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  1. Clinical Ethics, Patient Rights
  2. Patient Specific Medical Decision Making
  3. End of Life
  4. Communication and Privacy
  5. Corporate Integrity

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1. Clinical Ethics, Patient Rights


2. Patient Specific Medical Decision Making

  • Determination of Death by Neurologic Criteria (M-22)
    • Defines neurological death and the necessity of confirmation by a second licensed physician.
  • Employee-Patient relationships (I-73)
    • Outlines LLUMC’s purpose to build a cordial and helpful relationship between LLUMC employees and the patients we serve is an essential part of our healing ministry. Our helpfulness may be diminished, however, if the relationship extends beyond the established and historic parameters of the professional setting.
  • Living Donor Transplant (M-1)
    • Discusses the kidney donor team composition, informed consents, the donor selection process, the altruistic living kidney donor selection process, the process of ABO verification, post-donation follow-up, and independent living donor advocates.
  • Organ/Tissue Donation From Patients Determined Deceased By Neurologic Criteria (Q-10)
    • Discusses documentation and continuation of organ support.
  • Pain Management (M-140)
    • To provide interdisciplinary direction to all staff members involved in the care of patients experiencing pain.
  • Patients Suspected or Determined to be a Danger to Self or Others (M-47)
    • Defines patient management for a patient who is a danger to self or others.
  • Pregnancy Termination Guidelines (M-141)
    • Follows the SDA Church’s “guidelines on abortion,” which does not condone abortions for reasons of birth control, gender selection, or convenience. Exceptional circumstances include significant threats to the pregnant woman’s life or health, pregnancy resulting from rape or incest, and severe congenital defects that will result in demise or minimum cognitive potential. Caregivers can be excused from care based on conscience.
  • Sterilization Consent Requirements (M-18)
    • This policy applies to human reproductive sterilization, which is defined as any medical treatment, procedure, or operation, for the purpose of rendering a person permanently incapable of reproducing.


3. End of Life Care

  • Deaths Reportable to Coroner (Q-20)
    • This policy specifies the types of patient deaths and circumstances when a death may be reported to the coroner in order to comply with California Government Code 27491 and Health and Safety Code 102850.
  • Information and Counseling for Terminal Illness (M-139)
    • Addresses information counseling for terminal illness, including conversations about goals/values, palliative medicine consult, and information on end-of-life options.
  • Organ/Tissue Donation After Cardiac Death (Q-25)
    • Criteria for donor eligibility: 1) patient has devastating, irreversible, neurological injury that does not meet brain death criteria. 2) Legal next of kin has made decision to withdraw life support. 3) Cardio-respiratory death will likely occur within one hour following withdrawal of life support. 4) Current inpatient at LLUMC. 5) If patient is a transfer, must meet other listed criteria.
  • Physician Aid in Dying (P-24)
    • LLUMC does not participate in Physician Aid in Dying. Patients shall be informed of this policy and may be given information about their options if they make a request of Physician Aid in Dying. A referral will be provided if a terminally ill patient continues to request.
  • Palliative Sedation (M-132)
    • Outlines the criteria for use of palliative sedation and implementation guidelines.​


4. Communication/Privacy


5. Corporate Integrity

  • Chain of Command for Physician Contacts/differences in Professional Opinion (M-4)
    • Describes the chain of command for differences in professional opinion.
  • Charity Care/Discount Payment (C-22)
    • The purpose of this policy is to define the criteria which will be used by Loma Linda University Medical facilities to comply with the requirements of the California Hospital Fair Pricing Policies Act.
  • Conflict/Duality of Interest (A-6)
    • Provides guidance to employees in avoiding situations in their personal activities which are, or appear to be, in conflict with their responsibilities to LLUMC.
  • Disclosure of Information to Fiscal Intermediary (C-42)
    • Describes protocol by which LLUMC shall disclose to the fiscal intermediary all information to which it is entitled under the Medicare Program disclosure requirements, as well as any other information that may be useful to facilitate finalization of the Medicare cost report.
  • Drug Testing (I-59)
    • LLUMC has instituted a drug testing program for all applicants for employment. Employees are tested only when appropriate, as determined solely by LLUMC.
  • Gift Acceptance (A-21)
    • The purpose of the Gift Acceptance Policy is to provide guidance to the LLUMC community and the general public so as to facilitate the gift-giving process, in accordance with a Board-approved set of standards governing the negotiation and acceptance of gifts for LLUMC.
  • Gifts/Sponsorship (I-18)
    • This policy is intended to address a broad range of situations that may arise between patients, visitors and/or vendors and LLUMC personnel, questions may arise about certain situations that do not appear to be covered by this policy or any other relevant LLUMC policy.
  • Illegal Remuneration and Inducements (C-37)
    • In keeping with federal statute, payment schemes that involve the exchange of money or referrals or any other benefits shall be prohibited.
  • Interactions With Vendors (I-96)
    • The purpose of this policy is to establish guidelines for interactions of Loma Linda University Medical Center (LLUMC) personnel with vendor representatives.
  • Organizational Ethics (A-37)
    • Outlines five values of LLU: compassion, integrity, excellence, teamwork, and wholeness.
  • Student Learning Experience and Observation Requests (I-85)
    • Outlines the limitations and issues surrounding the presence and privileges of students in medically sensitive patient interactions.