Lecture 3: Consent Capacity & Children PDF

👶🏽 Lecture 3: Consent Capacity & Children Consent & Capacity For Medical Treatment FUNDAMENTAL RIGHTS. Right to treatment in an Emergency. Right to choose one’s own doctor Right to proper standard of care Right o...

👶🏽 Lecture 3: Consent Capacity & Children Consent & Capacity For Medical Treatment FUNDAMENTAL RIGHTS. Right to treatment in an Emergency. Right to choose one’s own doctor Right to proper standard of care Right of voluntary informed consent Right to decide whether or not to be used for research or teaching Right to confidentiality Right to treatment free of discrimination Right to be informed of applicable fees Right to protection of property Right to refuse treatment Consent Autonomy * Common law and statute recognizes that an individual has certain rights Must gain consent Violation of rights HEALTH CARE CONSENT ACT Right to, while capable, express wishes with respect to treatment Lecture 3: Consent Capacity & Children 1  No treatment without consent, unless: of the opinion that the person is capable with respect to the treatment, and the person has given consent; or of the opinion that the person is incapable with respect to the treatment, and the person's substitute decision-maker has given consent on the person's behalf Substitute Decision Maker SUBSTITUTE DECISION MAKER (SDM) When patient is incompetent to provide consent, SDM can Must be in accordance with best interests of patient SDM Ranking: Official guardian appointed by the court Attorney for personal care Board-appointed representative Spouse, partner or relative Elements of Consent → The consent must relate to the treatment → The consent must be informed → The consent must be given voluntarily → The consent must not be obtained through misrepresentation or fraud Consent Responsibilities → Involve the pt in the decision making → Be truthful an accurate w/ your information → Discuss options & outcomes Lecture 3: Consent Capacity & Children 2  → Stay within the law → Be mindful of your position of power to influence → Respect other decisions despite your own beliefs Capacity/ Competence → The pt must ALSO capacity to understand the information → A person is considered capable with respect to a treatment if s/ he is: ▫︎Able to understand the information that is relevant to making a decision about the treatment ▫︎Able to appreciate the reasonably foreseeable consequences of a decision or lack of decision Assessing Capacity → Presume Capable (Assume they are capable until they tell you otherwise) → Language Barrier (There is an ANT line that paramedics can connect with through dispatch which gets them a translator) → Indicators of lack of Capacity (Capacity to do anything, ie. give consent, make decisions, etc) ▫︎Evidence of confused or delusional thinking ▫︎Inability to make settled choice ▫︎Severe pain or acute fear or anxiety ▫︎Impairment by alcohol or drugs ▫︎Any other observations that give rise to a concern about the persons behavior Types Of Consent → Expressed Consent → Implied Consent → Involuntary Consent Lecture 3: Consent Capacity & Children 3  Informed Consent → Requires that a patient be given sufficient information about the proposed Tx or procedure (They have to be informed about outcomes/ benefits) → That They van appreciate the consequences of their decision → Either accepting or refusing Implied Consent → Implied consent can be inferred by the actions of the recipient → The legal presumption of implied consent is valid when 3 things are met: 1. The person is incapable of understanding the TX by way of incompetence or Altered LOAs 2. The Person is at risk, & if the Tx is not administered, the person could suffer serious bodily harm or death 3. It is not possible to obtain a consent or refusal on the person’s behalf from a SDM (or relative), or the delay would put the person at risk of serious bodily harm or death. Refusal Of Treatment → Cannot substitute your will for that of the pt → Parents or guardian do not have the authority to refuse needed treatment on behalf of minors (i.e their children) → A refusal could result in consequences up to & including death (even in a refusal you could be liable) → Paramedics not absolved of responsibility → Refusal MUST be valid & Informed → Most EMS systems require a signed refusal of service form Lecture 3: Consent Capacity & Children 4  Involuntary Consent → For safety & security of the pt or others → Police use of powers to arrest an individual for transport to medical facility → Pt in police custody/ Prisoners/ Detainees Emergency Treatment without Consent- Capable Person → A treatment may be rendered without consent to a person who is apparently capable if: a. there is an emergency b. communication barrier either due to language or disability c. you took steps to try & communicate but were unsuccessful d. the delay required to find a practical means of communication would prolong the person's apparent suffering or put them at risk of sustaining serious bodily harm; and e. there is no reason to believe that