

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-1 -LIFE SUSTAINING.TECHNOLOGIES AND THE ELDERLY LEGAL ISSUES YUGOSLAVIA CHRISTOPH HAUG JOHNS HOPKINS CENTER ON AGING

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-2 -FINANCING OF HEALTH CARE Different laws exist on the Federal, republic and provincial levels with regard to health insurance for about 98% of the population. The health insurance system is based on the principle of solidarity and is compulsory in character. The costs for health services are usually covered from the funds generated from contributions for health insurance, from governmental expenditures and other public revenues (1). All who are not covered by the health insurance, e.g., the poor and groups without income, are entitled to all medical services at the public expense. In addition some health services are offered free of charge for everyone, e.g. mental disorders or malignant illnesses. Furthermore, some medical services have to be paid in part by the patient. Especially prosthetic dentistry, medical services of aesthetic character and treatments in spas and health resorts. In some cases also rehabilitation, except if this is necessary as a follow-up of hospital treatment. Usually it is up to the individual health insurance system to decide on the coverage in accordance with relevant regulations but all patients suffering from chronic diseases are exempt from their part of the cost of medical treatment necessary. The health care system is financed from the following sources: -personal income contributions of workers, farmers and other groups covered by compulsory health insurance -enterprise income contributions and those of other organizations/institutions, e.g. health care/health protection for workers

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-3 --governmental expenditures especially for health care of temporarily unemployed and low income groups and partial coverage of health care expenses incurred in underdeveloped regions (2). Methods of Payment Users of health care allocate and pool resources for financing of health institutions according to the health care program. These are jointly adopted by health workers and users annually basis and serve as a basis for setting the price of health services. Within these programs, health institutions, users of their services and self-management comunities of interest determine type and scope of health services, prices for the health services as well as other regulations significant for the implementation of the health care program. Health institutions and patients together decide on the cost of health services and how they are covered. The income of health institutions is generated in several ways: flat-rate payment; per inpatient, according to the type of illness; per unit of health service. The salaries of health professionals and health workers are regulated by every health institution and are based on guideline salaries according to performance (3). In general the system of financing is structured to ensure equality of socioeconomic status of health workers and those employed in other organizations of associated labor. Patients Rights According to the Constitution of the Socialist Federal Republic of Yugoslavia, everyone has the right to health care as well as to a healthy environment (2).

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-4 'I These basic rights are specified in detail by numerous laws and regulations, passed in all the republics and autonomous provinces. The rights of patients are stipulated in regulations on health care and-health insurance schemes. Even the right to health services of high standard is not explicitly specified, especially due to the still limited territorial accessibility of health services in certain underdeveloped regions. It is understood that medical institutions which offer such services have taken all legal and professional measures to ensure services of high standard offered to patients. In addition to the basic rigtt to health services, the patients have the right to -financial benefits while on sick leave, -examination by a council of specialists, -medical record-keeping in secret, -personal or immediate family consent for surgery, objection to poor quality of service or treatment, -to be treated abroad in competent institutions if adequate treatment is not available in Yugoslavia itself (3). The patient may protect their rights and interests on the basis of the law on health care in civil or penal procedure. Special programs for the elderly There are programs for the elderly with so-called gerontological ambulatories which are a combination of educational and clinical institutions where long term care is also provided (1). Especially war veterans, disabled veterans and other disabled persons and those over 65 years of age have the right to IL

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5 periodical thorough examinations for prevention. Recent laws regarding the health care system: -Law on the system of social planning and the social plan of Yugoslavia (1978), -Constitution of Yugoslavia from 1974 introduced a new mode of self-management in the health field (3). Organizational and legal aspects The Constitution of Yugoslavia from 1974 introduced a new mode of self-management in the health field as in other social activities: Self-management organizations of the insured citizens have evolved parallel to health legislation and social insurance. The main purpose is to enable the insured to exert their direct influence on the management of funds allocated to health services and to exercise other rights within healthy retirement and disability insurance schemes (3). For this the users of health services (insured) and the providers (medical staff) establish self-management communities of interest for health care in which they determine the direction of the development of health services and health care including health promotion. There are also self-management communities of interest for retirement and disability insurance. The insured pool resources, define rights and obligations and realize their common interests on the basis of reciprocity and solidarity. These self-management communities of interest for

