Informed Healthcare Decision Making and Consent Flashcards
what is informed consent
The process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment. (Appelbaum, 2007)
Schloendorff Case (1908)
Justice Cardozo:
“Every human being of adult years and sound mind has a right to determine what happens to his body, and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages”
Ms Schloendorff was admitted to a hospital for “some disorder of the stomach.” Her MD discovered a “lump” which proved to be a fibroid tumor. The pt consented to an “ether examination” to determine the “character of the lump” but allegedly notified the MD that “there must be no operation.” She had the ether and the physical exam; while she was unconscious, the fibroid was removed. She argued this was without her consent or knowledge. Justice Cardozo’s famous maxim noted: “Every human being of adult years and sound mind has a right to determine what happens to his body, and a surgeon who performs an operation without his patient’s consent commits an assault for which he is liable in damages”
Canterbury v. Spence (1972)
Information that a physician must disclose:
(1) condition being treated;
(2) nature and character of the proposed treatment or surgical procedure;
(3) anticipated results;
(4) recognized possible alternative forms of treatment;
(5) recognized serious possible risks, complications, and anticipated benefits involved in the treatment or surgical procedure, as well as the recognized possible alternative forms of treatment, including non-treatment.
the pt was not informed of risk of paralysis from unguarded falls when he consented to a laminectomy
(similarly, many women have been routinely treated with mastectomies without being informed of the option of lumpectomy for localized breast CA)
elements of informed consent
- The nature of the decision/procedure
- Reasonable alternatives to the proposed intervention
- The relevant risks, benefits, and uncertainties related to each alternative
- Assessment of patient understanding
- The acceptance of the intervention by the patient
how much information needs to be provided? Three standards:
- Reasonable physician standard
- Reasonable patient standard
- Subjective standard
When is informed consent required?
All interventions –> some form of consent (following discussion)
Policies for which require signed consent
Implied consent for common decisions
implied vs. presumed consent
The patient’s consent should only be “presumed,” rather than obtained, in emergency situations when the patient is unconscious or incompetent and no surrogate decision maker is available, and the emergency interventions will prevent death or disability. In general, the patient’s presence in the hospital ward, ICU or clinic does not represent implied consent to all treatment and procedures. The patient’s wishes and values may be quite different from the values of the physician. While the principle of respect for person obligates you to do your best to include the patient in the health care decisions that affect her life and body, the principle of beneficence may require you to act on the patient’s behalf when her life is at stake.
When is consent not required
- Patient lacks decision-making capacity (requires proxy or surrogate)
- Lack of decision-making capacity in an emergency situation
- When the patient has waived consent
- Competent patient designates a proxy
exceptions to full informed consent are:
- If the patient does not have decision-making capacity, such as a person with dementia, in which case a proxy, or surrogate decision-maker, must be found.
- A lack of decision-making capacity with inadequate time to find an appropriate proxy without harming the patient, such as a life-threatening emergency where the patient is not conscious
- When the patient has waived consent.
- When a competent patient designates a trusted loved-one to make treatment decisions for him or her. In some cultures, family members make treatment decisions on behalf of their loved-ones. Provided the patient consents to this arrangement and is assured that any questions about his/her medical care will be answered, the physician may seek consent from a family member in lieu of the patient.
when should a patient’s decision making ability be questioned
If they are unable to:
- Understand his or her situation,
- Understand the risks associated with the decision at hand,
- Communicate a decision based on that understanding.
what abilities should you assess for competency?
Generally you should assess the patient’s ability to:
- Understand his or her situation,
- Understand the risks associated with the decision at hand, and
- Communicate a decision based on that understanding.
variation in decision making capacity
- Due to medications
- Changes in disease process (i.e. delirious states)
- Check for lucid consistency and persistence
incapacitated/incompetent patients
Requires surrogate / proxy / durable power of attorney (DPA)
No specific hierarchy of appropriate surrogates in California
what if a patient cannot give informed consent
If the patient is determined to be incapacitated/incompetent to make health care decisions, a surrogate decision maker must speak for them.
consent for children
-All states require parental consent for most medical care provided to minors (“permission” more than “consent”)
-Exceptions:
-“emancipated minors” can consent to all health care.
-living apart from the parent / financially independent
-married and/or a parent
in the military
-Adolescents may provide consent for matters regarding sexual and reproductive health, mental health, and substance abuse
-State laws vary
