WEEK 8 Flashcards
Who should decisions be made by?
Those whose life the decision impacts most
What is the foundation of consent?
Decision making
What are the three basic phases of decision making?
1) Gathering information
2) Recalling and pooling that information
3) Weighing things up
How may the quality of your decision making be adversely affected?
1) You aren’t competent to make it
2) You were coerced, or put under pressure to make the decision
3) You were deceived, or had information concealed from you
What are the fundamentals to patients’ decision making?
They must decide whether or not to go ahead with all stages of the medical process and it should be viewed as a joint enterprise between Pt and Dr
Where is consent derived from?
Patient autonomy as it is the ability to live according to our own beliefs/values
What is self-determination theory?
A theory dealing with human motivation, linking well-being, satisfaction and performance to autonomy, competence and relatedness
What is the role of the doctor in patients’ decision making?
To aid the patient to make the best choice possible
Define ‘benevolent concealment’
Where medical paternalism was more prominent, even to the point of lying or deceiving patients
What has been the shift in decision making with relation to autonomy and beneficence?
Advent of humanism resulted in the shift away from ‘benevolent concealment’ to autonomy
Define humanism
The belief that each individual creates their own set of ethics
Summarise the GMC’s definition on the 7 key principles of consent
1) Patients have right to be involved and supported in decisions
2) Decision making is an ongoing process focused on meaningful dialogue
3) Patients have right to be listened to and given relevant information for decisions, along with time and support
4) Doctors must try to find out what matters to patients so information given is more specific
5) Doctors must start from presumption that all adult patients have capacity to make decisions
6) Choice of treatment/care for those without capacity must be of overall benefit to them
7) Patient whose right to consent is affected by law should be involved in decision-making process
What is the shift in the Dr-Pt decision-making process?
Dr=Active, Pt=Passive to Dr=Facilitator, Pt=Active/Participant
What did the Sidway vs Bethlem Royal Hospital Governers 1985 case highlight?
The duty to provide enough information for patients to make a balanced decision (eg. alternative treatments and ‘common or serious’ consequences)
What dictates how much information is given to patients?
What it is you’re proposing to do and how much information they want
Give two cases where the need to provide enough information to patients was highlighted
Sidway vs Bethlem Royal Hospital Governers 1985 (risk of paralysis not explained before trapped nerve operation)
Montgomery vs Lanarkshire 2015 (risk of shoulder dystocia not explained, baby with cerebral palsy)
What is the test of risk materiality?
Whether a reasonable person in the patient’s position would attach significance to the risk or if the doctor knows that this particular patient would attach significance to this risk
What is the GMC guidance about giving patients information?
Must give clear, accurate and up-to-date information based on the best and most recent evidence about: benefits/risks for each option and option to take no action
What is a principle of consent?
That it is dynamic
When is consent not valid?
When it expires (consent is dynamic)
If certain conditions aren’t met or it was given in the wrong way
What 3 decision-making rules must apply for consent to be valid?
1) Voluntary (not coerced)
2) Informed (adequate information)
3) Patient must be competent to make it
In which situations is gaining consent not necessary?
1) Emergency treatment or unconscious/otherwise incapacitated patient
2) Urgent MH treatment under the MH act
What is the ‘therapeutic exception’ to consent?
Where it’s conceivable that obtaining informed consent would cause ‘significant psychological harm’ (not in patient’s best interests)
How would you act when gaining consent cannot be achieved due to the patient being unconscious/otherwise incapacitated patient?
Act in the patient’s best interest or what they would want (eg. advanced directive)
What is capacity?
How able someone is to consent to treatment/care
What is capacity a pre-requisite of?
Autonomy
What diminishes capacity?
Anything interfering with an individual’s ability to make decisions
What 4 steps are required by the patient for capacity?
1) Understand presented information
2) Recall information
3) Weigh up the information
4) Communicate that decision
How may capacity change from decision to decision?
A person may have capacity to make one decision but not another
What must always be done in terms of capacity?
Assess it (never assume someone doesn’t have capacity/ignore signs of a lack of capacity) and provide them with all possible help and support to enable decision to be made
What is the two-stage test (for capacity)?
Stage 1: is there an impairment or disturbance in the function of the person’s mind or brain?
–if so–
Stage 2: is the impairment or disturbance sufficient that the person lacks the capacity to make a particular decision?
What is the principle of patients’ understanding the information?