the person doesn’t / wouldn’t what the treatment Not Limited To The Following → Minors → Diabetics who are hypoglycaemic or hyperglycaemic → Confused individuals → Pt with GCS of < 15 → Intoxicated individuals or under the influences of a ‘toxic’ substance (drugs& alcohol) → Agitated or on shock → Persons who cannot otherwise appreciate the consequences of a Tx decision (subjective) Lecture 3: Consent Capacity & Children 5  Boundaries of Consent → Failure to obtain a legally valid consent from pt can result in allegations of negligence or Abandonment, Assault, Forcible Confinement Use of Force & PT Restraint → There are circumstances where it would be legally justified to use force in self- defense or in very specific → Use of some force necessary in life-threatening situations is covered in Ontario Health Care Consent Act → Documents the use of any restraints _ 53.(i) the use of restraint on a pt shall be clearly documented in the pt’s clinical record by the entry of: a. a statement that the pt was restrained; b. a descriptions of the means of restraints; c. a description of the behaviour of the pt that required that the pt be restrained or continue to be restrained. Mental Health Act MHA → All fundamental rights pertain to mental illness pt except when involuntary status occurs → Without consent Determine CAPACITY; 3 possible scenarios 1. Capable pt accepting treatment 2. Capable pt refusing treatment 3. Incapable pt treated & transported → Various “Forms” Lecture 3: Consent Capacity & Children 6  → EMS most likely to be involved in Form 1, Occasionally Form 2 → Applying a form 1 is a “police Power” → Form 1 not applied until signed by a physician MHA Criteria → The person/ pt a. has & or threatened or attempted to cause bodily harm to himself/ herself OR b. has/ is behaving violently towards another person or has caused or is causing another person to fear bodily harm from him/ her OR c. has shown or is showing a lack of competence to care for him/ herself At least one of the things or all three must apply → In addition, the physician is of the opinion that the person is apparently suffering from a mental disorder of a nature or quality that likely will result in: ⦁ Serious bodily harm to the person; ⦁ Serious bodily harm to another person; or ⦁ Serious physical impairment of the person Applicable Section → MHA, S.25 - Physician ⦁ “Application for a psychiatric assessment” by a physician = FORM 1 (issued by a doctor, enforced by police) → MHA, S.16 - Justice of the Peace ⦁ Justice of the peace’s order for psychiatric Examination = FORM 2 → S.16 (1) & (1.1) - Criteria (same as for physican) → MHA, s.17 - Police Officer ⦁ “Action by police Officer ⦁ If both Form 1 & Form 2 are not available at the time, person can be apprehended by police on scene under the MHA Lecture 3: Consent Capacity & Children 7  Apprehension Under The MHA → Action by police officer → Where a police Officer has reasonable & Probable grounds to believe that a person is acting or has acted in a disorderly manner & has reasonable cause to believe the person may harm themselves or other, → & that it would be dangerous to proceed under Section 16, (meaning it would be dangerous to try & get Form 2) → the police officer may take the person in custody to an appropriate place for examination by a physician FORM 1 → Application by a physician for a psychiatric assessment → Valid for 7 days; including the date of signature; ⦁ Apprehension of the person named ⦁ His/ Her detention in a psychiatric facility for Mx of 72 hrs → The doctor MUST examine the pt → Police are advised & Form submitted → Has an expiry date → Can be revoked if the individual ‘voluntary’ reports for examination → The individual MUST be served a form 42 ⦁ Outlines why the have been apprehended ⦁ Outlines their rights → within the 72-hour period, MD Must decide to do one of the following: ⦁ Release pt ⦁ make pt an informal or voluntary pt ⦁ make pt an involuntary pt Lecture 3: Consent Capacity & Children 8  FORM 2 → Justice of the Peace’s order for psychiatric examination → Where information upon oath is brought before a justice of the peace → Typically, the form 2 is used by a person’s family or friends → Permits the police to bring the person to a hospital → Does NOT authorize the person to be kept at the hospital FORM 9: Order For Return → The person is subject to detention (in- patient) at a psychiatric facility → If the pt is absent without leave, an Order for Return (FORM 9) signed by the officer in charge of the facility is required → An Order for Return provides authority for one month from the time the absence of the pt Child Protection “Working to keep Children Safe” Child & Family Service Act Mandate of CAS To Promote the Best Interest, Protection, & Well-Being of Children → Articulates the reason for finding a child “ in need for protection → Clarifies the duty to report → Sanctions Child Welfare with authority to intervene Legal Definition of Child ANY PERSON UNDER THE AGE OF 16 YEARS A Child In Need of Protection CFSA s.72(1) Lecture 3: Consent Capacity & Children 9  ⦁ Has suffered physical harm ⦁ Has suffered sexual harm ⦁ Has suffered emotional harm ⦁ Requires medical treatment & parent doesn’t obtain it ⦁ Requires treatment & parent doesn’t consent ⦁ Has been abandoned ⦁ is less than 12 yrs old & has killed or seriously injured another person ⦁ Has injured another person on more than one occasion due to parent’s failure to supervise the child properly → There is risk that the child is likely to: ⦁ Suffer physical harm ⦁ Be sexually molested ⦁ Suffer emotional harm resulting from a pattern of neglect on the part of the child’s parent ⦁ Suffer emotional harm & child’s parent doesn’t consent to treatment to prevent the harm Child Maltreatment → Child abuse or neglect by parents, guardians, or other caregivers, ⦁ Physical ⦁ Sexual ⦁ Emotional ⦁ Neglect Child Abuse Indicators → One indicator is not conclusive of child abuse → A number of indicators may be present → Pattern of behaviour with parent/ Caregiver Lecture 3: Consent Capacity & Children 10  → Child’s appearance (physical signs) → Child’s behaviour Child Abuse - Physical Signs → Swelling - Limbs, lips, Black eye(s) → Bruises both new & old → Abrasions & Lacerations → Head injuries, Skull (especially centered head injuries) → Abdominal Injuries: Spleen Liver → Burns: Cigarettes, Dipped In water Child Sexual Abuse → Sexual abuse occurs when a child is used for the sexual gratification of an adult or an older child → Coercion is intrinsic to sexual abuse → sexual intercourse → Exposing a child’s genitals → Indecent phone calls → Fondling for sexual purposes → Watching a child undress for sexual pleasure → Allowing a child to look at/ perform in pornographic pictures/ prostitution Indications Of Child Sexual Abuse Child’s Appearance ← Results ←Child’s Behaviour Difficulty walking or sitting Reluctance to participate in physical activity Pain, itching, bleeding & Bruises in the Unusual knowledge of sexual behaviour genital or anal area demonstrated through play or conversation Lecture 3: Consent Capacity & Children 11  Reluctance to undress or take a shower in Pregnancy the presence of others Reports stories of sexual contact with an Venereal Diseases, especially in pre-teens adult or older child Fear of normal physical contact, especially when initiated with a leader Depression Paramedics & Child Sexual Abuse → Mandatory reporting requirement → Rearrange only minimal clothing - preserve evidence → Symptom of a seriously disturbed family → You are there for the child, not to judge/ or punish the offenders → Injuries are physical & psychological → Usually Chronic & without force, so EMS response is seldom initiated Behaviours Types of Commonly Observed Behavioural Indicators Physical Indicators In Maltreatment in Adults Who in Child Child Maltreat Children age-inappropriate sexual play with toys, unusual or excessive Is usually protective Sexual Abuse self, others (i.e. itching in the genital or or jealous of the child replication of explicit anal area sexual acts) Torn, stained or bloody Discourage child from age-inappropriate, underwear many be unsupervised contact sexually explicit observed if the child with peers (fear they drawings &/ or requires bathroom might tell on them) descriptions assistance accuses child of bizarre, sophisticated Pregnancy being sexually or unusual sexual Lecture 3: Consent Capacity & Children 12  provocative knowledge May suggest or injuries to the vaginal Promiscuity, indicate marital or anal areas, (i.e. Prostitution difficulties swelling or infection Seductive behaviour misuses alcohol &/ or directed towards Venereal Diseases drugs members of the opposite sex Child Neglect → Neglect = failure to meet a child’s basic needs for food, clothing, shelter, sleep, medical attention, education, & protection from harm → Can occur when parents don’t know about appropriate care for children, or when they’re not able to plan ahead → The child requires medical treatment to cure, prevent, or alleviate physical harm or suffering, AND → The child’s parents/ guardian does not provide, or refuses or is unavailable or unable to consent to, the treatment Indications of Child Neglect Child’s Appearance Child’s Behaviour Persistent hunger, Malnutrition, Demands for constant attention from the underweight; dehydration leader poor hygiene, dirtiness, lice, skin disorders Lack of parental participation & interest associated with improper hygiene Indications that no one is ever home to look Persistent fatigue & listlessness after him/her Inadequate supervision; child left in the care of another child too young to protect Obvious lack of energy when playing him/her Inadequate clothing for the weather Lecture 3: Consent Capacity & Children 13  Unattended sores & cuts & other medical needs Behaviours Types of Commonly Observed Behavioural Indicators Physical Indicators In Maltreatment in Adults Who in Child Child Maltreat Children May display rejecting behaviour Injuries (bruises, cuts, Cannot recall how towards the child burns, factures, etc) that observed