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-6 -health care have constitutional rights in collective decisionmaking and deciding on the matters related to the health field together with competent government bodies as equal partners. The long run strategy is to further develop this system of collective rights and decision-making on a number of other health issues which are under the jurisdiction of government bodies so that the function of the state is gradually narrowed and reduced to the social supervision and surveillance of the self-management communities of interest~ This major change strengthened the role of the communities and provinces in the health field. Every republic and autonomous province regulates organization of health activities and implementation of health care services on its own; no development planning or programming takes place on the federal level. But in case there is a need to do so, there are no legal obstacles. There is a strong tendency towards association on one side and division of labor on the other side among specialized health institutions to ensure high standard of health services. There are no privately owned health institutions and they may be established only by legal persons. Regulations on social insurance and legal provisions on labor and employment have a strong and significant impact on the offered health services, since these regulations -proclaimed a widespread health and social welfare of workers -ensured their rights to health protection, treatment and rehabilitation

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-7 -Regulation of health care systems:. As mentioned, the legal responsibility and the legislative pow~r in the health field falls within th~ competence of republics and autonomous provinces and partly communies. The federation retained only the power to regulate some issues of significance for the entire country and the international community, e.g. -prevention of contagious diseases -production and marketing of narcotics -health certificates for food -health protection for foreigners -environmental protection and -rights rising from retirement and disability insurance. (3) On the federal as well as on the provincial level committees for labor, health and social welfare work closely together via numerous forms of working groups. The republics and provinces are responsible for the implementation of the federal regulation represented by the federal committee for labor, health and social welfare. Most laws passed in the field of health legislation serve mainly as guidelines and contain usually only the goals to be attained but leave the means and ways to the competent administrative bodies or health institutions or other agents determined by law on the federal, republican or provincial level. All laws on various levels prescribe fines fdr violation of certain provisions or offences against regulations such as those listed below:

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-8 --unconscientious treatment of the patient, -refusal to attend the patient, -practicing quack" medicine, : -careless behavior in preparing and prescribing medicines. In the annual development plan of health activities and health care adopted by the self-management communities of interest for health care the types and scope of health services, priorities and other issues of importance for the health promotion and funding for each region are specified. To ensure proper implementation and operation, a system of control was developed. Internal control is ca.ried out within every health institution by managers and other experts. External control includes supervision of professional work, supervision of legality of work, sanitary supervision, and supervision over the use of social funds. This is carried out by competent government bodies via special commissions of experts in accordance with procedures prescribed by republican and provincial laws on health. The legal responsibility of health workers is determined by regulations in the health field as well as in penal legislation under specific headings dealing with criminal acts against human health. In general the number of punished workers is low and there is no upward tendency. There is also a code of ethics which binds all medical and health workers regardless of title and position in the profession under health care laws. These laws prescribe all health workers to offer health protection according to contemporary scientific achievements and knowledge, respecting the patient's personality and safeguarding professional secrets.(3)

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-9 -Violation of these professional responsibilities are is prosecuted on several levels: discipline commissions in health institutions, -special courts of associated labor (in case of appeals), honor courts within associations of health workers (3). It should also be noted that private medical practice is prohibited in Yugoslavia for all health workers. The last exceptions in one of the republics came to an end in March, 1985. Therefore health institutions are independent self-management organizations of associated labor in which medical and other health workers are employed. Medical Ethics There are no specific government bodies concerned with medical ethics, but the ethical questions related to death and dying are increasingly debated. Therefore, the Yugoslavian government is working strongly for a legal base of the use of life-sustaining technologies and treatment decisions. One proposal discussed is that a commission of fa~ily members, physicians and lawyers should decide but this is still in progress. (1) In general,-universities play a leading role in the development of medical ethics, and five academic groups are currently involved in research concerning the quality of life. Several medical institutions have begun courses on death and dying. In addition two symposia on medical ethics were held on the subjects of Medical Ethics in Education and "Rights and Responsibility of the Patient. Furthermore, there is a growing understanding in Yugoslavia to participate in the discussion on medical ethical issues at the international level. For that, the

