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NURS 3560 - Ethics > Week 4 > Flashcards

Week 4 Flashcards

1
Q

what is the purpose of informed consent (7)

A
  • foundational to legal & ethical care
  • many nursing actions require physical touch –> an intimate relationship
  • actions may be well-meaning but are not necessarily risk free
  • nurses must respect & promote pt autonomy or choice, do good, and prevent/avoid harm –> to impose something else on a person denies their basic humanity
  • promotes dignity and recognizes inherent worth
  • ensures treatment plans are aligned with their values
  • provides an opportunity to prepare for risks and minimize harms
  • ethically, the Code of Ethics requires nurses to promote and respect informed decision making
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2
Q

in law, to touch another person without consent =

A

battery –> category of nonintentional tort

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3
Q

what is the precedent case for battery

A
  • Malette v. Shulman (ontario, 1990)
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4
Q

describe the malette v shulman case

A
  • Mrs. Malette involved in a MVA, unconscious
  • brought to er, dr. shulman assessed her & ordered blood products
  • prior to transfusion, a nurse found a signed care (undated) un Mrs. Malette’s purse indicating that the pt was a Jehovah’s witness and blood is not to be administered to her
  • physician went ahead w the transfusions –> pt sued Dr. Shulman
  • court rules that written instructions regarding future health care ought to be respected
  • Mrs. Malette awarded 20,000 in damages for the tort of battery (touching without consent)
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5
Q

for a pt to sue battery what is required

A
  • the pt must prove battery
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6
Q

for the HCP to defend against battery, what is required

A
  • provider must prove there was informed consent
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7
Q

courts generally favour the health care provider if there is…

A
  • evidence of informed consent or no prior knowledge of the pt’s refusal
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8
Q

what are certain situations where it is acceptable to intervene to treat someone without their consent? (3)

A
  • if the intervention is intended to prevent harm to the pt or someone else (ex. restrain a person, held involuntarily if at risk of suicide or have made threats against another)
  • act in self-defense
  • in an emergency situation if there is no info about what the person would want
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9
Q

what is expected if there is info, either written or in the form of a substitute decision maker’s direction, HCP are generally obligated to…

A
  • follow that direction unless it is well outside the boundaries of best practice
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10
Q

what is best to do if you don’t know what the pt wants and have no way of finding out what the pt would want?

A
  • it’s best to presume the pt consents if the situation is life threatening
  • the more urgent the procedure, the more likely you might be to proceed without saying “yes, pls go ahead” –> risk of harm needs to be considered
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11
Q

consent is a… what does this mean?

A
  • process NOT an event

- pts have the right to change their mind and revoke consent at any time

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12
Q

what is an important thing to remember r/t consent forms

A
  • a signed consent form does not imply that the consent obtained was fully informed
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13
Q

what are the 3 critical elements of informed consent to make consent valid

A
  1. capacity
  2. voluntary
  3. understanding
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14
Q

describe capacity r/t informed consent (2)

A
  • the person must have the legal and mental capacity to make a decision about treatment
  • must be legally competent and mentally capable of making a decision about treatment
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15
Q

describe the voluntary component of informed consent

A
  • the consent must be given freely and without coercion or a lack of important relevant info (such as a risk or side effect)
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16
Q

describe the understanding component of informed consent

A
  • all relevant info about risks and benefits required to make a decision that is consistent with their values
  • info must be given in a way they can easily understand (ex. using language appropriate to the pt’s cognitive state and ability, using an interpreter if language barrier)
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17
Q

what precedent case helps us understand what info a pt needs

A
  • Reibl v Hughes
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18
Q

describe the Reibl v Hughes case

A
  • pt had a stroke during surgery
  • surgeon held liable –> did not provide sufficient info for informed consent , did not tell the pt that stroke was one of the risks of the surgery
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19
Q

what is the healthcare provider’s obligation to tell pts for informed consent (7)

A
  • what a “reasonable” person would want to know
  • pt’s condition that is being treated
  • purpose of the intervention/ why it is being recommended
  • alternative treatments
  • material risks –> major and/or likely
  • risks of delaying surgery
  • consequences of not proceeding w recommended treatment
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20
Q

whose responsibility is it to ensure consent is obtained?

A
  • the responsibility of the person providing the intervention
    ex. if its a sugery, then the surgeon
    ex. nurses need consent to proceed w nursing interventions
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21
Q

getting consent is a …

A
  • process

- not a task or moment in time

22
Q

consistent with the Code of Ethics Value C, Promoting and Respecting Informed Decision Making, nurses are responsible for? (3)``

A
  • ensuring they have time & privacy to provide info
  • answer any questions to ensure understanding
  • sometimes may need a support person to be present to help the pt navigate the decision process
23
Q

the more invasive/risky the intervention…

A
  • the more thorough discussion needed
24
Q

describe the nursing role in informed consent (3)

A
  • nurses are often the witness
  • follow-up on any questions or concerns to the best of their ability, but refer specific questions back to the physician as needed
  • raise any concerns about the person’s understanding or voluntariness
25
Q

a witness for informed consent confirms: (2)

A
  • signature belongs to the pt
  • signature was voluntary –> not the result of threat, coercion, or misunderstanding

–> must report to the physcision or supervisor if the nurse does not believe that all 3 elements of consent are present

26
Q

what are 3 types of consenting behavior

A
  • expressed
  • implied
  • inferred or deemed
27
Q

what is expressed consent (3)? what are some examples (2)?

A
  • specific, expressed agreement to the proposed intervention or procedure
  • can be verbal or in writing
  • clearest type of consent
    ex. signed consent form,”yes, id like to go ahead w chemo”
28
Q

what is implied consent ? what are examples (3)?