injuries (i.e. leaves child are not consistent with Failure to Thrive occurred, or offers an alone in crib or the explanation offered inconsistent bedroom for (i.e. extensive bruising explanation. excessively long to one area) periods Presence of several wary of adults; may injuries that are in may ignore child’s cringe or flinch if various stages of affectionate touched healing; presence of overtures (i.e. unexpectedly; infants various injuries over a refuses to hold child may display a vacant period of time; facial or respond to child’s stare or frozen injuries in infants & pre- need to be held watchfulness school children (i.e. cuts, bruises, sores, etc) Extremely aggressive or extremely Unexplained injuries, May indicate that the withdrawn; displays (i.e. fractures, bruises, child is hard to care extremely etc); Injuries that are for (i.e. describes as indiscriminate inconsistent with the “demanding or hard affection - seeking child’s age & to feed) behaviour; extremely developmental phase compliant &/or eager to please Emotional Maltreatment → A pattern of behaviour that attacks a child’s emotional development and sense of self worth Lecture 3: Consent Capacity & Children 14  → Includes excessive, aggressive or unreasonable demands that place expectations on a child beyond his/her developmental and emotional capacity → Constantly… ⦁ Criticizing , Teasing ⦁ Belittling, Insulting ⦁ Rejecting, Ignoring ⦁ Isolating Indicators of Emotional Maltreatment → Extreme lack of confidence, withdrawal, depression → Inability to concentrate, continual procrastination → Excessive desire for leader’s attention → Over-participation, (i.e. involvement in too many activities) → “Has to win” attitude → Inappropriate “adult” or “infantile” behaviour Behaviours Types of Commonly Observed Behavioural Physical Indicators In Maltreatment in Adults Who Indicators in Child Child Maltreat Children - Constantly blames the child for life’s difficulties and Enuresis(peeing disappointments, (i.e. - Severe depression themselves) and/or Emotional Abuse uses child as a -Extreme withdrawal Encropesis that is scapegoat); - or aggressiveness non-medical in origin Constantly displays rejecting behaviours towards child Lecture 3: Consent Capacity & Children 15  - Constantly withholds physical Frequently and verbal affection - Overly compliant; psychosomatic from the child - too well-mannered; complaints; Constantly bribes, too neat and clean headaches, nausea, manipulates or abdominal pains intimidates the child - Constantly isolates the child, (i.e. doesn’t allow child to have contact with others - Extreme attention - both inside and seeking behaviours - Child fails to thrive outside the family - displays extreme Constantly verbalizes inhabitation to play negative feelings about child to the child or others. CareGiver/ Guardian → someone who undertakes legal custody of the person & property of someone unable to look after themselves → Person under the care of a parent/legal guardian if the person has not attained the age of 16 years → Treatment/ transport can be refused by guardian ⦁ Exception is an emergency situation when the child can be placed in police protection Risk Factors CareGiver/ Guardian → Families experience stress for many reasons ⦁ Alcohol/ Substance addiction ⦁ Mental Health issues ⦁ Domestic Violence ⦁ Poverty/ Housing issues Lecture 3: Consent Capacity & Children 16  ⦁ Parent-teen conflict ⦁ Isolated ⦁ Incapable of using support services ⦁ Usually victims of abuse themselves Reporting Can Be Difficult → What if i’m wrong about this? → What impact will this have on my relationship with the child/ family? → What if I’m blamed and held responsible for worsening a family crisis? → Will the family to try to retaliate against me? → Will CAS jump to conclusions and decide to apprehend the child without investigating first? → Fears that CAS will make matters worse → Concerns about making this difficult decision and hearing nothing back → Concerns that it will be pleasant to deal with CAS Paramedic Duty to report → If you suspect child abuse, you MUST report your findings to the authorities → Do not be judgemental - remain objective → No legal ramifications can be lowered upon the Paramedic if the suspicions are deemed to unfounded → Reasonable grounds to suspect → Ongoing duty to report Duty to Report → Person must report directly → Family and Children’s Services Lecture 3: Consent Capacity & Children 17  → Failure to Report Professionals Affected CFSA S.71 (5), (7), (8) → The professional’s duty to report Overrides the provision of any other provincial statue, specifically those provisions that would otherwise prohibit disclosure by the professional or official (PHIPA doesn’t include here) → Health care professionals, including physicians, nurses, paramedics, dentist, pharmacists and psychologists → If a Civil action is brought against a person who made a report ⦁ Protected unless you acted maliciously or without reasonable grounds for your suspicion → Disclosure Lecture 3: Consent Capacity & Children 18