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10 -Yugoslav Center for Medical Ethics and the Quality of Life sponsored an international conference at the Inter-University Center in Dubrovnik in June of 1984.(7) Foregoing Treatment Every patient has a right to refuse treatment as well as to be treated in a proper way, but the law only guarantees the universal right to treatment and health care. Overall there are few old terminally ill patients who commit suicide (or attempt it) and if they do, they are put into a mental hospital. do no~ know of any case when elderly patients refused treatment (2). They usually all want to live and survive no matter how sick and old they might be (4). If somebody expresses the wish to die, it is usually seen as a temporary thing or as a resul~ of depression and treatment is always continued. In a severe case, the patient would be transferred to a psychiatric hospital (5,6). But if a patient is fully conscious and refuses any treatment, the physician won't interfere. know of one case when the patient refused all treatments and insisted to die at home. He was sent home and died there without further interference by the physician (4). However usually the physician tries to persuade the patient who refuses treatment or wants to go home, so that he will stay. There are very few of such patients. (4) we only know of one terminally ill patient who tried to commit suicide. These cases are very rare (5,6). In general, suicide is not allowed or accepted as a proper solution. Neither providing means or passive assistance in suicidal actions nor active help is allowed for the physician or any other caregiver (4).

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-11 -INCOMPETENCE In case the patient is incompetent (unconscious or has a guardian) to decide for himself, the decision will be made by the physician in accordance with family members and relatives (2,4,5,6). If a patient seems to be mentally disturbed, he will be observed over a longer period of time until a decision is made as to whether he is able to anticipate the consequences of his actions (4,5). The assessment of disturbance is usually based on a ftcommon sense judgment" and not scientifically tested (4). If the patient has lost consciousness the physicianusually consults and informs the family, and then decides on further action. Family members as well as other care givers are not in a strong position to influence the decision however. Also guardian& are rarely involved in the decision making process (4). Living wills or other advance directives do not exist and there are rarely problems with the decision making process in case of incompetence, e.g. courts are never involved (2). There have been some cases of expression of advance directives, but the final decision depends on the physician with regard to diagnosis, chances of survival and availability of further treatment (4,5). The matter was also already discussed on public television (5,6). It seems that the situation in homes fo~ the elderly is more humane" than in hospitals, since the physician can decide not to send the patient to an intensive care unit of the hospital, but to let him die with dignityw in his environment if he has expressed that wish (5,6). Sometimes if the family members insist on taking the patient home, even if he is in critical condition, but has a 5 to

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12 101 chance of recovery, the physician would try to persuade the family to leave him in the hospital or to take him home on their own responsibility (4). s Overall it can be said that the patient has an "unwritten" right to die as long as he can decide for himself and as long as he expresses that wish seriously. The same situation is possible with the members of the Jehova's Witnesses. If they present a written statement that they will not accept blood transfusions, this will be accepted. However in case of emergency and without such statement it would not be accepted (4). Liability for Decisions There are no cases in Yugoslavia when the government prosecuted a physician for homicide (2,4,5) and only in very few cases courts were involved in law suits against physicians in general. In most of these cases when patients or family members sue their physician for malpractice, it was because of wrong or inappropriate treatment, but never because of omitted treatment (4). The new law will also help to clarify situations like that (2). only know of one case within the last two years when a physician was sued for malpractice, but the court decided that the treatment he gave was correct" (2). One reason for rare law suits might be the fact that patients as well as family members can not sue \heir physician for money, but only for punishment of the offender (e.g., the physician loses his license) (2,4). Ultimately the physician takes the responsibility for treatment decisions. Unlike in other countries, nurses have considerable responsibility for patient care but if something goes wrong, it is the physician

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-13 -or the hospital which is liable. Ethics committees are established in hospitals and they regulate the selection of patients for crgan transplantation, but in general, their main task is to serve as a commission for research projects (2,4). Influence of religion Muslims (in the south) and Christians (in the north) are the two main religious groups in Yugoslavia. A small group of Jehovah's Witnesses is also found. With regard to that matter, religion has no direct influence beyond the general value statements of the church but there has not been any official statement by any of these groups (2,4,5). Technical Issues Related to the critically or Terminally r11 Elderly Dialysis as well as kidney transplants are covered by the health insurance system, and there are enough machines available for everybody who needs them (2). However, some areas are not as highly developed as Slovenia (4). Kidney transplants are relatively rare and until recently patients were sent abroad for the operation. In 1986 a donor system was introduced which allows the removal of organs from dead people, rather than relying solely on live donors (usually relatives of the patient) (5). All physicians agreed that age is an important factor in allocation of kidney transplants, but it is not a deciding one. More for medical reasons, the age limit for transplantation is about 60-65 years.

