Nursing Informed Consent Case Study
INTRODUCTION
The ethical dimensions of code of professional conduct elevate various issues regarding the patients’ autonomy and informed consent in clinical nursing and midwifery practice. This essay is an overview of the patient’s right to accept or decline their treatment as a part of patients’ autonomy in self-decision making. Some issue that faced by the health professionals in refusal of treatment are highlighted. The discussion part deeply argue about the compromised autonomy of patients and the ethical dilemmas that confront by health professionals in safeguarding wishes of patients in that situations.
The nursing and midwifery council (NMC) in the United Kingdom (U.K) has introduced new code of conduct, which is mainly to ensure …show more content…
the health and wellbeing for the public. This code of conduct, which came in to effect on 1st of may 2008, has been praised by Dr. Peter Carter, who is the Chief Executive & General Secretary of Royal college of Nursing (RCN), as “this code is perfectly fit to meet the ever changing requirements of today’s nurses and midwives” (RCN 2008). Besides, Cowan (2009) says that this is a legal binding document, which gives a special right to patients to accept or decline their treatment.
Moreover, this law helps the patients’ to have some depth information about their illness and treatment options, and helps them to clear their usual doubts such as why this treatment? Or how this treatment is related to another? (Cowan, 2009). Though in words it sounds uncomplicated, as ever with the law, devil is in detail (Miola 2009). As it has been shown in the picture 1, there will be number of issues faced by health professionals in ensuring the patients autonomy in their treatment. The main reason for that, health professionals are obliged to do what is good for the patients’ on the other hand patients’ have got a right to refuse the treatment. As we know, the freedom to exert one’s rights may be restricted by the rights of others. Let us have a brief look at the situations where the autonomy of patients’ is getting collide with the professional duty of care and advocacy role of nurses and other health professionals while ensuring the rights of patients.
The principle of patient autonomy dominates the contemporary debate over medical ethics. In healthcare perspective the main reason for concern with autonomy is to guarantee that all clients or patience are being treated as human beings and their rights are protected and promoted. Being respected as human being means, nothing is being done against their will or wishes and getting every opportunity to make decisions about their treatment (Scott, et al., 2003). On the whole, adequate information should be given by health professionals to patients to decide whether or not to accept or decline treatment and care. Failing to inform all necessary information will result in an allegation of battery or civil assault and further legal actions. The NMC code (2008) strictly says that “Make the care of people your first concern, treating them as individuals and respecting their dignity”. According to Tomkin and Hanafin (1995) respect for the autonomy of patients can be expressed as ‘consent’. Put it in other way informed consent can be viewed as an agreement between both doctor and patient as a part of their mutual decision making (Johnstone, 1989).
Booth (2002) explains that Health professional should not make any decisions about their treatment until and unless they obtaining an informed consent from the competent patients’. In order to obtain a valid consent from patient, health care professionals should make sure that all necessary information about the diseases, which includes the diagnosis, treatment options, consequences that may happen due to the treatment etc.., have given to the patient in a sensitive and understandable way. The patient should avail sufficient time to think about the information and health professionals should not hesitate to clear their doubts if they wish to ask. (An example of consent form that issued by DOH included as appendix 1) Furthermore, nurses or midwifes simply do not assume that patients will have enough knowledge to make a choice about their treatment. The NMC code (2008) strictly instructs the health professionals to uphold people’s right to be fully involved in decisions about their care.
In line with Vasey (2009), the contradictory argument against informed consent and the major ethical dilemma that may be faced by the health professionals are how much information should be exposed to the patients’? Most doctors’ believe that telling patient of all the risks of a particular treatment can do actual harm. For example, if clients are told of possible side-effects they may begin to imagine that they have them. Obviously in this occasion, patients’ would be panic and the severity of diseases may increase. In order to keep these problems away, if health professionals decided not to inform the complication of treatment then it would be against the NMC code of ethics which says “all information should be revealed to the patient to maintain the right of autonomy” and could be argued that as ‘denial of patient right to exercise autonomy’. In line with Booth (2002), in this context, there are two major questions that contradicting each other. They are:
Is it ever possible for a patient to be fully informed and if not how much information is sufficient?
If a patient is not fully informed, is the consent he or she gives incomplete?
However many health professionals believe that over concern of patients’ autonomy or patients’ right to involve in their treatment will collide with the nurses’ professional duty of care.
Also it would puzzle and restrain beneficent involvements of nurses’ in the treatment (Glasper and Richardson, 2006). For an instance, to reduce the intensity of pressure sore, nurses might have change the position of a bed ridden patient regularly. But, if the patient compliant that at being disturbed, then what would be the nurse’s stand? Should nurse agree to the patient wishes or confer with the patient to perform duty of care? This is a special situation, where the autonomy of the patient and nurse’s professional duty of care are getting collide. If the nurse compels the patient then it will be considered as an allegation of restoring to strong paternalistic behaviour (Hyland 2002) whereas, if nurse has not performed the duty of care that will be purely against nursing …show more content…
ethics.
