PREVIEW

Illness

Illness

Statistics

The frequency of illness was somewhat stable between 2009 and 2014. However we have seen a steady rise in the average cost of illness over the past ten years and are now seeing a sharp increase in frequency. This high frequency is a warning sign and this category must be closely monitored going forward. The ever-increasing problem for the industry in finding experienced, properly trained seafarers, is another reason for keeping a close watch on this issue, as this seems to be a problem that is here to stay. For owners, it is essential that they know that their crew members are fit and healthy before they are employed. A serious illness can cause many other issues besides the person’s own illness - the vessel can be delayed in arriving at the next port; delayed in port and there can be problems finding replacement crew. The stress this will cause on board and ashore is difficult to measure in monetary terms. To help prevent these problems the owner can promote a healthier diet, ensure there are exercise facilities on board, discourage smoking and drinking; support crew members who wish to change their lifestyle, and offer a PEME (PreEmployment Medical Examination) to their crew members before being employed.
The top 10 individual most expensive illness claims over the past 10 years were in the following claims categories:

 

 

Average claim cost and frequency
Claims 5,000–3,000,000 (USD)

Period: 2005 - 2014
Type of vessel: Bulk carriers, containers and tankers 
Type of claim: Illness
As per 5/10/2015

The above statistics show that over the last ten years the frequency and cost for claims more than USD 5,000 is increasing. 

Distribution of cost (USD) 2013-2014

Average claim cost and frequency
Claims 1–3,000,000 (USD)

Period: 2005 - 2014
Type of vessel: Bulk carriers, containers and tankers 
Type of claim: Illness
As per 5/10/2015

The frequency for claims below USD 5,000 is fluctuating and was actually falling until 2013, but then started to increase. Costs have been constantly increasing over the past ten years. 

Number of claims (USD) 2013-2014

It is interesting to note that claims in the 1-5,000 interval have fallen, but those in the 5,000-50,000 interval have risen. Costs have risen in every category. The reason for this might be because of increased medical cost and older crew, which need more medical assistance.

 

Illness claims

The most common illness for all three types of vessel is cardiovascular disease (or coronary heart disease), which is also the most costly. The crew cannot do much while on board to prevent illness from happening apart from focussing on a healthy diet and exercise. It is very traumatising and complicated for the entire crew to deal with seriously ill crew members on board. The importance of ensuring that the crew members are healthy before joining the vessel is the best prevention and for the company to support and actively try to encourage healthy living and exercise. One of the main causes of coronary heart disease is high serum cholesterol levels, which increase in men at around 45 to 50 years of age, and is very hard to prevent. This means that crew members over 45 years old run a greater risk of suffering from cardiovascular disease. This, coupled with a predicted shortage of officers in the near future, could lead to an increase in cardiovascular disease statistics as older officers will continue to serve on board due to the difficulty of finding replacements. It is important that shipowners are aware of the risk factors that can cause heart disease and stroke, which include raised blood pressure, high cholesterol and glucose levels, inadequate intake of fruit and vegetables, overweight, obesity, smoking and physical inactivity. Addressing these issues is essential.

 


 

Case studies

First case study
The crew member had smoked for around 40 years and had a valid health certificate. While he was working on board he suffered a heart attack and was rushed to hospital. In the days prior to this he had experienced shortness of breath and a rapid heart rate. At the hospital he was found to have respiratory failure and required mechanical ventilation, he had little if any respiratory reserve. The cause was diagnosed to be Chronic Obstructive Pulmonary Disease (COPD). This means that the airways become narrowed, limiting the flow of air from the lungs. The most common cause is from smoking. After a couple of weeks he was finally allowed to leave hospital and fly home to his native country to rest and receive further treatment. Unfortunately he was found dead in his home a couple of weeks later. 

Causes:
Heavy smoking for several years. The health certificate did not identify any concerns and questions must be raised as to whether a normal health certificate is sufficient for
determining a crewmember’s health. If health certificates are not treated seriously by doctors, it could lead to severe consequences, as in this case.

Second case study
A crew member suffered a stroke on board the vessel and was repatriated by helicopter to the nearest hospital. At the hospital he was surgically treated for three aneurisms. In addition, he suffered a complication after surgery resulting in another operation and a prolonged stay in intensive care for one month. He was finally discharged and repatriated under escort to his native country where he was immediately transferred to a specialist clinic, where intensive physical therapy was arranged. The crew member will not be fit for duty after the end of the treatment.

