Autonomy and Consent

Question 1

What is autonomy?

Answer 1

Exercising a choice within a moral framework and consistent with one’s identity

Question 2

How can we respect autonomy in health care?

Answer 2

• Respect for patient’s values and decisions
• Avoiding deception of patients
• Providing information about choices for patients
• Optimizing their capacity to make autonomous decisions
• Avoiding coercion

Question 3

Give 4 examples of where consent is required in healthcare

Answer 3

• Treatment
• Investigation
• Examination
• Disclosure of information
• Research
• Education

Question 4

Consent and battery in healthcare

Answer 4

Battery
To avoid a charge of battery a doctor must have a valid consent. For a patient to give a valid consent he/she must understand the broad nature of the procedure.

The patient need not be harmed by the procedure to claim damages if battery is proved.

Question 5

Requirements for valid consent

Answer 5

Capacity (competence)

Information

Voluntariness

Question 6

What is Capacity?

Answer 6

The ability (competence) of a patient to make their own descisions (maintain autonomy)

Capacity is function/decision specific
Capacity can fluctuate
There is an assumption of capacity in adults.
An imprudent decision is not grounds for deciding someone lacks capacity.
Assessment of capacity is ultimately a legal decision.

Question 7

Under the mental capacity act 2005, when is a person deemed to lack capacity?

Answer 7

If they are unable to:

a) to understand the information relevant to the decision,
(b) to retain that information,
(c) to use or weigh that information as part of the process of making the decision
(d) to communicate this decision (whether by talking, using sign language or any other means

A person is not to be treated as unable to make a decision unless all practicable steps to help them do so have been made with no success

Question 8

What information is required for valid consent?

Answer 8

Broad nature of the treatment. Failure to do this is battery

Information about reisks, benefis and alternatives. Level of information required relates to the standard of care. Failure to do this may result in allegation of negligence

Question 9

What does voluntariness mean in consent?

Answer 9

Descision is made without explicit or implicit coercion by the medical professional or pressure from the family.

Question 10

How can you enhance autonomy in the consent process?

Answer 10

Treat any mental or physical condition affecting a patient’s competence

Be aware of medication affecting competence e.g. morphine

Pay attention to environment and timing to enhance competence and avoid coercion

Make explanations simple and appropriate

Provide choices

Help patients to communicate their decision

Question 11

Consent in adults

Answer 11

An adult (over 16) is assumed to be competent unless shown to lack capacity.

A competent adult can refuse treatment

A reason for refusal does not have to be prudent (sensible/careful) one

A competent adult patient (over 18) can make an advanced refusal of treatment ot appoint a proxy decision maker

Question 12

Consent in children

Answer 12

Competence is not assumed in a child under 16, it must be demonstrated.

Competent consent to treatment should be respected.

Proxy consent can be given by someone with parental authority/court. Proxy must act in the child’s best interests.

Emergency treatment can be given without the consent of a proxy

Competent refusal can be overriden by consent from someone with authority (under 18)

Question 13

Who has parental authority to consent in children?

Answer 13

Mother and married fathers

Unmarried fathers if name is on the birth certificate

Adoptive parents

Someone with parental responsibility from the court

Local authority if the child is under a care order

Question 14

How to respect children’s autonomy

Answer 14

Involve them as much as possible in the decision

Provide information in a way they can understand

Respect a competent decision (consent confidentiality)

• Be aware of the difficulties of evaluating competence in a child.

Question 15

Who can make advanced refusals of treatment?

Answer 15

Patients 18 and over

Person must have capacity at the time of the decision

Must be applicable to the treatment in question (treatment and circumstances must be specified)

Must be a valid refusal (i.e. not withdrawn decision, not done anything inconsistent with advanced decision, given power of attorney that allows person to make decisions about treatment)

Refusals for life sustaining treatments must be in writing, signed and witnessed.

Question 16

What are the four grounds for the importance of confidentiality

Answer 16

Respect of patient autonomy: patient has a right of control over their life and thier information.

Implied promise: Dr-patient relationship has an implied contract that assumes that Drs will treat information confidentially. Breach is breaking that implied promise

Virtue eithics: focuses on the position of the Dr. Trustworthy and will respect his patient’s confidences

Consequentialism: The consequences of breach in confidentiality may mean loss of trust in Drs and HCPs by the patient and/or wider community.

Question 17

Three situations when information may be disclosed to a 3rd party

Answer 17

When it is required by law

When the patient consents

When it is in the public interest.

Implied consent is assumed for sharing of information between HCPs involved in the patient’s care

Question 18

Consent of treatment in competent adults

Answer 18

Competent adults may refuse any (even lifesaving) treatment. Patient’s consent is needed for treatment otherwise it is a battery.

Patient should be given information about the nature of the procedure (otherwise battery) and information about common, or rare serious side effects, benefits and alternatives (otherwise negligence).

If the patient has a mental illness they may be detained for treatment of the mental illness (but no other problems).

Question 19

Treatment of non-competene adults

Answer 19

A valid and applicable advance refusal of treatment must be respected.Someone may have a lasting power of attorney and can give proxy consent.

A proxy must act in the best interest of the patient. Doctors should act in the best interest of the patient (professional judgement).

Relatives, friends and other informal carers should be consulted re: the previous and present values and wishes of the patient. A patient’s previous competent wishes are relevant in judging best interests.

Question 20

Children act

Answer 20

Concerned with the protection of children’s welfare and interests. Anyone caring for children, including parents, social services, teachers and health professionals, must act in the child’s best interests.

Question 21

Consent in individuals betwen 16-18

Answer 21

Anyone aged over 16 is presumed to be competent (MCA 2005). Requirements for consent are the same as in an adult. They are not permitted to make an advanced refusal of treatment or appoint a lasting power of attorney. Refusal of treatment can be overridden by the consent of someone who has parental authority or by the court (legal flack jacket). If the doctor has consent from one person who could lawfully give consent that treatment can be given.

Question 22

Consent in individuals under 16 (competent)

Answer 22

Test for competence. If Gillick competent then they hold the same authority as an adult. Refusal of treatment can be overridden by someone with parental responsibility or the court.

Question 23

Consent in non-competent individuals uner 18

Answer 23

Parents are proxy decision makers and are responsible for making decisions about treatment. They must act in the best interest of the child. If there is a concern that the parents aren’t acting in the best interests, seek other opinons and legal advice. In an emergency treatment can be provided without consent to save life or prevent serious deterioration of health.

Question 24

Doctrine of necessity

Answer 24

Patients who lack capacity may be treated without consent if the treatment is necessary to save life or prevent significant harm, and cannot wait until consent is sought.

Question 25

What is an advanced refusal of treatment?

Answer 25

A decision on healthcare made by a patient for when they no longer have capacity. Can be verbal or written.

Advanced refusals of life-sustaining treatment must be signed and witnessed.

Question 26

What are the Fraser-Gillick guidelines

Answer 26

Framework for under 16s making decisions on sexual health

• Patient must understand information
• Patient cannot be persuaded to inform their parents
• Patient likely to continue/begin having sex with/without contraception
• Physical/Mental may suffer without treatment