In addition to that, the other major area that may create a moral dilemma in ensuring this right is fully maintained is the advocacy role of nurses. Leader (2006) precisely says that nurses have a moral obligation to work as an advocate for the patients. Although there are many definitions that can be drawn to the word ‘advocacy’, in the clinical aspect the advocacy role of a nurse is “creating an atmosphere that is open and supportive of the individual patient’s decision concerning care” (Hyland 2002). Even though, nurses have a unique function to act as advocates for the patient, sometimes it may not well-suited to patients. For an example, while caring diabetic patients the advocacy role of a nurse is to recommend some dietary restrictions instead of allowing the patients to eat whatever they want, regardless of the consequences. Obviously there would be a conflict between nurses duty of care and advocacy role. Furthermore, in this context, the advocacy role of the nurses restricts the patient’s right to exercise autonomy (Rumbold 2000).
Before we begin to think possible solutions for the questions that paused ethical dilemma so far, it is necessary to know a set of principles that developed by Beauchamp and Childress (2001), in order to guide nurses and other health professionals in decision making. These are namely; respect for autonomy, justice, beneficence and non-maleficence. The principle of beneficence is about the physicians’ duty to ‘do good’ for the patients’; whereas the principle of non-maleficence is about ‘do no harm’ the patients’. On the whole these prima facie moral obligations or principles instruct the health professionals to respect the patients’ autonomy and maintain justice in the treatment by ‘doing good’ and ‘do no harm’ the patients (Vasey, 2009).
However, as it has been mentioned earlier there will be many situations where the autonomy of patients and ethical principles of health professionals would collide. In these circumstances, if justice is to do with respect for the persons, then to allow them personal autonomy is just. On the other hand, if justice is about ensuring that individuals get what will be best for them then giving the best treatment would be just. As long as patients have a right to self determination, health professionals must allow them to decide for themselves which course of action to take. Sometimes patients decisions might not be the ‘healthiest’ decision, but it might be the most just (Rumbold 2000).
Discussion
Feinberg (1982) and Seedhouse (1988) argue that for someone to be defined as an autonomous person they must possess certain characteristics. These include a self-concept, self-awareness, possession of consciousness, the capacity to reason to be able to choose freely and the ability to direct his own life. In this context the ‘right to exercise autonomy’ pauses a new debate regarding ‘compromised autonomy’. This is mainly due to some patients, which include children, mentally handicapped people and people in some emergency situation such as coma, are being considered as vulnerable and incapable to take a decision for themselves. The main confronting issue is ‘is that possible to respect their autonomy? Or how health professionals may uphold patient’s wishes in these circumstances?
In the U.K children under sixteen years old children’s are not being regarded as adults. Obtaining consent from parents is the main custom and practice in the U.K while carrying out a treatment on a minor. But there will be cases in which the child’s wishes should be overruled. For example if a 14 year old girl, who seeks treatment on any Sexually Transmitted Diseases (STD), does not want wish her parents to know about her diseases, then she has every right to consent to that treatment and have her privacy respected. However there are some other situations which may appear less clear. What, for example, of the 10 year old suffering from carcinoma who does not want to undergo the amputation of a limp, the intention of which is to prolong life? In this context weather should the nurse support child’s wishes or those of the parents that the operation be carried out? (Rumbold, 2000).
The Children act 1989 states that parents have a right to give consent on behalf of child in the best interest of child Bates, et al., (2000). But what if child refuses the treatment still? However, though the children under 16 seem incompetent in front of law, they can give a legal consent if they prove they have “sufficient understanding and intelligence to enable him or her to understand fully what is proposed”. This ability is now known as “Gillick competence”. As with adults, health professionals should respect any form of request from a competent under-16 year old to keep their treatment confidential (DOH, 2001).
While caring older people or patients in coma, the application of law seems to be changing to some extent. If older people are not capable to take up with a decision regarding their treatment, it is possible for health professionals to provide treatment and care. But if not such care has been logically refused earlier in advance, and then health professionals should respect their decision. No-one even spouse or any other close to the patient never can give consent on behalf of such vulnerable patients if they refuse such treatment earlier (DOH, 2001).
The mental capacity act 2005 is an important piece of legislation which puts the patient, who requires decision making capacity, at the centre of a more holistic decision making procedure (Griffith and Tengnah, 2008).
According to Hill and Seymour (2010) the all people with dementia, learning disability, brain injury and severe mental illness will come under this act. In these circumstances, when patients have lacks of competency, health professionals, relatives, lawyers, judges can take decision on behalf of patients. In some situations the government will appoint a third party to act on best interest of patients (Ross, 2007). However this process seems to be more holistic by considering individual wishes, feelings beliefs and values of the person at the centre of the decision (Factors need to be considered in assessing mental capacity is included in appendix
2).
Though there are many arguments about maintenance of autonomy of vulnerable people, I personally believe that U.K health care system taking the best effort to ensure their rights in their treatment.
Conclusion
To sum up, patients’ right to exercise autonomy and involved in decision making about their treatment beginning to question and create some challenges to both nursing and medical ethics of paternalistic beneficence. Moreover, the underpinning principles of this right are rather complicated and make some moral dilemma to all health care professionals in ensuring these rights are fully maintained. If patients have legal competency to decide their treatment then health professionals have a moral obligation to respect their dignity and autonomy and maintain justice in treatment. While in the case of vulnerable patients, who are children, older people, mentally handicapped patients, health professionals have more right to induce a great paternalistic beneficence for the best interest of patients.
