Legal and Regulatory Aspects of Sleep Disorders

Sleep disorders and criminal behavior

Behaviors that would otherwise be considered criminal acts, but occur in the context of a sleep disorder, pose challenges to the traditional application of legal principles of criminal responsibility. Determining the degree to which consciousness is present during such behaviors becomes a necessary step in assigning criminal culpability. Historically, legal defense theories of unconsciousness, automatism, and insanity have been raised to negate culpability for parasomnia related behaviors. Accordingly, proper assessment of sleep disorders in the context of criminal charges becomes critical in assisting the functions of the justice system. This article reviews principles related to the legal tradition, expert assessment, and elements of expert testimony related to criminal behaviors and sleep disorders.

Clinical Evaluation of the Sleepy and Sleepless Patient

OBJECTIVE

This article addresses the approach to the evaluation of patients who present to a neurologist with excessive daytime sleepiness or difficulty sleeping.

LATEST DEVELOPMENTS

Greater emphasis on the importance of sleep reflects the growing scientific understanding that sleep is critical to overall health and well-being. Consumer sleep technologies, which measure parameters related to sleep, may provide insight into an individual's sleep-related symptoms and tendencies and have a role in patient-centered sleep evaluation when used within an appropriate clinical context.

ESSENTIAL POINTS

A thorough review of a patient's history and physical examination findings are important components of the assessment and management of their sleep-related symptoms. An understanding of how the clinical context relates to the categorization of sleep disorders can impact a patient's symptoms, comorbid neurologic disorders, and overall well-being. Many neurologic conditions are strongly associated with sleep disturbance, risk factors for the development of a sleep disorder, or both. Therefore, it is critical for neurologists to be familiar and comfortable with taking a focused sleep history. Modalities such as in-laboratory polysomnography, home sleep apnea testing, multiple sleep latency testing, and actigraphy, as well as contextualized and prudent use of data obtained from consumer sleep technologies, can be helpful in appropriately selected patients. Mindful integration of these objective data facilitates the diagnosis and management of sleep disorders.

Guidelines of the Indian Society for Sleep Research (ISSR) for Practice of Sleep Medicine during COVID-19

Background

Sleep services are assigned a non-essential status during COVID-19. The American Academy of Sleep Medicine strongly urges sleep clinicians to continue postponing non-urgent care until a later date, if such a recommendation is made by state officials due to local conditions. At the same time, one cannot ignore the fact that sleep is important for people’s health and wellbeing. Therefore, to protect the health of the population, it is essential to find ways and means to continue the practice of sleep medicine even during the COVID-19 pandemic.

Method

Social environment and work ethics in sleep clinics and sleep laboratories in Asia, Africa, and Latin America are different from those in the US. Under these circumstances, the Indian Society for Sleep Research (ISSR) created a task force to develop guidelines for the practice of sleep medicine, not only for the Indian environment but also for other countries that are affected by the COVID-19 pandemic. The task force examined documents regarding practice of sleep medicine and associated specialities  during COVID-19 by various professional organizations and governmental authorities. The recommendations were examined for their applicability. Wherever gaps were identified, consensus was reached keeping in view the available evidences.

Outcome and Recommendations

The emphasis of the guidelines is on avoiding doctor to patient contact during the pandemic. Teleconsultation and other modes of audio-visuals can be used as modes for medical practice during the COVID-19 pandemic. However, in addition to the patient, the presence of a family member, or a reliable informant is recommended. Patients of most sleep disorders can be provided tele-aftercare service. ISSR guidelines also give a list of medications allowed to be prescribed during the first and the follow-up teleconsultation. Hospitals and clinics are slowly opening in India and many other countries. As sleep services resume operations, there is a need to find innovative ways to reduce contact with COVID-19 patients, follow personal protection guidelines, as well as social distancing. This article does discuss strategies for the safe conduct of Level 1 sleep studies. Home sleep testing, which had greater acceptance during the last few years, should be given more attention during the COVID-19 period. Once the decision to reopen the sleep laboratory and resume operations is made, the safety of the patients and office staff should become the major priority. The ISSR recommendation is to postpone and reschedule in-laboratory positive pressure therapy, but it mentions the considerations to be followed in emergency situations. At the same time, high clinical risk patients may be diagnosed on the basis of clinical findings, and without performing polysomnography or home sleep testing. However, at some point, there is a need to reinitiate the in-lab testing. In addition, daily assessment of the COVID-19 situation in the community, along with a review of the situation with local public health and the state health department is advised.

Sleep and Transportation Safety: Role of the Employer

Human fatigue is an important factor in transportation safety and a major causal factor of accidents. Employers play a vital role in minimizing fatigue-related risk, and are legally liable for damages arising from failure to address the risk. By taking an active role as stakeholders in transportation safety, employers not only reduce their risk of adverse safety events and limit their legal liability but may also benefit from improvements in productivity, morale, and health care expenditures. Employers should focus on reducing fatigue-related risk, with ongoing support from sleep safety research.

Legal Aspects of Sleep Medicine in the 21st Century

Multiple manifestations of sleep disorders may interact with the law, making it important to increase awareness of such interactions among clinicians. Patients with excessive sleepiness may have civil (and in some states criminal) liability if they fall asleep while driving and cause a motor vehicle accident. Employers may be held vicariously liable because of the actions of sleepy employees. Hence, awareness of causes of excessive sleepiness, such as sleep deprivation and OSA, is increasing among trucking, railroad, and other safety-sensitive occupations. Interestingly, litigation related to perioperative complications because of OSA is more frequent than nonoperative issues such as a failure to diagnose OSA. Parasomnia-associated sleep-related violence represents a challenge to clinicians because they may be asked to consider parasomnia as a possible contributing, mitigating, or exculpatory factor in criminal proceedings. Clinicians should also familiarize themselves with the legal and regulatory aspects of running an independent sleep laboratory. Sleep telemedicine practice using 21st century technology has opened novel and unique challenges to existing laws. In this review, we cover the most common interactions between sleep disorders and the law, including the challenges of excessive sleepiness and driving, other legal issues involving patients with OSA, and the liabilities associated with parasomnia disorder. We will also cover some practical legal aspects involving independent sleep laboratories and the field of sleep telemedicine.