Causes:
The advice stated that a cerebral aneurism can be present from birth, but can also be caused by hypertension, which the crew member had apparently been suffering from and which had been disclosed during the Pre-Engagement Medical Examination (PEME) when he was declared fit for duty.

Third case study
The vessel was forced to deviate as the Master was suffering from severe abdominal pain and cramps and needed hospitalisation. When arriving at hospital he was diagnosed as suffering from diverticulitis with bowel obstruction, severe dehydration and malnutrition. The doctor at the hospital stated that the Master would have died had he spent one more day at sea. The severity of illness and the time that elapsed before definite treatment could be provided resulted in five operations and major complications. The Master was finally repatriated to his native country.

Causes:
The Master had a ten-year history of diverticulitis episodes and it was known that his present condition had commenced prior to this incident as he had seen a doctor in a previous port.

Fourth case study
The Chief Engineer was taken to hospital with heart problems and irregular blood pressure. His condition soon deteriorated and it was decided that he should be taken to a better, specialist hospital, where he was immediately taken into intensive care. It was established that he had chronic pneumonia with very high blood pressure and his lungs were in a very bad condition. After a month in intensive care his condition improved and it was decided to try to take him by air ambulance to his native country. However his condition deteriorated and the air ambulance had to be cancelled. A similar repatriation attempt failed a couple of weeks later and the Chief Engineer passed away soon thereafter. 

Causes:
The Chief Engineer was a heavy smoker. His poor lung capacity had not been identified when his health certificate was issued.

 

PEME (Pre-Engagement Medical Examination)

To prevent illness and ensure that the crew is fit and healthy, the normal medical examination seems inadequate. It can take years of unhealthy living for a serious illness to develop as a consequence, and this is also true for many other illnesses that are not obvious in the early stages.. If the warning signs can be identified and preventative measures taken at an early stage, it is likely that this could prevent a lot of suffering and even premature death. To this end, the Club has developed its own PEME, which is much more comprehensive than the medical examination normally required. Two clinics in the Philippines are currently approved to carry out PEME examinations on behalf of the Club. If the
PEME is followed correctly a serious illness is more likely to be discovered. The number of claims caused by illnesses, which could and should have been detected in thoroughly conducted PEMEs, has increased substantially, both in number and cost. The best hope of reversing the increase in illness is to develop much wider recognition of the problem by the company’s management, coupled with more emphasis on thorough PEMEs.

 

Illness – how to treat crew members

Respect for a seafarer’s personal decision, in relation to recommended medical treatment, is paramount in handling cases involving personal injury or illness. There is always a balance between maintaining respect for a decision made by an adult of sound mind (possibly based on religious or cultural determination) and the
recommendation given by a medical expert. The objective of the Club in a situation like this is to ensure that the seafarer makes an informed decision and, if required, obtains the advice of several experienced medical experts enabling him to do so. There is also the question of what constitutes a sound mind and whether the information on which the seafarer’s decision is to be
made is fully recognised. It becomes particularly difficult if family members who do not have access to the same information put pressure on the member. Usually, any situation can be resolved by reasoning and close cooperation between the parties involved, including the seafarer, the member, the family, the treating physician and the Club. In most cases, where this delicate issue arises, the Club will utilise the network of medical experts available, to make certain that the seafarer is fully informed of the consequences any decision he may make e.g. to refuse treatment. While in the first
instance the Club respects the decision of the seafarer, at this stage it may be necessary for the Club to protect the member’s interests by obtaining a declaration from the seafarer, in which he confirms that he is fully aware of the risks he is assuming by making a decision that
is against expert medical advice and recommendations given, and further that he releases the member from any liability regarding the consequences of his decision.

 

Prevention

Illness claims are somewhat different in nature to injury and cargo claims. To prevent illness it is essential that the company has established preventative measures, before the crew member joins the vessel, and that the company promotes healthy living on their vessels. It is also very important to have comprehensive new-hire procedures, to ensure that the new crew member is healthy. It is unfortunate that the normal health certificate appears to be insufficient and the Club believes that a more extensive health certificate is required. The best prevention is to carry out a PEME. Of course there is also a need for procedures that ensure that all the crew in the company are healthy. Illness can strike at any time but by trying to identify problem areas and risks before they occur is good loss prevention and minimises the exposure in this respect. 
• If possible complete a PEME on the crew member 
• Promote healthy food and diet on board the vessel 
• Help crew members to stop smoking
• Ensure alcohol consumption is limited
• Promote both physical activity on board and when home on vacation 
• Have a functional gym on board the vessel

 

Why PEME?