References:
Bates, P., McIntosh, N., Brykczynska, G., et al[->0]; (2000) in Guidelines for the ethical conduct of medical research involving children in Royal College of Paediatrics, Child Health: Ethics Advisory Committee. Arch Dis Child- Cited in Consent to Treatment in Children (Mental Capacity and Mental Health Legislation) in www.patient.co.uk[->1] Accessed on 29-04-2010 at 7:45 pm.
Beauchamp & Childress., (2004), – cited in Butts, J., and Rich, K., (2005) in Nursing Ethics, Jones and Bartlett Publishers, Inc
Booth, s., (2002) in a philosophical analysis of informed consent in Nursing Standard, vol: 16, No: 39, 43-46.
Butts, J., and Rich, K., (2005), in Nursing Ethics, Jones and Bartlett Publishers, Inc
Cowan, T., (2009), in Where do you stand on patient choice? In Journal of Wound Care , VOL 1 9 , NO 2, February 2009, MA health care Ltd.
DOH- Department of Health, (2001), in when adults lack capacity in Seeking consent: working with older people, Crown Copyright
DOH- Department of Health, (2001), in younger children in seeking consent: working with children, Crown Copyright.
Feinberg, J., (1982), in The Vulnerable patient- cited in Rumbold, G (2000) in Beneficence, non-maleficence and autonomy in Ethics in nursing practice Bailliere Tindall publications
Fry, T. s., and Johnstone, M.J., (2002), in Ethics in Nursing Practice: A Guide to Ethical Decision making, (2nd edi), Blackwell Publishing.
Glasper, A., and Richardson, R..,(Eds)., (2006), in A textbook of children's and young people's nursing. London: Elsevier Publication
Griffith, R and Tengnah, C, (2008) in Mental capacity act 2005: statutory principles and key concepts in British Journal of Community Nursing, Vol 13, No 15.
Hill, J., and Seymour, J., (2010), in The mental capacity act 2005: Making decisions on capacity in British Journal of Neuroscience Nursing, Vol: 6 No:4
Hyland, D., (2002) in An exploration of the relationship between patient autonomy and patient advocacy: Implications for nursing practice in Nursing Ethics., Arnold publishers, Dublin
Lachman, D. V., (2006), in Applied ethics in Nursing, Springer Publishing Company, Inc., New York.
Leader, M., (2006) in Designing a new patient centred nursing strategy in Nursing Times, VOL: 102, Issue: 25.
Miola, J., (2009), in Informed consent and the rise of autonomy in British Journal of Nursing Vol: 18, No: 8
RCN- Royal College of Nursing ,(2008), in RCN responds to the publication of new NMC Code of Conduct in www.rcn.org.uk[->2] accessed on 05/03/2010
Ross, C., (2007), in The mental capacity Act: An overview in Nursing and residential care, Vol,9, No 12.
Rumbold, G., (2000) in Beneficence, non-maleficence and autonomy in Ethics in nursing practice Bailliere Tindall publications
Scott, P., A., Välimäki, M., Leino-Kilpi, H., Dassen,T., Gasull, M., Lemonidou, C., and Arndt, M., (2003) in Autonomy, privacy and informed consent 1: concepts and definitions in British Journal of Nursing vol:12 No: 1
Seedhouse, D., (1988), in Ethics: the heart of Health care, Chichester: J, Wiley & sons publications
Tomkin, D., and Hanafin, P., (1995) in Irish medical law. Dublin: Round Hall Sweet & Maxwell
Vasey, J., (2009) in Consent and refusal: Selective respect for young person’s autonomy in Journal of Community Nursing, Vol 23, Issue 4.
Website References www.britishjouranalof nursing.com www.dh.gov.uk[->3] www.intermid.co.uk[->4] www.internurse.com[->5] www.nhs.uk[->6] www.nhsdirct.nhs.uk[->7] www.nursingtimes.net[->8]
Appendix: 1.
[NHS organisation name] consent form 1
Patient agreement to investigation or treatment
Patient details (or pre-printed label)
Patient’s surname/family name..………………………….
Patient’s first names .……………………………………….
Date of birth ………………………………………………….
Responsible health professional.……………………………
Job title ……………………………………………………….
NHS number (or other identifier)……………………………..
Male Female
Special requirements ………………………………………
(eg other language/other communication method)
To be retained in patient’s notes
Patient identifier/label
Name of proposed procedure or course of treatment (include brief explanation if medical term not clear) ………………………………………………….
……………………………………………………………………………………………………………………………………………………………………………………
Statement of health professional (to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in consent policy)
I have explained the procedure to the patient. In particular, I have explained:
The intended benefits ……………………………………………………………..……….………
………………………………………………………………………………………………………………………………………………………………………..…………………………..………………
Serious or frequently occurring risks ……………………………………………...………………
...………………………………………………………………………………………….……………
………………………………….………………………………………………..…………………….
