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COMPETENCE & CONSENT

COMPETENCE & CONSENT. Rels 300 / Nurs 330 October 2013. Recommended On-line resource. Bioethics for Clinicians a series of papers on bioethics published in the Canadian Medical Association Journal http://epe.lac-bac.gc.ca/100/201/300/cdn_medical_association/cmaj/series/bioethic.htm.

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COMPETENCE & CONSENT

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  1. COMPETENCE & CONSENT Rels 300 / Nurs 330 October 2013 300/330 - appleby

  2. Recommended On-line resource Bioethics for Clinicians • a series of papers on bioethics published in the Canadian Medical Association Journal • http://epe.lac-bac.gc.ca/100/201/300/cdn_medical_association/cmaj/series/bioethic.htm 300/330 - appleby

  3. What is consent? Consent is the “autonomous authorization of a medical intervention … by individual patients.” Consent is a process that is ongoing • Patients may give their consent to a treatment • Patients may refuse to give consent to a treatment 300/330 - appleby

  4. Elements of Consent What are the 3 elements of consent? • disclosure of relevant information and its comprehension by the patient • patient capacity for responsibility (or ability to come to a decision and live with it) • voluntariness (or freedom from force, coercion or undue reward) 300/330 - appleby

  5. What are the foundations of consent? • Right to be treated as a person • Right to be treated with respect • Right NOT to be treated as an object What is involved in being a person and being treated with respect? • Capacity for rational thinking • Capacity for making our own decisions • Capacity for acting on the basis of our own decisions What ethical principle is most closely related to issues of consent? 300/330 - appleby

  6. Informed consent:the requirement of information Why must the patient be informed? • so that as the patient considers medical options, he or she has enough information to evaluate options and make a choice • so that the patient knows what alternatives are available • so that the patient understands what is likely to result from each treatment alternative and from refusal of treatment What does the physician imagine that a patient would want to know before coming to a decision? 300/330 - appleby

  7. What is the final goal of disclosing information? • to ensure that the patient’s consent to treatment is the expression of a responsible choice What is involved in making a “responsible choice”? • the patient is capable of making a choice and living with the consequences of his or her choices What counts as a responsible choice? • the patient agrees with the doctor’s recommendation? • the patient is able to take responsibility for his or her own choices 300/330 - appleby

  8. Consent must be responsible.Consent must also be voluntary. What must consent be free FROMin order to count as voluntary? • has a big reward been promised for those who consent? • has some threat been made to those who may not consent? • what would make the consequences of a choice turn into coercion? [coercion = persuade or dissuade by force] 300/330 - appleby

  9. Case of Mary Northern Mary Northern, 72, has gangrenous feet from severe frostbite and thermal burns. Without amputation, she has a 5–10% chance of surviving and will not be able to walk. With amputation, she has a 50% chance of surviving without being able to walk. Her attending doctors, nurses and judges have all alerted her to the fact her feet are not improving, that she will never walk again, and that she will very likely die if left untreated. (excerpt from “Conditional Preferences and Refusal of Treatment” by William Glod; HEC Forum; DOI 10.1007/s10730-010-9133-6) 300/330 - appleby

  10. CAST: Miss Mary Northern; Judge Todd; Judge Drowota; Rev. Sorrow; Nurse 300/330 - appleby

  11. Aid to Capacity EvaluationJoint Centre for Bioethics, Univ. of Toronto For each item, indicate YES, UNSURE, or NO to the questions. Is the patient able to understand: • the medical problem? • the proposed treatment? • the alternatives to the proposed treatment? • what refusal of the proposed treatment would mean? • the consequences of accepting the proposed treatment? • the consequences of refusing the proposed treatment? • Is the person affected by depression? • Is the person affected by delusions or psychosis? 300/330 - appleby

  12. Does Mary Northern have the capacity to give her informed consent to or refusal of treatment? Yes, she has this capacity: We are unsure because: No, she does not have this capacity: We are still unsure because: 300/330 - appleby

  13. Additional features of consent • If a patient refuses to consent to a life-preserving medical intervention, can it be initiated anyway to save a life? • If a patient suffers a sudden injury and requires treatment to save his or her life, may a physician initiate treatment without consent? • If a patient is brought unconscious into the emergency room, how should medical staff proceed? 300/330 - appleby

  14. 2 kinds of consent;lack of (or refusal to) consent • If a patient rolls up her sleeve in a laboratory setting, what will you assume? • If a patient lets you take blood for testing, will you assume that she will accept a blood transfusion? • What is the difference between explicit consent and implied consent? • If a patient refuses to accept a blood transfusion, and the physician orders one anyway, how will that action be judged? 300/330 - appleby

  15. http://as01.ucis.dal.ca/dhli/cmp_documents/documents/case_studies_2.pdfMallette v. Shulman - Ontario On June 30, 1979, Georgette Malette, a 57 year old woman living in Ontario, was rushed to the hospital following a motor vehicle accident. Mrs. Malette always carried a card with her indicating that she did not want a blood transfusion in the event where she was not able to voice her desires. This card was signed by Mrs. Malette but neither dated nor witnessed. It Read: 300/330 - appleby

  16. “As one of Jehovah’s Witnesses with firm religious convictions, I request that no blood or blood products be administered to me under any circumstances. I fully realize the implications of this position, but I have resolutely decided to obey the Bible command: “Keep abstaining…from blood.” (Acts 15:28, 29). However, I have no religious objection to use the nonblood alternatives, such as Dextran, Haemaccel, PVP, Ringer’s Lactate or saline solution.” • NO BLOOD TRANSFUSIONS! 300/330 - appleby

  17. Dr. Shulman discovered that Mrs. Malette was suffering from shock due to severe blood loss. Despite being aware of the card in her wallet, Dr. Shulman decided to perform a blood transfusion and accepted full responsibility for doing so. As an emergency department nurse, should you support or challenge Dr. Shulman’s decision? 300/330 - appleby

  18. What do you think happened? The Court found that Dr. Shulman had committed the tort of battery by administering medical treatment to Mrs. Malette without her consent… the card was an accurate, current reflection of Mrs. Malette’s wishes…the right of an adult to refuse medically necessary treatment prevails 300/330 - appleby

  19. The Law in Canada • An adult person [19 or over in most provinces] who is deemed to be competent may consent to the provision of any treatment OR • May refuse consent to any treatment – even if it is life-saving or life-sustaining 300/330 - appleby

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