The following is an extract from a bachelor thesis by Marcus Waserbrot at Chalmers University regarding Pre-Engagement Medical Examination (PEME). From this thesis we can see that having a PEME will save cost and prevent illnesses. The thesis compared regular government required medical examinations in the Philippines compared with The Swedish Club’s PEME carried out at two approved clinics in the Philippines. In one case a crew member suffered from unspecified intestinal obstruction along with other conditions such as dehydration and hypertension and was air lifted from the vessel. The doctor stated that it was likely that the crew member would have died if he had stayed one more day on the vessel. Furthermore the doctor believed that a thorough PEME would have found that the crew member had a serious medical condition. As a result, the claim’s total cost arose to approximately USD 600,000. 

 

 

Most common medical conditions for not complying with PEME 
Limit: USD claims 1 - uncapped 

Period: 2011-2014
Type of vessel: All vessel types
Type of claim: Illness

Not complying with TSC PEME but would pass a government required medical examination
Limit: USD claims 1 - uncapped

Period: 2011-2014
Type of vessel: All vessel types
Type of claim: Illness

 The graph above describe the most common conditions that would not be in compliance with The Swedish Club’s PEME, but which would have passed a government required medical examination. The most common conditions are gallstones followed by kidney conditions and diabetes.

 

 

 

From the graph to the left, the most common reasons for not being in compliance with The Swedish Club’s PEME is related to gallstone or gall polyps and kidney conditions such as kidney stones or kidney disease. The third most common reason, called other, includes various types of medical conditions with low frequency that could not be categorised in remaining categories. In this case, cardiovascular disease could be seen as the second largest category if it would be combined with hypertension, which also is a condition of the cardiovascular system. Furthermore, claims related to conditions of the cardiovascular are the claim category with the highest frequency for illness claims, which also has a higher average claim cost at USD 47,115 in relation to other illness claim categories.

 

 

 

 

 

 

 

Not complying with TSC PEME but would pass a government required medical examination
Limit: USD claims 1 - uncapped

Period: 2011-2014
Type of vessel: All vessel types
Type of claim: Illness

 The graph above shows claim cost avoided and the cost for PEME. The claim cost avoided is the cost saved because PEME would have detected the medical condition and the government examination would not. The calculation is the following, Claim costs avoided more than = USD 1,550,000 Extra costs for PEME is about = USD 300,000 (this is the extra cost for the PEME compared to the government examination) Total cost benefit for the period 2011-2014 = 1,550,000 – 300,000 = USD 1,250,000

As a result, the avoided claims costs are greater than the increased PEME costs. In addition, the total avoided deductible is greater than the increased PEME cost, which means that the enhanced PEME has a direct cost beneficial impact to the member alone. This once again emphasizes the importance and benefit of having PEME.

 

Medical confidentiality, consent and disclosure

Nigel Griffiths

 All the classic codes of medical practice imply some qualification of an absolute duty of professional secrecy, that medical matters disclosed in confidence, should not be disclosed generally. Depending on the country in which the seafarer is hospitalised, jurisdictional issues surface as to how confidentiality is addressed. A general common law duty is imposed on a doctor to respect the confidences of his patient. 

 In an age of computerisation, progression of medical information to be regarded as ‘data,’ subjects it to data laws. Further, disclosure may be seen as breaching the ‘right to respect for private life’ as contained in, for example Article 8 of the European Convention on Human Rights. 

 Specific statutes exists in many countries whose laws have originated from the Napoleonic Code (France, Benelux, etc.), and there, medical information is treated as sacrosanct by the medical professional with an almost absolute imperative on non-disclosure. It is in these countries that clubs perhaps encounter the most resistance to disclosure and have the most difficulty in establishing what is wrong with the seafarer and his clinical management. 

 There are three exceptions, so let us look at the exceptions to the rule and how confidentiality can be addressed in the context of the hospitalised seafarer. 