Any extra procedures which may become necessary during the procedure blood transfusion…………………………………..…….………………………………………. other procedure (please specify) ………………………………...……...…………….…..…….
…………………………………………………………………………...………………….…..…….
I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient.
The following leaflet/tape has been provided ……………….…………………………..…
This procedure will involve: general and/or regional anaesthesia local anaesthesia sedation
Signed:…….…………………………………… Date .. …………………….……….
Name (PRINT) ………………………. ……… Job title …….. ………………….…
Contact details (if patient wishes to discuss options later) …..……………….……………
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand.
Signed ………………………….……………………. Date ………………..…………….
Name (PRINT) …………………..………………………………………………………………
Top copy accepted by patient: yes/no (please ring)
Statement of patient Patient identifier/label
Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy of page 2 which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further questions, do ask – we are here to help you. You have the right to change your mind at any time, including after you have signed this form.
I agree to the procedure or course of treatment described on this form. I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience.
I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the procedure, unless the urgency of my situation prevents this. (This only applies to patients having general or regional anaesthesia.)
I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health.
I have been told about additional procedures which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion. …………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
Patient’s signature ………………………………………….. Date…………………………..
Name (PRINT) ………………………………………………………………………………………
A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people/children may also like a parent to sign here (see notes).
Signature …………………………………………… Date ……………………..….………
Name (PRINT) ………………………………………………………………………………….…
Confirmation of consent (to be completed by a health professional when the patient is admitted for the procedure, if the patient has signed the form in advance)
On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further questions and wishes the procedure to go ahead.
Signed:…….…………………………………… Date .. …………………….……….
Name (PRINT) ………………………. ……… Job title …….. ………………….…
Important notes: (tick if applicable)
See also advance directive/living will (eg Jehovah’s Witness form) Patient has withdrawn consent (ask patient to sign /date here) ……………...……….
Guidance to health professionals (to be read in conjunction with consent policy)
What a consent form is for
This form documents the patient’s agreement to go ahead with the investigation or treatment you have proposed. It is not a legal waiver – if patients, for example, do not receive enough information on which to base their decision, then the consent may not be valid, even though the form has been signed. Patients are also entitled to change their mind after signing the form, if they retain capacity to do so. The form should act as an aide-memoire to health professionals and patients, by providing a check-list of the kind of information patients should be offered, and by enabling the patient to have a written record of the main points discussed. In no way, however, should the written information provided for the patient be regarded as a substitute for face-to-face discussions with the patient.
The law on consent See the Department of Health’s Reference guide to consent for examination or treatment for a comprehensive summary of the law on consent (also available at www.doh.gov.uk/consent[->9]).
Who can give consent
Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has “sufficient understanding and intelligence to enable him or her to understand fully what is proposed”, then he or she will be competent to give consent for himself or herself. Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign this form for themselves, but may like a parent to countersign as well. If the child is not able to give consent for himself or herself, some-one with parental responsibility may do so on their behalf and a separate form is available for this purpose. Even where a child is able to give consent for himself or herself, you should always involve those with parental responsibility in the child’s care, unless the child specifically asks you not to do so. If a patient is mentally competent to give consent but is physically unable to sign a form, you should complete this form as usual, and ask an independent witness to confirm that the patient has given consent orally or non-verbally.
When NOT to use this form
If the patient is 18 or over and is not legally competent to give consent, you should use form 4 (form for adults who are unable to consent to investigation or treatment) instead of this form. A patient will not be legally competent to give consent if:
· they are unable to comprehend and retain information material to the decision and/or
· they are unable to weigh and use this information in coming to a decision.
You should always take all reasonable steps (for example involving more specialist colleagues) to support a patient in making their own decision, before concluding that they are unable to do so.
Relatives cannot be asked to sign this form on behalf of an adult who is not legally competent to consent for himself or herself.
Information
Information about what the treatment will involve, its benefits and risks (including side-effects and complications) and the alternatives to the particular procedure proposed, is crucial for patients when making up their minds. The courts have stated that patients should be told about ‘significant risks which would affect the judgement of a reasonable patient’. ‘Significant’ has not been legally defined, but the GMC requires doctors to tell patients about ‘serious or frequently occurring’ risks. In addition if patients make clear they have particular concerns about certain kinds of risk, you should make sure they are informed about these risks, even if they are very small or rare. You should always answer questions honestly. Sometimes, patients may make it clear that they do not want to have any information about the options, but want you to decide on their behalf. In such circumstances, you should do your best to ensure that the patient receives at least very basic information about what is proposed. Where information is refused, you should document this on page 2 of the form or in the patient’s notes.
Appendix:2
Ross, C., (2007), in The mental capacity Act: An overview in Nursing and residential care
[->0] - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=10648379
[->1] - http://www.patient.co.uk
[->2] - http://www.rcn.org.uk
[->3] - http://www.dh.gov.uk
[->4] - http://www.intermid.co.uk
[->5] - http://www.internurse.com
[->6] - http://www.nhs.uk
[->7] - http://www.nhsdirct.nhs.uk
[->8] - http://www.nursingtimes.net
[->9] - http://www.doh.gov.uk/consent
The ethical dimensions of code of professional conduct elevate various issues regarding the patients’ autonomy and informed consent in clinical nursing and midwifery practice. This essay is an overview of the patient’s right to accept or decline their treatment as a part of patients’ autonomy in self-decision making. Some issue that faced by the health professionals in refusal of treatment are highlighted. The discussion part deeply argue about the compromised autonomy of patients and the ethical dilemmas that confront by health professionals in safeguarding wishes of patients in that situations.
