LECT 2 - PATIENT AUTONOMY AND CONSENT TO TREATMENT_EM.pptx.pdf

PATIENT AUTONOMY AND CONSENT TO TREATMENT MODULE - 7 OBJECTIVES Define the concept of autonomy Define informed consent Understand how consent protects the interests of both the patient and the p...

PATIENT AUTONOMY AND CONSENT TO TREATMENT MODULE - 7 OBJECTIVES Define the concept of autonomy Define informed consent Understand how consent protects the interests of both the patient and the physician. Describe the consent process for the incompetent using proxy or substitute decision makers and advance directives Define the concepts of competence and capacity and how they are assessed in the patient. LECTURE OUTLINES 1. TERMINOLOGY AND CONCEPTS 1. Autonomy 2. Consent 3. Competence 4. Paternalism 5. Best interest standard 1. Medical decision making 2. Advance treatment directives 3. Substitute or proxy decision makers  TERMINOLOGY AND CONCEPTS 1. AUTONOMY Is the innate human right of a patient to control access to his/her body and what is done to him or her. The right to choose who treats him/her, where he/she is treated, and what treatment is used. Authorization of the treatment. TERMINOLOGY AND CONCEPTS 1. CONSENT Is a decision of a competent patient to accept the medical procedures proposed. The patient has the right to refuse the proposed treatment. Both consent and refusal must be informed ( Based on full disclosure of the details of the proposed treatment, including its benefits and risks). CHILDREN’S CONSENT Children with some degree of competence can assent( approval) to treatment. Parents may assent to the decision of a fully competent post-pubertal child who is below the age of majority, currently 18 years in SAUDI ARABIA. AGE OF MAJORITY Is the age above which a patient is considered to be an individual and responsible for all medical decisions if fully competent. THE AGE OF 7 Is considered the age of discrimination, SINN AL TAMYIIZ after which a child can make some decisions. AT PUBERTY a person becomes MUKALLAF fully responsible for fulfilling all religious obligations.  TERMINOLOGY AND CONCEPTS 1. COMPETENCE Is the intellectual capacity to understand, analyze, and judge information. The main component of competence is intellectual competence, but other factors- such as emotional and psychological factors-make their contribution. Another term used for competence is capacity. TERMINOLOGY AND CONCEPTS 1. PATERNALISM Is a negative attitude that was common among physicians. (Mostly abolished) Paternalism is a violation of the patient's autonomy rights.  TERMINOLOGY AND CONCEPTS 1. MEDICAL DECISION MAKING Is a joint process involving the physicians and the patient regarding Treatment choice. It should be a rational( logical) process but the final word is with the patient. The patient's decision will stand even if it is considered irrational (not logical ) by the physicians. TERMINOLOGY AND CONCEPTS 1. ADVANCE TREATMENT DIRECTIVES Are instructions on treatment or its withdrawal made by a competent patient, to be applied when competence is lost. Such directives are best made in writing and with witnesses.  TERMINOLOGY AND CONCEPTS 1. SUBSTITUTE OR PROXY DECISION MAKERS Are the persons who are authorized to make decisions on behalf of a patient who Does not have the intellectual competence to decide for him or herself. TERMINOLOGY AND CONCEPTS 1. BEST INTEREST STANDARD Is the criterion used to judge decisions by physicians and decisions of substitute decision makers. These decisions must be in the best interests of the patient.  NOW GIVE YOUR IDEAS ON----- Why it is important to know about autonomy and consent...??????? ETHICAL, LEGAL AND POLICY ISSUES 1. AUTONOMY AS THE BASIS OF INFORMED CONSENT This includes decisions about what they do or what others can do to them. (The right of autonomy has to be respected and cannot be denied by any other human being)  ETHICAL, LEGAL AND POLICY ISSUES The right of autonomy has restrictions clearly by the law. 1. The first legal restriction -----------age. Below 15 to 18 years do not have full autonomy---decisions made by their parents 2. The second restriction is -----------person's mental state ETHICAL, LEGAL AND POLICY ISSUES 1. SCOPE AND LIMITATIONS OF CONSENT A patient has a right to make autonomous decisions regarding any medical procedures on his or her body. This includes decisions to allow health professionals 2. To take a history 3. To carry out physical examinations 4. To undertake any curative or preventive medical procedures  LIMITATIONS OF CONSENT Any permission to undertake medical procedures has to specify 1. Part of the body to be treated 2. Type of procedure to be carried out 3. Time decided (The medical professional can go beyond these limits only by getting new permission from the patient) PATIENT'S RIGHTS REGARDING CONSENT Patient has a right To decide which profession can treat him. To reject any professional procedure without having to give a reason. To withdraw the permission at any time without being required to explain why.  Rules for consent Consent has a limited time period. Consent given in one admission will have to be repeated on re-admission. If a long time elapses, consent needs to be repeated (because circumstances might have changed). 1. CONSENT AND PROTECTION OF THE PATIENT The patient’s autonomous right to consent or reject medical interventions Ensures that the patient retains (keeps) the ultimate right to protect his interests. 