By Adriana Krasniansky
On March 5, 2019, a terminally ill patient from Fremont, California, learned that he was expected to die within several days. The doctor who delivered the news did so via a robotic video teleconferencing device.
Ernest Quintana, a 79-year-old patient with a previously-diagnosed terminal lung condition, was taken to the Kaiser Permanente Fremont Medical Center emergency room after reporting shortness of breath. His 16-year-old granddaughter, Annalisia Wilharm, was with him when a nurse stopped by and said that a doctor would visit shortly to deliver Mr. Quintana’s results.
The video below, recorded by Ms. Wilharm, shows Mr. Quintana’s consultation with a critical care doctor through an Ava Robotics telepresence device—in which the doctor explains Mr. Quintana’s rapidly worsening condition and suggests transitioning to comfort care. Ms. Wilharm and her family chose to share the video with local media and on Facebook, inciting a debate around the legal and ethical challenges of using telemedicine in critical care conversations.
Telepresence in the hospital room
Mr. Quintana’s experience is part of a larger change happening within hospital communication.
Telemedicine, defined as the practice of caring for a patient through technology when the provider and patient are not physically with each other, isn’t a new concept in health care. Doctors offered medical consultations through telegraphs as early as the Civil War, and phone lines such as the Poison Control Center have provided care management directly to individuals since 1953. Traditionally, telemedicine was only recommended when a geographic barrier or urgent situation prevented an in-person consultation.
Today, widespread internet access and adoption offers the scale necessary for telemedicine to broach another important barrier—affordability. High-quality video conferencing gives clinicians the ability to hold real-time conversations with patients remotely, transmitting video, text, and even biometric data. Telemedicine improves access to care while reducing operational costs, such as specialist staffing at hospitals. When used in concert with in-person care, telemedicine creates hybrid hospital environments such as the unit where Mr. Quintana was treated.
The chances of a hospital patient encountering hybrid hospital care are rapidly increasing. In 2017, an estimated 76% of U.S. hospitals used telemedicine in some capacity, and the American Hospital Association has publicly supported expanding telehealth services within the American hospital system. However, patients aren’t always aware when they are entering a hybrid hospital environment; even if informed consent is granted, in units such as emergency rooms, it may be done so under considerable duress.
For routine patients with common medical needs, hospital telemedicine is usually met with little resistance. Yet, for certain patients, such as the elderly or those with disabilities, telemedicine can add an unexpected and unnecessary emotional burden to hospital communication and patient-doctor relationships. In cases such as Mr. Quintana’s, this burden can be vastly magnified when bad news or sensitive information is expressed.
Laws, regulations, and what’s missing
Contemporary telemedicine law tends to focus on two concerns: minimizing the risk of fraud or abuse and protecting patient privacy. Every state allows physicians to establish new relationships with patients through telemedicine, though states have varying restrictions regarding provider credentialing, appropriate medical contexts, and acceptable channels of communication. Additional restrictions affect HIPAA compliance, Medicaid and Medicare reimbursement, and cross-state licensing.
The American Medical Association maintains that a patient-provider relationship should be established prior to a telemedical consultation but explicitly identifies on-call environments like hospitals as exceptions. Hospitals and health care networks often establish their own best practice guidelines for telemedicine. It was reported that Mr. Quintana’s hospital required a staff member to be present during a telemedicine consultation to offer secondary support—a service allegedly not offered to Mr. Quintana. Further, it is unclear the extent to which Mr. Quintana was informed of the possibility of receiving a telemedical consultation and whether or not he demonstrated comprehension and consent.
The nuances of a doctor-patient-machine relationship
Mr. Quintana’s family explained that their concerns were related to the sensitivity of the information communicated, not to telemedicine generally. “If you’re coming to tell us normal news, that’s fine,” said Mr. Quintana’s daughter, Catherine, “but if you’re coming to tell us there’s no lung left and we want to put you on a morphine drip until you die, it should be done by a human being and not a machine.”
Mr. Quintana’s case helps us think about the standard of care when devices serve as clinical intermediaries. Physicians are understood to owe certain duties to their patients, such as providing medical treatment to their full skill and knowledge and considering patient interests. Mr. Quintana’s doctor presumably provided his assessment and recommendation using the full extent of his knowledge and skillset. There still exists the question of whether (in the case of sensitive information such as Mr. Quintana’s prognosis) doing so through a telemedical channel violated the patient’s emotional interests and vulnerability.
More colloquially, we might compare Mr. Quintana’s experience to that of “poor bedside manner.” While insensitive bedside manner itself is not a breach of doctor-patient duties, it can affect patients’ perception of their quality of care. This disparity has been suggested to impact everything from patients’ likelihood of filing malpractice lawsuits to complicating a full recovery. Is using telemedicine in certain situations “insensitive” and, if so, how should insensitivity be regulated or addressed?
How do we weigh the pros and cons? Telemedicine provides clear benefits to our health care system: it cuts operating costs, democratizes access to care, and helps physicians extend their reach with reduced chances of burnout. But telemedicine also comes with its own particular drawback— the propensity to create even more emotional distance between a patient and doctor, especially if the two do not have an established rapport.
For now, it’s up to hospital networks and the doctors on their frontlines to determine which conversations require higher degrees of sensitivity and address accordingly. As screens and devices expand their presence in our hospital halls, clinicians, technologists, and ethicists must be ready to work together towards responsible product, protocol, and legislative development—keeping patient health and dignity at the center of it all.