The nursing and midwifery council (NMC) in the United Kingdom (U.K) has introduced new code of conduct, which is mainly to ensure …show more content…
the health and wellbeing for the public. This code of conduct, which came in to effect on 1st of may 2008, has been praised by Dr. Peter Carter, who is the Chief Executive & General Secretary of Royal college of Nursing (RCN), as “this code is perfectly fit to meet the ever changing requirements of today’s nurses and midwives” (RCN 2008). Besides, Cowan (2009) says that this is a legal binding document, which gives a special right to patients to accept or decline their treatment.
Moreover, this law helps the patients’ to have some depth information about their illness and treatment options, and helps them to clear their usual doubts such as why this treatment? Or how this treatment is related to another? (Cowan, 2009). Though in words it sounds uncomplicated, as ever with the law, devil is in detail (Miola 2009). As it has been shown in the picture 1, there will be number of issues faced by health professionals in ensuring the patients autonomy in their treatment. The main reason for that, health professionals are obliged to do what is good for the patients’ on the other hand patients’ have got a right to refuse the treatment. As we know, the freedom to exert one’s rights may be restricted by the rights of others. Let us have a brief look at the situations where the autonomy of patients’ is getting collide with the professional duty of care and advocacy role of nurses and other health professionals while ensuring the rights of patients.
The principle of patient autonomy dominates the contemporary debate over medical ethics. In healthcare perspective the main reason for concern with autonomy is to guarantee that all clients or patience are being treated as human beings and their rights are protected and promoted. Being respected as human being means, nothing is being done against their will or wishes and getting every opportunity to make decisions about their treatment (Scott, et al., 2003). On the whole, adequate information should be given by health professionals to patients to decide whether or not to accept or decline treatment and care. Failing to inform all necessary information will result in an allegation of battery or civil assault and further legal actions. The NMC code (2008) strictly says that “Make the care of people your first concern, treating them as individuals and respecting their dignity”. According to Tomkin and Hanafin (1995) respect for the autonomy of patients can be expressed as ‘consent’. Put it in other way informed consent can be viewed as an agreement between both doctor and patient as a part of their mutual decision making (Johnstone, 1989).
Booth (2002) explains that Health professional should not make any decisions about their treatment until and unless they obtaining an informed consent from the competent patients’. In order to obtain a valid consent from patient, health care professionals should make sure that all necessary information about the diseases, which includes the diagnosis, treatment options, consequences that may happen due to the treatment etc.., have given to the patient in a sensitive and understandable way. The patient should avail sufficient time to think about the information and health professionals should not hesitate to clear their doubts if they wish to ask. (An example of consent form that issued by DOH included as appendix 1) Furthermore, nurses or midwifes simply do not assume that patients will have enough knowledge to make a choice about their treatment. The NMC code (2008) strictly instructs the health professionals to uphold people’s right to be fully involved in decisions about their care.
In line with Vasey (2009), the contradictory argument against informed consent and the major ethical dilemma that may be faced by the health professionals are how much information should be exposed to the patients’? Most doctors’ believe that telling patient of all the risks of a particular treatment can do actual harm. For example, if clients are told of possible side-effects they may begin to imagine that they have them. Obviously in this occasion, patients’ would be panic and the severity of diseases may increase. In order to keep these problems away, if health professionals decided not to inform the complication of treatment then it would be against the NMC code of ethics which says “all information should be revealed to the patient to maintain the right of autonomy” and could be argued that as ‘denial of patient right to exercise autonomy’. In line with Booth (2002), in this context, there are two major questions that contradicting each other. They are:
Is it ever possible for a patient to be fully informed and if not how much information is sufficient?
If a patient is not fully informed, is the consent he or she gives incomplete?
However many health professionals believe that over concern of patients’ autonomy or patients’ right to involve in their treatment will collide with the nurses’ professional duty of care.
Also it would puzzle and restrain beneficent involvements of nurses’ in the treatment (Glasper and Richardson, 2006). For an instance, to reduce the intensity of pressure sore, nurses might have change the position of a bed ridden patient regularly. But, if the patient compliant that at being disturbed, then what would be the nurse’s stand? Should nurse agree to the patient wishes or confer with the patient to perform duty of care? This is a special situation, where the autonomy of the patient and nurse’s professional duty of care are getting collide. If the nurse compels the patient then it will be considered as an allegation of restoring to strong paternalistic behaviour (Hyland 2002) whereas, if nurse has not performed the duty of care that will be purely against nursing …show more content…
ethics.