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14 -Borne dialysis machines are very rare. In Slovenia there are only two machines available. Right now also no specific interest or priority exists to make them more popular (6). The treatment of endstage renal disea~e has generated heated debates since 1974 when chronic hemodialysis was introduced on a limited basis. (7) Nutritional Support and Hydration are considered as minimum and very basic treatment. It is not permitted to withdraw them in any case, but there is no specific legal base for this. Especially since the physician is also not obliged to continue maximum treatment. Theoretically the physician could decide to withdraw nutritional support and hydration, but it is almost never done. As long as there is no legal regulation, it is still with the physician that the decision rests (4). Elderly as well as young patients are treated the same according to their needs. Withholding treatment is not a common practice. Resuscitation. Written DNR orders are not used in the hospital (2,4,5,6). Nursing homes usually do not have the equipment to resuscitate although heart massage is performed (5,6). In some cases resuscitation is not likely to be applied, e.g. metastatic cancer patients (2,4,5,6), cardiac patients with several rehospitalizations (4). Age is not considered a deciding actor, instead the diagnosis and the general condition of the patient is more important (2,4,5,6). If the physician knows a patient and his history very well, and he and his colleagues agree that resuscitation is not

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15 -appropriate anymore, an R is sometimes marked on the patient's chart (4). But if the physician does not know the patient, resuscitation is always performed even if the patient is very old (4). Elderly patients are commonly resuscitated (4,5,6), and in general it is recognized that more technical difficulties are involved (5,6). Failure to resuscitate does not lead to civil or criminal proceedings since family members rarely question the physician's decision (2,4,5,6). But since the family members have the right to sue foi malpractice, it may be that in the future family members will become more sensitive and aware of that possibility (4). On the other side, it is m~re likely to be criticized by colleges (4). Ventilation: Mechanical ventilation is widely available in hospitals, but not in nursing or private homes (2,4,5,6). It is done primarily in intensive care units and one center in Slovenia specializes in long term ventilation of patients with neurological or severe internal diseases (2,4,5,6). Some of these patients are ventilated for 2 to 3 years (5,6). Once applied, ventilation is never withdrawn and usually it is easier to withhold it in the first place which is decided by a team of physicians (4). Financial aspects never influence the decision only the medical needs of the patient (4,5,6). One reason for that might be that there is not a high demand for ventilation machines anyway ( 4)

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16 -Antibiotics: All physicians agreed that infections are a common cause of mortality and that in general terminally ill elderly are treated as aggressively as other patients (2,4,5,6). If they are treated less or with smaller doses, it is always due to their limited renal function (4). Differences in the use of antibiotics can be found on several levels. There are differences between hospitals and homes for the elderly in so far as different levels of training and knowledge of the physicians have to be taken into account as well as the greater variety of antibiotics available in hospitals (4,5,6). On the othr hand, gen~ral physicians seem to prescribe antibiotics much more frequently than hospitals which might be due to the reasons mentioned above (4). Doctors do not profit from giving prescriptions (4,5,6) but it is relatively frequent that they are pressured by their patients to prescribe antibiotics. Not infrequently, the drug the patient asks for will be prescribed, if. it can be justified, even though it may be the less appropriate choice (4). ff

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17 -REFERENCES (1) Ivan Pusnik, vice consul in Munich, (2) Dr. Dinko Leskovsek, President Deputy, Republic Committee for Health & Social Welfare, Ljubljana, (3) Georgievski, N. and Odovicic, B. Trends in Health Legislation in Yugoslavia, in Health Legislation in Europe, WHO Regional Office for Europe, Copenhagen, 1984. (4) Doc. Dr. Dusan Kleber, Director of the Slovenian Institute for Gerontology, Ljubljana, (5) Dr. Cec Alenka, Institute for Gerontology, Ljubljana, (6) Dr. Vincenc Logar, General physician at a home for the elderly, Ljubljana. (7) Lang, s., Woolhandler, St., Bantic, z. and Himmelstein, D. u. Yugoslavia: Equity and Imported Ethical Dilemmas in The Hastings Center Report, December, 1984.


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