 1. Clearly, if a seafarer has given his consent to disclosure of medical information then it is reasonable for such information to be passed on. The first instrument in obtaining the consent to release is to request that the patient himself (if he is able, or the next of kin if not) signs a declaration that he has no objection to the passing of information to specified parties, which may include the correspondent, ship owner, club or their medical adviser. With this release, a copy retained by the patient, a second by the hospital and the third by the agent, medical information may be forthcoming. However, in some instances, even though the consent to disclosure is obtained, that hospital may well be reluctant to pass on the information to non-professionals and it is at this juncture that clubs should appoint their medical advisers to intercede on their behalf. This is especially so in the jurisdictions mentioned, if the patient is extremely ill (when the concern is that an agent would be unable to handle the information), if the information is sensitive, and even more so if it involves a diagnosis such as HIV or AIDS.

 2. Sharing of information with others providing care, or for the continuation of care. It is generally accepted that medical information will need to be passed to those organising ongoing or follow-up care in the patient’s own country, or those associated with organising the seafarer’s repatriation to his homeland. Whilst treating doctors may obtain consent to disclose from the patient directly if possible, inter-disciplinary dialogue is seen as appropriate and necessary for the continuity of care. In the UK the General Medial Council recognises this in permitting the sharing of information with other practitioners who assume responsibility for clinical management of the patient, and to the extent that the doctor deems it necessary for the performance of their particular duties, with other care professionals who are collaborating with the doctor in his patient’s management. 

 3. Other reasons for disclosure:
• When communicable/infectious diseases are diagnosed in accordance with public health law, including mandatory reporting
• On the direction of a Judge for judicial proceedings
• When direct identifiable threat to life or serious harm is made evident to medical professionals by mentally ill patients 

 There are cases when the patient refuses medical treatment. It could be that a foot has to be amputated for the well-being of the patient but that the patient refuses. If emergency surgery or other life-saving treatment is required, every attempt should be made to reason with the patient and obtain the proper consent in writing. There will be times when consent cannot be obtained, for example when the patient is unconscious. In such instances the doctor is bound to follow the best interest factor in determining treatment, from which a substituted judgment must serve as the basis of consent. The weight of the family’s opinion, whilst valuable, if they are thousands of miles away may not be sufficiently informed to override the best interest. 

 If a seafarer refuses to follow medical advice, it is very important that this is documented and is brought to the member’s/ Club’s attention immediately. If seafarers request an alternative treatment to that recommended by the doctor, this should be carefully considered and brought to the Club’s attention. Terms of treatment, whilst not wishing to encroach on the patient’s autonomy, treatment must also be in keeping with terms of the Club for reimbursement to the member. Generally speaking, a patient should be stabilised in the port of incident and treated in his own country for ongoing care and not long term in the port of incident.

 Unnecessary and costly investigations should also be avoided, and doctors reassured that stabilisation is their goal and not long-term care. The Club has excellent advice regarding suitable facilities in the countries that seafarers come from, and if facilities are not available there then alternative arrangements can be made.

Conclusion

It is prudent to have consent to release documents to be signed by the patient (or next of kin) in the first instance, and if difficulty is still encountered, then the Club’s medical adviser should be appointed, to obtain the necessary information and handle in accordance with his own professional code of ethics. 

• Obtain the consent to release information about the patient himself (or the next of kin if he is not able).
• The patient signs a declaration that he has no objection to the passing of information to specified parties, which may include the correspondent, shipowner, the Club or their medical advisor.
• If a seafarer refuses to follow medical advice, it is very important that this is documented and is brought to the member’s/ Club’s attention immediately.
• If seafarers request an alternative treatment to that recommended by the doctor, this should be carefully considered and brought to the Club’s attention.
• Treatment must also be in keeping with terms of the Club for reimbursement to the member. Generally speaking, a patient should be stabilised in the port of incident and treated in his own country for ongoing care and not long term in the port of incident.
• Unnecessary and costly investigations should also be avoided, and doctors reassured that stabilisation is their goal and not long-term care.

 

Fit to fly? - Promissory notes and other fictious stories

Nigel Griffiths
Marine Advisory Medical Service
UK, Australia and Singapore               

The determination of fitness of seafarers to fly following hospitalisation, accident or illness is a point which has much been discussed and this article sets to distinguish between fact, misconception and myth.