In addition to that, the other major area that may create a moral dilemma in ensuring this right is fully maintained is the advocacy role of nurses. Leader (2006) precisely says that nurses have a moral obligation to work as an advocate for the patients. Although there are many definitions that can be drawn to the word ‘advocacy’, in the clinical aspect the advocacy role of a nurse is “creating an atmosphere that is open and supportive of the individual patient’s decision concerning care” (Hyland 2002). Even though, nurses have a unique function to act as advocates for the patient, sometimes it may not well-suited to patients. For an example, while caring diabetic patients the advocacy role of a nurse is to recommend some dietary restrictions instead of allowing the patients to eat whatever they want, regardless of the consequences. Obviously there would be a conflict between nurses duty of care and advocacy role. Furthermore, in this context, the advocacy role of the nurses restricts the patient’s right to exercise autonomy (Rumbold 2000).
Before we begin to think possible solutions for the questions that paused ethical dilemma so far, it is necessary to know a set of principles that developed by Beauchamp and Childress (2001), in order to guide nurses and other health professionals in decision making. These are namely; respect for autonomy, justice, beneficence and non-maleficence. The principle of beneficence is about the physicians’ duty to ‘do good’ for the patients’; whereas the principle of non-maleficence is about ‘do no harm’ the patients’. On the whole these prima facie moral obligations or principles instruct the health professionals to respect the patients’ autonomy and maintain justice in the treatment by ‘doing good’ and ‘do no harm’ the patients (Vasey, 2009).
However, as it has been mentioned earlier there will be many situations where the autonomy of patients and ethical principles of health professionals would collide. In these circumstances, if justice is to do with respect for the persons, then to allow them personal autonomy is just. On the other hand, if justice is about ensuring that individuals get what will be best for them then giving the best treatment would be just. As long as patients have a right to self determination, health professionals must allow them to decide for themselves which course of action to take. Sometimes patients decisions might not be the ‘healthiest’ decision, but it might be the most just (Rumbold 2000).
Discussion
Feinberg (1982) and Seedhouse (1988) argue that for someone to be defined as an autonomous person they must possess certain characteristics. These include a self-concept, self-awareness, possession of consciousness, the capacity to reason to be able to choose freely and the ability to direct his own life. In this context the ‘right to exercise autonomy’ pauses a new debate regarding ‘compromised autonomy’. This is mainly due to some patients, which include children, mentally handicapped people and people in some emergency situation such as coma, are being considered as vulnerable and incapable to take a decision for themselves. The main confronting issue is ‘is that possible to respect their autonomy? Or how health professionals may uphold patient’s wishes in these circumstances?
In the U.K children under sixteen years old children’s are not being regarded as adults. Obtaining consent from parents is the main custom and practice in the U.K while carrying out a treatment on a minor. But there will be cases in which the child’s wishes should be overruled. For example if a 14 year old girl, who seeks treatment on any Sexually Transmitted Diseases (STD), does not want wish her parents to know about her diseases, then she has every right to consent to that treatment and have her privacy respected. However there are some other situations which may appear less clear. What, for example, of the 10 year old suffering from carcinoma who does not want to undergo the amputation of a limp, the intention of which is to prolong life? In this context weather should the nurse support child’s wishes or those of the parents that the operation be carried out? (Rumbold, 2000).
The Children act 1989 states that parents have a right to give consent on behalf of child in the best interest of child Bates, et al., (2000). But what if child refuses the treatment still? However, though the children under 16 seem incompetent in front of law, they can give a legal consent if they prove they have “sufficient understanding and intelligence to enable him or her to understand fully what is proposed”. This ability is now known as “Gillick competence”. As with adults, health professionals should respect any form of request from a competent under-16 year old to keep their treatment confidential (DOH, 2001).
While caring older people or patients in coma, the application of law seems to be changing to some extent. If older people are not capable to take up with a decision regarding their treatment, it is possible for health professionals to provide treatment and care. But if not such care has been logically refused earlier in advance, and then health professionals should respect their decision. No-one even spouse or any other close to the patient never can give consent on behalf of such vulnerable patients if they refuse such treatment earlier (DOH, 2001).
The mental capacity act 2005 is an important piece of legislation which puts the patient, who requires decision making capacity, at the centre of a more holistic decision making procedure (Griffith and Tengnah, 2008).
According to Hill and Seymour (2010) the all people with dementia, learning disability, brain injury and severe mental illness will come under this act. In these circumstances, when patients have lacks of competency, health professionals, relatives, lawyers, judges can take decision on behalf of patients. In some situations the government will appoint a third party to act on best interest of patients (Ross, 2007). However this process seems to be more holistic by considering individual wishes, feelings beliefs and values of the person at the centre of the decision (Factors need to be considered in assessing mental capacity is included in appendix
2).
Though there are many arguments about maintenance of autonomy of vulnerable people, I personally believe that U.K health care system taking the best effort to ensure their rights in their treatment.
Conclusion
To sum up, patients’ right to exercise autonomy and involved in decision making about their treatment beginning to question and create some challenges to both nursing and medical ethics of paternalistic beneficence. Moreover, the underpinning principles of this right are rather complicated and make some moral dilemma to all health care professionals in ensuring these rights are fully maintained. If patients have legal competency to decide their treatment then health professionals have a moral obligation to respect their dignity and autonomy and maintain justice in treatment. While in the case of vulnerable patients, who are children, older people, mentally handicapped patients, health professionals have more right to induce a great paternalistic beneficence for the best interest of patients.