A
  • agreement/consent is suggested by non-verbal behavior, actions, failure to resist or protest/inaction
    ex. the pt provides their arm for injection, attends a dialysis appointment , someone who is non-verbal and requires spoon-feeding who closes their mouth and turns away is assumed to be refusing food
29
Q

what is inferred or deemed consent?

A
  • agreement is presumed, assumed, or judged only if the pt has not previously expressed non-consent
  • least clear
30
Q

in which situations is inferred or deemed consent used

A
  • situation where express or implied consent is not possible but not treating would cause harm or death
  • “treat first, ask questions later”
    ex. unconscious pt in life-threatening condition in ER
31
Q

what is an important consideration w inferred or deemed consent

A
  • important to have a consent discussion as soon as it is reasonable either w a stablized pt who is capable of understanding what is happening, or w someone authorized to have a consent decision on their behalf
  • imp bc they can withdraw consent for its continuation
32
Q

competence and capacity both are… (3)

A
  • presumed by default in adults –> we operate on the assumption that someone is competency/capable unless there is strong evidence they are not
  • questioned when a person’s choices are risky, unusual, or appear to not be in their best interests
  • assessed more frequently and thoroughly when decisions are higher risk –> will ask more questions about a life-and-death decision than about something that might be inconvenient
33
Q

describe capacity (5)

A
  • the degree to which a person can understand information relevant to a treatment decision
  • “having capacity”
  • a clinical judgment made by the HCP
  • can vary over time
  • decision specific (may not be capable of financial decisions while being capable of deciding what clothes to wear)
  • often confused w competence
34
Q

describe competence (6)

A
  • a legal judgement made by the court on the advice of a clinician who has completed a capacity assessment
  • a property or characteristic of the person
  • “being competent” –> all or nothing
  • based on capacity assessment
  • examined when considering whether to intervene against the pt’s wishes (without consent)
  • is a global characteristic of the person: either they are or are not legally competent, like an on-off switch
35
Q

it is important to remember that people who do not follow medical advice…

A
  • are not necessarily incompetent or lacking in capacity
36
Q

for informed consent, a person must be capable of understanding: (5)

A
  • condition for which treatment is proposed
  • nature & purpose of proposed procedure or treatment
  • consequences (risks & benefits) of undergoing the procedure or treatment
  • consequences (risks & benefits) of not undergoing the procedure or treatment
  • any alternatives available
37
Q

nurses should be satisfied if there is evidence of a ____ choice

A
  • reasoned (we can see they understand and have thought carefully about the situation)
38
Q

describe how to assess voluntariness of consent

A
  • observation of interactions and relationships
  • careful attention to the pt’s body language and questions
  • watching for nudging and coercion
  • speak w the pt alone if needed to assess voluntariness
39
Q

for consent from an incompetent or incapable adult, healthcare providers still need to: (5)

A
  • provide info to the extent the person can understand
  • respect wishes wherever possible (ensure they have as much choice as possible about the things they are deciding)
  • protect dignity and privacy
  • offer as much choice as possible
  • get consent from a legal decision maker
40
Q

who is a substitute decision maker (5)

A
  • speaks for the pt only when the pt cannot speak for themselves (only when the pt cannot provide consent)
  • knows the person and can represent their wishes
  • public guardian and trustee can be appointed to make decisions on their behalf for pts without friends or family
  • aka proxy, surrogate decision maker
  • must follow instruction in valid Health Care Directive
41
Q

describe consent for minors

A
  • children can be capable of making decisions about their health
  • as a general rule, under the age of 16 parents provide consent
42
Q

what is the mature minor rule

A
  • one who has the capacity to fully appreciate the nature and consequences of medical treatment and thus has the maturity to make their own decision
43
Q

a child as young as __ can be considered mature, depending on the circumstances

A
  • 12
44
Q

describe the Emancipated Minor Rule

A
  • a minor can validly consent to medical treatment when they are married, living on their own, or has shown in some other way independence from their parents
45
Q

how do we know what the person wants

A
  • first ask them
  • advance directives, health care directive, living will, or other written document that outlines the person’s values and wishes
46
Q

what is an advanced directive (4)

A
  • gives instructions for care in the event the person cannot speak for themselves
  • names a proxy or substitute decision maker
  • comes into force only when the person is no longer competent
  • compel providers to follow instructions unless they are not consistent w accepted health practices
47
Q

describe advance directives in manitoba (5)

A
  • person must have the capacity to make directive
  • be 16 or older
  • the named substitute decision makers must be 18 or older
  • HCD must be in writing, signed by maker, and dated
  • is mandatory to follow a HCD unless it is directing the HCP to do something illegal or contrary to accepted practices
48
Q

what must we do without a HCD if the pt cannot speak for themselves

A
  • we consider what is in the person’s best interests
49
Q

how are best interests determined (in order of preference and certainty) (5)

A
  • direct evidence (a written HCD, a video of the person describing their wishes, etc.)
  • knowledge gleaned from conversation between SDM (or others) and the pt
  • the pt’s previous choices (ex. lifestyle, religious convictions, values, beliefs, reactions to cases in media, etc.)
  • what the SDM would want in their position
  • what the SDM thinks they need
50
Q

describe best interests in Manitoba’s Mental Health Act (4)

A

considers:

  • will the pts condition be improved by treatment
  • will the pts conditions deteriorate without treatment
  • do benefits of treatment outweigh risks of harm
  • is treatment the least restrictive and least intrusive to improve condition
51
Q

describe documentation r/t consent

A
  • the consent process & outcome, including consent or refusal must be documented

NURS 3560 - Ethics (7 decks)

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