The Ministry of Health has made transparent a draft order that modifies the rules regarding access to the medical documents of deceased patients who were unable to give their consent while hospitalized. The change comes to clarify the procedure by which dependents or heirs can obtain the information. Patient association representatives say things are in a gray area at the moment, and hospitals can decide whether or not to provide the data based on how they interpret the law.
What is happening at the moment
“There are cases when patients end up in the hospital from a car accident or with some form of neurological pathology (such as Alzheimer’s, dementia), when they cannot give consent and do not sign, and somehow it remains up in the air whether or not medical institutions can disclose information without presumed consent.” explains Radu Gănescu, president of the Coalition of Chronic Illness Patient Organizations.
Currently, the rules state that, if the patient has not been able to express his consent and death has occurred, confidential medical information can be provided to family members or legal heirs, under the law:
“In the situation where the patient was unable to express his consent provided for in paragraph (2) and his death occurred, the confidential information from the observation sheet, the consultation sheet, the patient sheet and those regarding the patient’s condition, the results of the investigations, the diagnosis, the prognosis and the treatment can be provided to the family members or the legal heirs, under the law.”
However, the wording generated different interpretations in practice, shows the representative of the patients:
“What I can tell you from the information I received from patients’ families is that it was often very bureaucratic and absolutely impossible to get that kind of data, with each medical institution applying according to how they interpreted the law to release that data. Even though a request was made from the family, it didn’t mean that every time they got the information.”
The problematic situations arose in cases of life insurance or suspected malpractice, when medical documents were needed for legal proceedings, says Radu Gănescu.
“There are cases when you end up in a car accident or when you end up with some form of neurological pathology (like Alzheimer’s, dementia) where the patient can’t give consent and sign, and it’s kind of up in the air whether or not medical facilities can release information without presumed consent.”
What changes the order placed in transparency
The proposed amendment introduces the phrase “on request” instead of “under the law”, comes with the condition of the heir certificate and establishes the obligation of all medical service providers who have provided care to the patient to make available the relevant documents.
“In the situation where the patient was unable to express his consent (…) and his death occurred, the confidential data from the observation sheet / consultation sheet / patient sheet, information on the patient’s condition, the results of investigations, diagnosis, prognosis, treatment, personal data are provided, upon request, based on the heir’s quality certificate, by all the medical service providers who provided care to the patient.”
“To reduce the bureaucracy and to be able to make the law uninterpretable from one medical unit to another — because, in fact, we have this problem in Romania, everyone interprets the legislation in a certain way — I don’t think a clarification is a bad thing.” says Radu Gănescu.
The ministerial order proposing the changes is now in decisional transparency.