References:
Bates, P., McIntosh, N., Brykczynska, G., et al[->0]; (2000) in Guidelines for the ethical conduct of medical research involving children in Royal College of Paediatrics, Child Health: Ethics Advisory Committee. Arch Dis Child- Cited in Consent to Treatment in Children (Mental Capacity and Mental Health Legislation) in www.patient.co.uk[->1] Accessed on 29-04-2010 at 7:45 pm.
Beauchamp & Childress., (2004), – cited in Butts, J., and Rich, K., (2005) in Nursing Ethics, Jones and Bartlett Publishers, Inc
Booth, s., (2002) in a philosophical analysis of informed consent in Nursing Standard, vol: 16, No: 39, 43-46.
Butts, J., and Rich, K., (2005), in Nursing Ethics, Jones and Bartlett Publishers, Inc
Cowan, T., (2009), in Where do you stand on patient choice? In Journal of Wound Care , VOL 1 9 , NO 2, February 2009, MA health care Ltd.
DOH- Department of Health, (2001), in when adults lack capacity in Seeking consent: working with older people, Crown Copyright
DOH- Department of Health, (2001), in younger children in seeking consent: working with children, Crown Copyright.
Feinberg, J., (1982), in The Vulnerable patient- cited in Rumbold, G (2000) in Beneficence, non-maleficence and autonomy in Ethics in nursing practice Bailliere Tindall publications
Fry, T. s., and Johnstone, M.J., (2002), in Ethics in Nursing Practice: A Guide to Ethical Decision making, (2nd edi), Blackwell Publishing.
Glasper, A., and Richardson, R..,(Eds)., (2006), in A textbook of children's and young people's nursing. London: Elsevier Publication
Griffith, R and Tengnah, C, (2008) in Mental capacity act 2005: statutory principles and key concepts in British Journal of Community Nursing, Vol 13, No 15.
Hill, J., and Seymour, J., (2010), in The mental capacity act 2005: Making decisions on capacity in British Journal of Neuroscience Nursing, Vol: 6 No:4
Hyland, D., (2002) in An exploration of the relationship between patient autonomy and patient advocacy: Implications for nursing practice in Nursing Ethics., Arnold publishers, Dublin
Lachman, D. V., (2006), in Applied ethics in Nursing, Springer Publishing Company, Inc., New York.
Leader, M., (2006) in Designing a new patient centred nursing strategy in Nursing Times, VOL: 102, Issue: 25.
Miola, J., (2009), in Informed consent and the rise of autonomy in British Journal of Nursing Vol: 18, No: 8
RCN- Royal College of Nursing ,(2008), in RCN responds to the publication of new NMC Code of Conduct in www.rcn.org.uk[->2] accessed on 05/03/2010
Ross, C., (2007), in The mental capacity Act: An overview in Nursing and residential care, Vol,9, No 12.
Rumbold, G., (2000) in Beneficence, non-maleficence and autonomy in Ethics in nursing practice Bailliere Tindall publications
Scott, P., A., Välimäki, M., Leino-Kilpi, H., Dassen,T., Gasull, M., Lemonidou, C., and Arndt, M., (2003) in Autonomy, privacy and informed consent 1: concepts and definitions in British Journal of Nursing vol:12 No: 1
Seedhouse, D., (1988), in Ethics: the heart of Health care, Chichester: J, Wiley & sons publications
Tomkin, D., and Hanafin, P., (1995) in Irish medical law. Dublin: Round Hall Sweet & Maxwell
Vasey, J., (2009) in Consent and refusal: Selective respect for young person’s autonomy in Journal of Community Nursing, Vol 23, Issue 4.
Website References www.britishjouranalof nursing.com www.dh.gov.uk[->3] www.intermid.co.uk[->4] www.internurse.com[->5] www.nhs.uk[->6] www.nhsdirct.nhs.uk[->7] www.nursingtimes.net[->8]
Appendix: 1.
[NHS organisation name] consent form 1
Patient agreement to investigation or treatment
Patient details (or pre-printed label)
Patient’s surname/family name..………………………….
Patient’s first names .……………………………………….
Date of birth ………………………………………………….
Responsible health professional.……………………………
Job title ……………………………………………………….
NHS number (or other identifier)……………………………..
Male Female
Special requirements ………………………………………
(eg other language/other communication method)
To be retained in patient’s notes
Patient identifier/label
Name of proposed procedure or course of treatment (include brief explanation if medical term not clear) ………………………………………………….
……………………………………………………………………………………………………………………………………………………………………………………
Statement of health professional (to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in consent policy)
I have explained the procedure to the patient. In particular, I have explained:
The intended benefits ……………………………………………………………..……….………
………………………………………………………………………………………………………………………………………………………………………..…………………………..………………
Serious or frequently occurring risks ……………………………………………...………………
...………………………………………………………………………………………….……………
………………………………….………………………………………………..…………………….