1. CONSENT AND THE PROTECTION OF THE PHYSICIAN Prior consent by the patient for medical procedure protects the medical practitioner in case of error or side effects. The legal protection for the medical practitioner is, however, limited. Consent does not protect a physician from prosecution in the event of professional errors and malpractice. Consent prior to medical intervention also protects the hospital in which the practitioner works from certain forms of litigation, but does not remove all liability. 1. THE PROCESS OF INFORMED CONSENT Is consent following full disclosure of all medical facts The disclosure should include Explanation of the diagnosis as much as possible to a lay (put) patient Explanation of the intended procedure in non-technical terms Disclosure of all known side effects To enable the patient to make an informed decision, alternative procedures and treatments, and their benefits and side effects, should also be disclosed. 1. CAPACITY/COMPETENCE TO CONSENT For informed consent to be legally valid, the patient making the decision must be judged to be legally competent. (To have the capacity for decision making) Competence is judged by intellectual ability to understand, retain, and judge information. Children below the age of majority are considered not competent. A normal adult is judged legally competent unless there is a reason to suspect otherwise. IN CASE OF MENTAL DISABILITY In simple cases, a physician can test for competence by asking simple questions In more complicated cases, a clinical psychologist may be invited to test for competence in a formal way. The testing for competence should be recorded clearly in the patient's chart. The record should preferably include the items used for testing. 1. PROXY CONSENT AND SUBSTITUTE DECISION MAKER A patient who is judged legally incompetent cannot make decisions regarding his or her treatment. A proxy or substitute decision maker must be found. Substitute is usually a member of the family. (Father or the most senior member of the family) 1. CONSENT FOR CHILDREN Parents have the overall right to decide for children below the age of majority, which is 18 years in SAUDI ARABIA. If both parents refuse-------- the physician can give (the physician can go ahead and give emergency life-saving treatment with no consent in in the interests of saving life Refusal by one or both parents of non-urgent treatment------- reference to the law courts. Children below the age of discrimination (7)-------- everything is in the hands of the parents.  Children above the age of seven, but below puberty------- can only assent. Consent still done by parents. Children above puberty ----------should be allowed to make decisions about their treatment. Parents can assent only. 1. CONSENT FOR THE MENTALLY IMPAIRED In cases of total loss of mental capacity------physicians has right to make decisions within the safeguards set by the law Selective or partial impairment ---------should be allowed to make some relevant decisions Complete loss of intellectual capacity------- members of the family can make decisions 1. CONSENT FOR THE UNCONSCIOUS Patients with complete loss of consciousness are considered incompetent Decisions will be made by priority 2. Next of kin (relatives). 3. Physician 4. Advance directive, if placed by patient CASE (ETHICAL SCENARIO) An 80-year-old, fully conscious, and competent man with advanced incurable cancer needed palliative chemotherapy. The family objected when the doctor wanted to obtain informed consent from the patient because that would involve disclosing the diagnosis, which would make the patient very sad and depressed. The family wanted to make the decision without informing the patient. What should the doctor do? Provide your moral reasoning.  DISCUSSION The doctor should respect the patient's autonomy. He should first ask the patient whether he personally wanted to receive information about his condition in order to make decisions on his treatment, or whether he would prefer that the information be disclosed to his family, and the family authorized to make decisions on his behalf. If he insists on making decisions for himself, he must receive full disclosure and exercise his autonomous right to informed consent. If he chooses to leave everything to the family, the doctor can deal with the family accordingly. CASE (ETHICAL SCENARIO) A university professor admitted for stroke refused life-saving treatment even after a thorough explanation by his son, who was a neurosurgeon. While in the hospital, he seemed to forget essential information about his illness, forgot his age and his wife's name, and was confused about the day of the week. However, he was in continuous telephone contact with his laboratory at the university, guiding the young researchers. What should the doctor do? Provide your moral reasoning.  DISCUSSION A formal testing of competence by a physician or psychologist is necessary in this case. If the professor is found competent, his refusal of treatment should be upheld. CONCLUSION AND SUMMARY 1. Informed consent ensures respect for patient autonomy. 2. The decisions of a competent patient are final regarding his treatment. 3. Children below the age of majority, the mentally ill, and the unconscious are considered incompetent to decide on their treatment. 4. Proxy and substitute decision makers decide for incompetent patients. 5. Prospective autonomy of the patient in the form of an advance directive must be respected.