Insurers assess the risk in what they are considering to insure and propose the terms whereby the insurance is offered. An airline (through its medical department) assesses the risk a patient presents and will accept or decline the patient for transportation

There is a common thread to both preceding sentences i.e. the organisation taking the risk is the one that sets the limits on acceptability. It is the airline’s medical department that is the final arbiter on whether someone who is sick or has been injured can fly. It is a common misconception that the treating doctor is the person that declares that a patient is fit to fly and a note, hastily scribbled by him and given to a port agent, is a green light to fly the patient home. 

The chances are that the treating doctor may well not be a specialist in aeromedicine, and have no particular training or skills in the altered physiology and affect that the flight may have on an individual compromised by illness. 

A letter of fitness to fly by a treating doctor serves no other purpose than to demonstrate that the doctor has no objection to the patient being discharged, and in his opinion can fly.

Who decides who can and cannot fly 

The opinion of the treating doctor quite often differs from doctors that work for airlines and whose job it is to determine who can and cannot fly. The process is initiated by the Medical Information Form (MEDIF).

This is a form devised by the International Air Transport Association (IATA) in the 1970s (when it was referred to as the INCAD), and serves as the basis of the questionnaire style pro-forma individualised by each airline. An example of the British Airways MEDIF can be found at: http://www.british-airways.com/cms/ global/pdfs/health/BA_Medif_Oct2012. pdf . The form is completed by the treating doctor, on which he has the opportunity of expressing his opinion regarding fitness to fly. 

This in turn is sent to the airline’s medical department, where an endorsement of fit to fly may be made or further questions asked or the need for further investigations listed. An airline may also refuse to accept a passenger if they consider the risk too great. The airlines will apply their criteria of what they consider fit to fly.

Let us look at when the MEDIF should be submitted: 

  • Acute medical condition, recent hospitalisation, recent accident or recent operation 
  • Progressive and/or unstable medical condition 
  • Inability to sit up in seat (stretcher transport required) 
  • Oxygen or other medical equipment required on board
  • Travel is for medical reasons (e.g. for special treatment abroad)
  • Passenger requires a companion to provide medical support

They may impose limits 

Once accepting the MEDIF, airlines also accept the risk associated with air travel, providing the MEDIF is honestly and fairly completed. In cases when the treating doctor is unfamiliar with the MEDIF or not prepared to complete the document, the airline is happy to accept, if the doctor of the assistance company carrying out the repatriation completes the form. 

Their acceptance or declination to the request usually follows, but they may impose limits, such as a certain number of days from surgery or heart attack for example, or a certain time period after the patient is free of symptoms, as in the case of psychiatric illness. The criteria that an airline uses in defining fitness is summed up by Cathay Pacific below.

The principle factors to consider when assessing a passenger’s fitness for air travel are: 

  • Reduced atmospheric pressure: Cabin air pressure changes occur after takeoff and before landing and lead to gas expansion and contraction which may cause pain and pressure effects. 
  • Reduction in oxygen tension: The aircraft cabin is pressurised to an equivalent of 6,000-8,000 feet and oxygen partial pressure is approximately 20% less than on ground. Healthy passengers have no problems at these altitudes, but passengers with anaemia or heart and lung conditions may be at risk and require supplemental oxygen during air travel. 
  • Inaccessibility to advanced medical care: The aircraft cabin is a closed environment where access to advanced medical care may not be possible for several hours. 

When is the risk too great that an airline would decline medical clearance? 

  • Any passenger who poses a risk to himself or other passengers aboard the aircraft. 
  • Any passenger that cannot use the seat in the upright position for take-off and landing (stretcher may be considered in some instances).
  • Any passenger suffering from a notifiable or contagious disease. 
  • Any passenger with the potential to divert an aircraft.
  • Any passenger with mental health issues presenting with (but not limited to) psychotic symptoms or disruptive or aggressive behaviour. 
  • The moribund (those who are about to die). 
  • ICU patients in which there is too great a risk for commercial transportation, and which the airline believes are more appropriate travelling on an air ambulance.

Specific criteria of fitness to fly 

Some airlines publish advice to doctors on their specific criteria of fitness to fly. Airlines may also authorise passengers to fly with a medical escort – either a doctor or nurse. The airlines can also order oxygen for patients who may require it in flight either on a continuous, or on an as needed basis. Wheelchairs are also requested on the MEDIF form and come as three options, for distance in the terminal, to the cabin of the aircraft or to the aircraft seat.