Any extra procedures which may become necessary during the procedure blood transfusion…………………………………..…….………………………………………. other procedure (please specify) ………………………………...……...…………….…..…….
…………………………………………………………………………...………………….…..…….
I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient.
The following leaflet/tape has been provided ……………….…………………………..…
This procedure will involve: general and/or regional anaesthesia local anaesthesia sedation
Signed:…….…………………………………… Date .. …………………….……….
Name (PRINT) ………………………. ……… Job title …….. ………………….…
Contact details (if patient wishes to discuss options later) …..……………….……………
Statement of interpreter (where appropriate)
I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand.
Signed ………………………….……………………. Date ………………..…………….
Name (PRINT) …………………..………………………………………………………………
Top copy accepted by patient: yes/no (please ring)
Statement of patient Patient identifier/label
Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy of page 2 which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further questions, do ask – we are here to help you. You have the right to change your mind at any time, including after you have signed this form.
I agree to the procedure or course of treatment described on this form. I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience.
I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the procedure, unless the urgency of my situation prevents this. (This only applies to patients having general or regional anaesthesia.)
I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health.
I have been told about additional procedures which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion. …………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..
Patient’s signature ………………………………………….. Date…………………………..
Name (PRINT) ………………………………………………………………………………………
A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people/children may also like a parent to sign here (see notes).
Signature …………………………………………… Date ……………………..….………
Name (PRINT) ………………………………………………………………………………….…
Confirmation of consent (to be completed by a health professional when the patient is admitted for the procedure, if the patient has signed the form in advance)
On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further questions and wishes the procedure to go ahead.
Signed:…….…………………………………… Date .. …………………….……….
Name (PRINT) ………………………. ……… Job title …….. ………………….…
Important notes: (tick if applicable)
See also advance directive/living will (eg Jehovah’s Witness form) Patient has withdrawn consent (ask patient to sign /date here) ……………...……….
Guidance to health professionals (to be read in conjunction with consent policy)
What a consent form is for
This form documents the patient’s agreement to go ahead with the investigation or treatment you have proposed. It is not a legal waiver – if patients, for example, do not receive enough information on which to base their decision, then the consent may not be valid, even though the form has been signed. Patients are also entitled to change their mind after signing the form, if they retain capacity to do so. The form should act as an aide-memoire to health professionals and patients, by providing a check-list of the kind of information patients should be offered, and by enabling the patient to have a written record of the main points discussed. In no way, however, should the written information provided for the patient be regarded as a substitute for face-to-face discussions with the patient.
The law on consent See the Department of Health’s Reference guide to consent for examination or treatment for a comprehensive summary of the law on consent (also available at www.doh.gov.uk/consent[->9]).
Who can give consent
Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has “sufficient understanding and intelligence to enable him or her to understand fully what is proposed”, then he or she will be competent to give consent for himself or herself. Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign this form for themselves, but may like a parent to countersign as well. If the child is not able to give consent for himself or herself, some-one with parental responsibility may do so on their behalf and a separate form is available for this purpose. Even where a child is able to give consent for himself or herself, you should always involve those with parental responsibility in the child’s care, unless the child specifically asks you not to do so. If a patient is mentally competent to give consent but is physically unable to sign a form, you should complete this form as usual, and ask an independent witness to confirm that the patient has given consent orally or non-verbally.
When NOT to use this form
If the patient is 18 or over and is not legally competent to give consent, you should use form 4 (form for adults who are unable to consent to investigation or treatment) instead of this form. A patient will not be legally competent to give consent if:
· they are unable to comprehend and retain information material to the decision and/or
· they are unable to weigh and use this information in coming to a decision.
You should always take all reasonable steps (for example involving more specialist colleagues) to support a patient in making their own decision, before concluding that they are unable to do so.
Relatives cannot be asked to sign this form on behalf of an adult who is not legally competent to consent for himself or herself.
Information
Information about what the treatment will involve, its benefits and risks (including side-effects and complications) and the alternatives to the particular procedure proposed, is crucial for patients when making up their minds. The courts have stated that patients should be told about ‘significant risks which would affect the judgement of a reasonable patient’. ‘Significant’ has not been legally defined, but the GMC requires doctors to tell patients about ‘serious or frequently occurring’ risks. In addition if patients make clear they have particular concerns about certain kinds of risk, you should make sure they are informed about these risks, even if they are very small or rare. You should always answer questions honestly. Sometimes, patients may make it clear that they do not want to have any information about the options, but want you to decide on their behalf. In such circumstances, you should do your best to ensure that the patient receives at least very basic information about what is proposed. Where information is refused, you should document this on page 2 of the form or in the patient’s notes.
Appendix:2
Ross, C., (2007), in The mental capacity Act: An overview in Nursing and residential care
[->0] - http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=10648379
[->1] - http://www.patient.co.uk
[->2] - http://www.rcn.org.uk
[->3] - http://www.dh.gov.uk
[->4] - http://www.intermid.co.uk
[->5] - http://www.internurse.com
[->6] - http://www.nhs.uk
[->7] - http://www.nhsdirct.nhs.uk
[->8] - http://www.nursingtimes.net
[->9] - http://www.doh.gov.uk/consent