Autonomy & Informed Consent

Question 1

What is the model of physician focus care to patient centred care?

Answer 1

The triangle: Nurse & Physician (bottom of triangle points)
Patient is the centre of the triangle
Institution is the top point of the triangle

Question 2

What is the meaning of “Autonomy”?

Answer 2

Auto = Self
Nomos = Rule
It means “I’m the boss of me”

Question 3

Why is autonomy important?

Answer 3

1. It shifts away from physician centred medicine (paternalism)
   with its emphasize to limit paternalism with patient centred care
2. Legal reasons: respect the patient autonomy by asking for consent
3. Respect for persons (deontological perspective): assume the patient is autonomous, which is the reason we respect the persons

Question 4

What is paternalism ?

Answer 4

It means the physician is empowered to make decisions on behalf of the patient even if the patient is capable of making decisions for themselves

Question 5

Presumption of Autonomy

Answer 5

Always assume I’m dealing with an autonomous patient unless proven otherwise
Mental illness causes patients to be autonomous and sometimes not autonomous, we need to be paternalistic sometimes
EX. when the patient is unconscious

Question 6

3 Standards to identify an autonomous patient:

Answer 6

1. They are at liberty (freedom)
2. They are capable of effective deliberation
3. They are capable of authenticity

Question 7

They are at liberty (freedom)

Answer 7

Majority of the patients are NOT at liberty, especially with the MHA

Question 8

They are capable of effective deliberation

Answer 8

• The patient can think about what’s happening
• Patients are free to make decisions you disagree with
• Patient decisions should reflect their own goals and desires, not what your goals are for them
• Because of the illness, patient’s lack effective deliberation

Question 9

They are capable of authenticity

Answer 9

• Think of the decisions based on goals and desires
• The TR is necessary to allow the patient to be their authentic self and share their thoughts and goals truthfully and authentically
• Medication alters patient authenticity

Question 10

Limited paternalism applies when:

Answer 10

• When it is an emergency and it is in the patient’s best interest
• When the patient is unconscious
• When a patient is high
• When a patient is a child (parents make decisions - ascent)

Question 11

What is the age for a child to make health decisions ?

Answer 11

There is no age restriction in BC for a child to make health decisions

Question 12

What happens when a patient does not meet autonomous criteria?

Answer 12

1. Documentation
2. Advanced Directives
3. Psychiatric Advanced Directives
4. Legal Proxy Decision Maker

Question 13

What happens when none of the documentation is available?

Answer 13

• Speak with a social worker
• Speak with the ethics committee
• Speak with the case worker
• Speak with patient’s family* LAST because stress can influence the families input to the patient care

Question 14

Documentation includes DNR:

Answer 14

DNR = Do not resuscitate, which refers to CPR
The survival rate is 12-20%

Question 15

Advanced Directive (AD)

Answer 15

• It is a living will
• It is a set of instructions for the patient’s care that has no limitations on what it can say
• It is not always recognized by HC

Question 16

Psychiatric Advanced Directive

Answer 16

• It is a set of instructions for patient’s care in case of psychiatric illness
• COMFORT PLAN: it allows the patient to be authentic, what makes them worse and what makes them better
  The comfort plan;
• Is more usable
• It is less legal
• The patient population is able to answer these questions

Question 17

Legal Proxy Decision Maker

Answer 17

• Also known as a medical power of attorney
• It is a designated person that knows the decisions the patient wants regarding their care
• The power of attorney needs to be connected to the patient

Question 18

Problems with patient autonomy include -

Answer 18

1. The impact of the illness
2. Conflict over treatment plans
3. Poor health literacy
4. Patient “noncompliance”

Question 19

The impact of illness:

Answer 19

• You’re not the most “you” when sick with an illness
• Vulnerability leads to dependency

Question 20

Conflict over treatment plans:

Answer 20

• There may be disagreement with the nurse, patient, patient’s family, and physician
• Use negotiation and compromise to solve disagreements

Question 21

Poor health literacy:

Answer 21

• Jargon affects patient understanding of instructions
• There needs to be accessible language
• Patient needs clarification on their options*

Question 22

Patient “noncompliance”

Answer 22

• This is a warning the patient is difficult
• This word is judgmental and changes the treatment and the way we have a TR with this patient
• Change it to say: “patient has chosen not to adhere to their treatment plan” because this identifies the patient made a choice and it shows the patient found reasons not to adhere to their plan because…. (their personal reasons)
  *Understand when patient tells you what’s wrong

Question 23

Voluntary Informed Choice = “Informed Consent”

Answer 23

• The patient needs to volunteer
• Consent means to agree, CHOICE means you decide yes or no
• HCP needs to provide enough information to have the patient decide yes or no, not just enough information to agree*
• The information given is enough to expect the patient to make the decision, but not enough information to scare them from making the right decision

Question 24

What is the reasonable person?

Answer 24

The patient is given information at a grade 8 level of reading who is an ordinary person
We do not meet the reasonable person standard because we have additional knowledge that the average person does not have*

Question 25

Elements of Informed Consent (E)

Answer 25

The health care provider gives the adult the information a REASONABLE PERSON would require to make a decision, including information about:
1. The condition for which the HC is proposed,
2. The nature of the proposed HC,
3. The risks and benefits of the proposed HC that a reasonable person would expect to be told about, and
4. Alternative courses of HC