In cases of a psychiatric patient, they will usually need to be free of symptoms for at least 14 days prior to the application for medical clearance being submitted. The airline may and often does request a copy of the patient’s medical records, so they can see for themselves what behavioural problems the patient presents with and the related timeframe and response to medication. In these days of heightened security the airline may insist on more than one escort, though usually only one needs to be medical. 

  • Dismiss any suggestion by the treating doctor that a psychiatric patient must be escorted by a psychiatrist – if the patient is that sick, he is not fit to fly. An experienced psychiatric nurse is of much more value once one is sure that the patient is manageable and symptom free.
  • Stretchers were once commonplace, but nowadays an increasing number of airlines are withdrawing this service either for commercial reasons or for fear of the potential for litigation. 
  • Post-surgery the length of time will vary depending on the procedure and whether a medical escort is accompanying the patient. 
  • Illness such as anaemia will need to be corrected prior to flight and respiratory conditions carefully assessed given to pressurisation changes etc. 
  • The use of air ambulances is costly, but there is a greater option to divert in cases of deterioration and to carry a more comprehensive selection of lifesaving equipment not practical aboard a commercial aircraft.

Club Recommendation

The Club will recommend that the treating physician declares a crew member fit to be repatriated before the repatriation is arranged. Even with the knowledge that most doctors are not specialists in aeromedicine the request is made on the basis that should a doctor declare a patient/ crew member unfit for repatriation i.e. unfit to fly on medical grounds that has an undisputed impact on the handling of the case. Depending on the merits of the case we will advise our member to wait for the recommended period of time and possible medical re-evaluation or we may seek the advice of our medical experts to establish and confirm the correct position being fully aware of the fact that the deciding party in effect is the doctor working for the airline. A concern is of course the nature of the information provided by the agent or correspondent to the airline based on which they make their assessment and decision.

 

Seafarers’ right to refuse treatment

Nigel Griffiths Marine Advisory Medical Service
UK, Australia and Singapore 

In the last edition of Triton, we looked at aspects of consent and access to medical records, which are subject to the common law principle of medical confidentiality. So what of the seafarer who refuses treatment or seeks alternative treatment, whilst hospitalised for accident or illness?

Autonomy is the corner stone of biomedical ethics. It is the patient’s right to self-determination and is summed up in the famous words of Benjamin Cardoso from a judgment in the State of New York: 

“Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages.” [Schloendorff v. Society of New York Hospital (1914)] 

More recently, the Court of Appeal in Quebec has stated: 

“For a competent person of the age of majority, the making of his own decisions with respect to his own body is the legal expression of the principle of personal autonomy and the right to self-determination.” [Nancy B v Hotel-Dieu de Quebec(1992)] 

Years earlier the philosopher J S Mill stated: 

“The only purpose for which power can be rightfully exercised over any members of a civilised community, against his will is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant. He cannot rightfully be compelled to do or forebare because it will be better for him to do so, because it will make him happier, because, in the opinion of others, to do so would be wise, or even right.”  [Mill JS On Liberty Longman, Robert and Green London 1869] 

The spirit of the law has crossed the Atlantic and can also be seen in UK case law. When a person chooses a course of action which risks their health and possibly their life, it raises a moral dilemma between their autonomy and society’s interest in preserving their well-being and life. The Court of Appeal, in R v Collins, “was correct in re-stating the principle that; Even when his or her own life depends on receiving medical treatment an adult of sound mind is entitled to refuse it.” This reflects the autonomy of each individual and the right of self-determination’. [St George’s Healthcare NHS Trust v S; R v Collins and others, ex parte S [1998] 3 All ER 673]

Refusal of treatment 

England and Wales case law demonstrates a right to refuse treatment: C had paranoid schizophrenia and was detained in a high security hospital. He developed gangrene in his leg but refused to agree to an amputation, which doctors considered was necessary to save his life. The Court upheld C’s decision. 

“The fact that a person has a mental illness does not automatically mean they lack capacity to make a decision about medical treatment.”

