Click one of the categories below to jump to that section on this page:
- Clinical Ethics, Patient Rights
- Patient Specific Medical Decision Making
- End of Life
- Communication and Privacy
- Corporate Integrity
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1. Clinical Ethics, Patient Rights
Outlines the order of authority for consent to treat a minor: parent, legal guardian, qualified adult relative, other third party. Lists special circumstances.
Clinical Ethics Consultations (M-138)
Provides assistance to anyone (without retaliation) involved in a patient’s care in the identification, analysis, and resolution of ethical dilemmas. This is not to be used as a means to resolve interpersonal conflict or peer review.
Discusses the patient’s right to formulate an advance directive, name an agent with legal authority regarding health care matters, and others.Describes the chain of command for differences in professional opinion.
Discusses varying degrees of emerging autonomy to embrace the principle of shared decision-making based on best interest of pediatric patient.
- Custody of Newborn (Safe Surrender/Safe Haven) (M-122)
- Outlines the protocol by which the Emergency Department (ED) shall be the department in LLUMC at which a parent or legal guardian may voluntarily surrender an infant within 72 hours of birth and steps to be taken by ED personnel in such a circumstance.
Outlines the criteria for emergency consent.
Employees with concerns regarding aspects of care in conflict with cultural values, ethics, or religious beliefs should put it in writing to their department head/designee. Department head will discuss alternatives including transfer of care.
Describes process for making ethically and medically appropriate treatment decisions on behalf of persons who lack health care decision-making capacity and for whom there is no surrogate decision maker.
Human Studies (Q-4)
Outlines IRB role and regulations in conducting human studies. Includes informed consent, adverse event reporting, periodic reports, and budget.
- Illegal Drug Possessions/Use by Patients (M-112)
- Describes policy by which Illegal drug possession/use by patients shall be prohibited, regardless of claims of prescriptive/therapeutic use.
Protocol by which Home care services departments shall report, review, and resolve ethical issues and conflict in care decisions.
Patient Consent (P-2)
Outlines procedure of obtaining consent as well as different modes of consent, including surrogacy, conservator.
Discusses the rights of patients and the rights of staff and proper legal protocol when a patient chooses to leave AMA.
Outlines the rights and responsibilities of patients.
Discusses right of competent patients to make medical decisions regarding withholding or withdrawing of life sustaining treatment.
- Police Cases - Rights of Patients and Responsibilities of Personnel (M-13)
- Describes the protocol for responding to police contact with patients.
- Victims of Dependent Adult/Elder Abuse/Exploitation (M-75)
- Definitions and protocol when dealing with suspected or confirmed instances of abuse and exploitation noticed by any LLUMC personal.
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 Kidney Donation (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 or Gravely Disabled (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.
- Communication with Patients who have Limited English Proficiency and/or are Hearing, Speech or Vision Impaired (M-113)
- Discusses the necessary provisions to be undertaken to ensure adequate patient care.
- Communication With Patients Following an Unexpected Outcome, Adverse Event, or Medical Error (P-20)
- When there is an unexpected clinical outcome, adverse event or error in the delivery of medical care, we believe that there is an even greater obligation for timely communication with the patient and/or the patient’s family.
- Conflict Resolution Regarding Patient Care (P-12)
- Conflict resolution between patients/families and their physicians should be resolved with a thorough discussion among involved parties in a reasonable time period (usually within same day). Unresolved conflicts can then be discussed with Ethics Chair and Committee. Final authority rests with CEO.
- Correction of Mistaken Entries and Omissions in the Medical Record (D-12)
- Outlines the required steps and responsibilities in the correction of medical mistakes within a patient’s record by the responsible party.
- Disposal and Destruction of Confidential Media (G-34)
- Includes the disposal and destruction of paper waste, non-paper waste, and electronic media which includes confidential information.
- Protection of Patient Privacy (P-16)
- Computer and workstation rules of conduct regarding patient information security.
- Use of Patient Information for Fundraising Purposes (E-16)
- The purpose of this policy is to provide guidance to Loma Linda University Medical Center (LLUMC) workforce members on the use of patient information for fundraising purposes. This policy also outlines the proper procedures to follow when a patient opts out of receiving fundraising communications.
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.
- Financial Assistance (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.
- Sabbath Environment (A-17)
- Guidelines on Sabbath observance for employees, students, faculty, and visitors at LLUMC.
- 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.