Week 4 Flashcards
what is the purpose of informed consent (7)
- 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
in law, to touch another person without consent =
battery –> category of nonintentional tort
what is the precedent case for battery
- Malette v. Shulman (ontario, 1990)
describe the malette v shulman case
- 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)
for a pt to sue battery what is required
- the pt must prove battery
for the HCP to defend against battery, what is required
- provider must prove there was informed consent
courts generally favour the health care provider if there is…
- evidence of informed consent or no prior knowledge of the pt’s refusal
what are certain situations where it is acceptable to intervene to treat someone without their consent? (3)
- 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
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…
- follow that direction unless it is well outside the boundaries of best practice
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?
- 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
consent is a… what does this mean?
- process NOT an event
- pts have the right to change their mind and revoke consent at any time
what is an important thing to remember r/t consent forms
- a signed consent form does not imply that the consent obtained was fully informed
what are the 3 critical elements of informed consent to make consent valid
- capacity
- voluntary
- understanding
describe capacity r/t informed consent (2)
- 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
describe the voluntary component of informed consent
- the consent must be given freely and without coercion or a lack of important relevant info (such as a risk or side effect)
describe the understanding component of informed consent
- 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)
what precedent case helps us understand what info a pt needs
- Reibl v Hughes
describe the Reibl v Hughes case
- 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
what is the healthcare provider’s obligation to tell pts for informed consent (7)
- 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
whose responsibility is it to ensure consent is obtained?
- 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
getting consent is a …
- process
- not a task or moment in time
consistent with the Code of Ethics Value C, Promoting and Respecting Informed Decision Making, nurses are responsible for? (3)``
- 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
the more invasive/risky the intervention…
- the more thorough discussion needed
describe the nursing role in informed consent (3)
- 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
a witness for informed consent confirms: (2)
- 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
what are 3 types of consenting behavior
- expressed
- implied
- inferred or deemed
what is expressed consent (3)? what are some examples (2)?
- 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”
what is implied consent ? what are examples (3)?
- 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
what is inferred or deemed consent?
- agreement is presumed, assumed, or judged only if the pt has not previously expressed non-consent
- least clear
in which situations is inferred or deemed consent used
- 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
what is an important consideration w inferred or deemed consent
- 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
competence and capacity both are… (3)
- 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
describe capacity (5)
- 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
describe competence (6)
- 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
it is important to remember that people who do not follow medical advice…
- are not necessarily incompetent or lacking in capacity
for informed consent, a person must be capable of understanding: (5)
- 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
nurses should be satisfied if there is evidence of a ____ choice
- reasoned (we can see they understand and have thought carefully about the situation)
describe how to assess voluntariness of consent
- 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
for consent from an incompetent or incapable adult, healthcare providers still need to: (5)
- 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
who is a substitute decision maker (5)
- 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
describe consent for minors
- children can be capable of making decisions about their health
- as a general rule, under the age of 16 parents provide consent
what is the mature minor rule
- 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
a child as young as __ can be considered mature, depending on the circumstances
- 12
describe the Emancipated Minor Rule
- 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
how do we know what the person wants
- first ask them
- advance directives, health care directive, living will, or other written document that outlines the person’s values and wishes
what is an advanced directive (4)
- 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
describe advance directives in manitoba (5)
- 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
what must we do without a HCD if the pt cannot speak for themselves
- we consider what is in the person’s best interests
how are best interests determined (in order of preference and certainty) (5)
- 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
describe best interests in Manitoba’s Mental Health Act (4)
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
describe documentation r/t consent
- the consent process & outcome, including consent or refusal must be documented