Information should be presented to be best accessible, prior knowledge shouldn’t be assumed-only understanding of salient information required
What is the principle of patients’ retaining the information?
Need to retain it long enough to make the decision
What is the principle of patients’ weighing up the information?
The capacity to engage in the decision-making process and see various parts of the argument and relate them to each other-only need to weigh salient information and don’t have to reach a rational conclusion
What aids in understanding whether a patient has capacity?
A knowledge of their values to more easily understand rational
What is the principle for patients’ communicating the decision?
Facilitate communication as far as you can
What are two principles of capacity?
1) It’s dynamic
2) It’s independent of whether you agree
What prevents dominion (control) over decision-making/erodes or destroys capacity?
Temporary factors such as confusion, shock, fatigue, pain or drugs, or panic induced by fear
What does capacity not confer?
The right to demand treatment, only to choose between offered treatments
Where does the Mental Capacity Act (MCA) (2005) apply?
To all those involved in care for those over 16 unable to make some or all decisions for themselves
What are the five key principles that underpin the MCA?
1) Presumption of capacity
2) Support of individuals to make decisions
3) Unwise decisions must be honoured regardless
4) Best interests
5) Less restrictive options-what will give them most choices when capacity may resume
What should you do when patients don’t have capacity?
Decide what would be of overall benefit to the patient
How would you go about deciding what would be of overall benefit to a patient without capacity?
1) Consult with people close to the patient and HCT about patient preference
2) Consider which option aligns most closely with patient’s needs, preferences, values and priorities
3) Consider which option would be least restrictive of patient’s future options
What are the series of questions you should ask yourself when a patient doesn’t have capacity?
1) Can it wait?
2) What would be best in general?
3) What would be best for the specific patient?
4) Can you get any more information?
5) Is there anyone else that has the right to make the decision? (Leading Power of Attorney)
6) If there is total lack of information, employ Independent Mental Capacity Advocate
What is an advance statement?
Any information the patient feels is relevant to their future care, should they lose capacity
What is an advance decision?
Refers only to advanced decision to refuse treatment in specified circumstances
How is an advanced decision different from an advanced statement?
Legally binding and only covers treatment refusals
When is an advanced decision legally binding?
When it’s in writing, signed by the patient and a witness
What is needed by the Leading Power of Attorney (LPA)?
Their own capacity
What circumstances are required to employ an Independent Mental Capacity Advocate?
1) Person aged 16 or over
2) Decision to be made about either long-term change in accommodation or serious medical treatment
3) Person lacks capacity to make decision
4) No one independent of services who is “appropriate to consult”
What is the Court of Protection (CoP)?
Created by MCA to supervise it’s implementation
How does the Court of Protection supervise the MCA’s implementation?
1) Makes decisions on whether someone has capacity
2) Handles best interests’ disputes
3) Rules on questions about liberty deprivation
Who can the CoP appoint?
Deputies to make decisions if there’s a longstanding lack of capacity and no previously established LPA
What is the meaning of competence in UK law?
Denotes whether or not a person under 18, but commonly under 16, can make autonomous decisions about their health
Describe the case of Gillick vs. West Norfolk & Wisbeck Area Health Authority
Gillick proposed it would be unlawful for a doctor to prescribe contraceptives to girls under 16 without parental knowledge or consent, this declaration was refused
What came of the case of Gillick vs. West Norfolk & Wisbeck Area Health Authority?
Standard of ‘Gillick competence’ to consent to treatment
What is ‘Gillick competence’?
Children under 16 can consent if they have sufficient understanding and intelligence of what is involved in treatment
What aspects of treatment are required to be understood in ‘Gillick competence’?
Purpose/nature/risks/effects/chance of success/other treatment options
What is assumed for people over 16?
They have ‘Gillick competence’
How can a competent refusal by a child with ‘Gillick competence’ be overruled in England, Wales and NI?
By a court or person with parental responsibility
What does ‘Gillick competence’ give right to?
Consenting to treatment but not necessarily refusing it
What are children particularly vulnerable to which should be taken into account when gaining consent?
Coercion-therefore consent still needs to be informed and voluntary
What would you do if a child is not deemed to have ‘Gillick competence’?
Seek parental consent, usually one is sufficient. If patents can’t agree, seek legal advice
What are the Fraser guidelines?
Refer specifically to whether or not someone under 16 can be prescribed contraceptives without parental knowledge
What do the Fraser guidelines apply to that doesn’t involve contraceptives?
STI treatment and termination of pregnancy (ToP)