Patients who have capacity (that is, who can understand, believe, retain and weigh the necessary information) can make their own decisions to refuse treatment, even if those decisions appear irrational to the doctor or may place the patient’s health or their life at risk.” [Re C (Adult, refusal of treatment) [1994] 1 All ER 819 The right of a competent adult to refuse medical treatment]

And so to seafarers 

I was called to Hong Kong to assist in a very similar matter some years ago. An Indian seafarer hospitalised at a reputable Government hospital, was advised by the treating doctor that an emergency amputation through ankle was required, following a rope injury whilst the vessel was in port. The patient refused surgical intervention and it was apparent to doctors treating him that gangrene was setting in very quickly. 

The local agent attended the hospital, but to no avail in persuading the patient to follow medical advice. The patient insisted, after discussion with his wife and a priest in India, that God had already cured him, and there was no necessity for amputation. The hospital secured a ‘refusal of medical advice’ form signed by the seafarer. Respecting his autonomy, we very quickly arranged for same day repatriation where the patient was able to obtain a local opinion, which as it happened concurred with that of the Hong Kong doctors. The priest, realising the gravity of the matter then praised the wisdom of the almighty in enabling doctors to be gifted in the art of medicine. The patient, in discussion with his family consented to amputation, which unfortunately by this time needed to be performed below knee. 

What to do in a situation like this 

Those who encounter such a situation should always try to reassure the patient as best they can, mindful of the patient’s autonomy. If emergency surgery or other life-saving treatment is required, every attempt should be made to reason with the patient and obtain the proper consent in writing. There will be times when consent cannot be obtained, for example when the patient is unconscious. In such instances the doctor is bound to follow the best interest factor in determining treatment, from which a substituted judgment must serve as the basis of consent. The weight of the family’s opinion, whilst valuable, if they are thousands of miles away may not be sufficiently informed to override the best interest determination of the doctor.

If a seafarer refuses to follow medical advice, it is very important that this is documented and is brought to the member’s/Club’s attention immediately. If seafarers request an alternative treatment to that recommended by the doctor, this should be carefully considered and brought to the Club’s attention.

Terms of treatment

Whilst not wishing to encroach on the patient’s autonomy, treatment must also be in keeping with terms of the Club for reimbursement to the member. Generally speaking, a patient should be stabilised in the port of incident and treated in his own country for ongoing care and not long term in the port of incident, as we see requested from time to time by South American doctors for example. A plethora of unnecessary and costly investigations should also be avoided, and doctors reassured that stabilisation is their goal and not long-term care. The Club has excellent advice regarding suitable facilities in the countries that seafarers come from, and if facilities are not available there can make alternative arrangements.

The Club is of course ready to assist members and correspondents in times of need, and has medical expertise available 24 hours a day.

 

THE RESPECT for a seafarer’s decision in relation to recommended medical treatment is paramount in the handling of a case involving personal injury or illness. As a claims handler, there is always a balance between maintaining the respect for a decision made by an adult of sound mind, whether that decision is based on religious or cultural determination, and the recommendation given by a medical expert. The objective of the Club in a situation like this is to ensure that the seafarer makes an informed decision and, if required, obtain the advice of several experienced medical experts enabling him to do so. There is also the question of what constitutes a sound mind and whether the information on which the seafarer’s decision is to be made is fully recognized. It becomes particularly difficult if family members who don’t have access to the same information put pressure on the member. 

Usually the situation can be resolved by reasoning and a close cooperation between the parties involved including the seafarer, the member, the family, the treating physician and the Club. In most cases where this delicate question arises, the Club will utilize the network of medical experts available, though not in any way to disrespect the decision of the seafarer but to make certain that the he is fully informed of the consequences of his decision to, for example, refuse treatment. At this stage it may be necessary for the Club to protect the member’s interests by obtaining a declaration from the seafarer, in which he confirms that he is fully aware of the risks he is assuming by making a decision that is against expert medical advice and recommendations given and further that he releases the member from any liability regarding the consequences of his decision.

Visiting address

The Swedish Club
Gullbergs Strandgata 6
SE-411 04 Gothenburg
Sweden


Postal address

The Swedish Club
Gullbergs Strandgata 6
P.O Box 171
SE-401 22 Gothenburg
Sweden

Phone/Fax/E-mail

Tel +46 31 638 400
Fax +46 31 156 711
E-mail swedish.club@swedishclub.com

Emergency

GOTHENBURG:
+46 31 151 328

Piraeus:
+30 6944 530 856

Hong Kong:
+852 2598 6464

Tokyo:
+81 44 222 0082

Oslo:
+46 31 151 328

The Swedish Club is a member of: