Practice issues related to Practice issues related to patient self-determination patient self-determination

chapter 11chapter 11

Autonomy and paternalismAutonomy and paternalism

• Self-determination derives from the principle of autonomy.– Autonomy: freedom to make choices about

issues that affect our life & make decisions about personal goals.

- Self governing implies respect for person, the ability to determine personal goals and decide on a plan of action and the freedom to act on the choices made

Paternalism (discussed in chapter 3)• Paternalism: Acting in fatherly manner, role

behavior as leadership• Parentalism: non-gender term, parallel

• Paternalism: professionals who restrict others’ autonomy, usually to protect the person from perceived or anticipated harm

• Appropriate: incompetent pt, diminished decision making capacity

Decisions may reflect the interests of HCPs more than the pt. ( sedated pt, agitation/ confusion) to make life easier for the staff or for the benefit of the pt

Factors affect patient’s autonomyFactors affect patient’s autonomyFactors threatening patient’s autonomy

-Paternalistic attitudes (dependent role of pt)

-Assumption of pt’s values -Failure to appreciate a difference in

knowledge level regarding health matters -Focus on technology rather than caring.

Factors limiting patient’s autonomy- Requests outside accepted standards of

care or contrary to practitioner’s own ethical views.

- Availability of resources - Economic circumstances

• Justice implies fair, equitable, and appropriate treatment

• Considers the needs of family and society as well as our own desires. (limited availability and expense → brings such questions).

Informed consentInformed consent

It provides legal protection of patient’s rights to personal autonomy

It includes the opportunity to choose or refuse

This meansThis means::

• Pt given the opportunity to autonomously choose a course of action in regard to plans for health care

• To choose from available therapeutic alternatives

• The choice includes the right to refuse intervention or recommendation about care

Ethical and legal elements of Ethical and legal elements of informed consentinformed consent

Ethically valid consent is a process of shared decision making based upon mutual respect and participation

Information Consent

• Exception to informed consent include:-– Emergencies there is no time to disclose

information– Waivers by patient who not want to know

Emergencies of Informed ConsentEmergencies of Informed Consent (IC) (IC)

• it has been affected by several factors– Institutionalization of health care associated

technologies and prolonging life– The court– In home visit IC not necessary

Ethical and legal elements of ICEthical and legal elements of IC

• Information (sufficient not as book )– the nature of health concern and

prognosis – description of all treatment options – benefits, risks, and consequences of

various treatment including not intervention

How to determine the adequacy of How to determine the adequacy of informationinformation

• The professional practice standard—disclosure consistent with standard

• The reasonable person standard—disclosure is what reasonable person in similar circumstances would need to make a decision

• The subjective standards—what particular person wants or need to know

• Verification of understandings accomplished through discussion ( ask questions and described their understanding)

ConsentConsent

• Implies the freedom to accept or reject it• Must be voluntary /without force, coercion

or manipulation • Obtaining consent: no common language

The role of the nurse in the ICThe role of the nurse in the IC

• Advocate (ensure all criteria met)• Act if the nurse believes that pt does not

understand implication of any part – Inform the physician and requesting further

information – Stop the process– Require signature on consent form– Nurse’s signature attests that pt is giving

consent willingly, competent

Witnessing patient sign and document any communication or teaching done– Importance of nursing documentation for their

communication of any concern (language, reading or writing ability)

Competence: Means the ability to take a meaningful life decision which requires a legal actions

Decision Making CapacityDecision Making Capacity

• Is a medical determination relating only to the issue at a hand

• Ability to take a reasonable decisions which is required in the IC

• We need here the patient or his surrogate

Elements for Decision Making CapacityElements for Decision Making Capacity

Have the ability to understand all information

Have the ability to communicate understanding and choices

Have personal values & goals that guide decision

Reason & deliberate

Decisions About CompetenceDecisions About Competence

• Persons are considered competent unless there is a ruling by a judge that they can’t make meaningful decisions

• In the case of children usually parents or legal guardian

• Adult ---spouse, parent, adult children

Legal process for choosing a Legal process for choosing a SurrogateSurrogate

• Willing to serve in this role (can make decision in accordance with pt’s wishes

• Should demonstrate care and concern • **decisions made by surrogate should

reflect the pt’s values ,cultural , and spiritual perspective

Advance DirectivesAdvance Directives

It is instructions that indicate health care interventions of when to initiate, withhold, in the event of unability (loss of decision making capacity).

Designate some one who will act as a surrogate in making decisions

• Pt should be encouraged to express their wishes about tube feeding breathing machine, CPR

• **verbally• **writing• Include how long to stay on an intervention• Presence of clearly advance directive can

alleviate stress on family and clinician dealing with end of life concern

It contains two thingsIt contains two things

o Living wills: legal document that give direction to withhold or withdraw life support intervention

o Durable power attorney allow a competent person to act on behalf of the patient in making health care decisionso No particular form, 2 witnesso Authority does not become effective until it has been

determined that person loss capacity for decision

Pt self determination act (PSDA)Pt self determination act (PSDA)

• Provide written information to adult pt regarding their rights to make health care decisions, such decisions include the right to refuse treatment and to write advance directive for guiding decisions should they become incapacitated

Nsg role in advance directiveNsg role in advance directive • Ensuring that pt have an opportunity to complete

advance directive• To know state’s statues that guide and govern

advance directive• Explore pt and family understanding of the

information received• Informing other health team member of the

presence and content of advance directive• Increase public awareness about advance

directive through pt and community education research

Choices concerning life and healthChoices concerning life and health..1 .Choices regarding recommended treatment

- Noncompliant pt (challenging), or make unhealthy choices

- Complementary therapies. massage, healing touch

2 .Controversial choices - Abortion

- Reproductive rights - Active euthanasia

- Issues related to HIV/AIDS3 .Confidentiality

• Many people who come into our care are suffering from ill effect of such thing as overeating, tobacco, drug , work related stress

• Our job to deal with present health concern (change toward healthier living)

• Pt not willing to follow the treatment plan• Unhealthy life practices are part of the whole

person and should be taken into consideration in plans of care

Issues related to use of complementary Issues related to use of complementary therapies (CT)therapies (CT)

1 .People have the right to use modalities other than conventional medicine to address their health needs.

2 .Nurses need develop some knowledge of such therapies. Be nonjudgmental in decision regarding all modalities being used.

3 .CT should not be discounted, council the pt to explore the validity of claims made about particular therapy.

4 .In research: whether informed consent will needed to acknowledge CT

5 .Expert CT nurses: need to know what CT are within their scope of practice. Nurse should be disclose and document of their use

Controversial choicesControversial choices

-The value of pt self-determination support two controverter issue: abortion and active euthanasia.

-Affected by ethical and religious opinion and debate.

AbortionAbortion

-Mother’s right to control her body and her life ( right to choose) in contrast to right of unborn fetus to chance at life (right to life).

-Values involved: believe when life begins, QOL, unwanted children, mother’s life and health.

-Who has rights & whose rights take precedence .

abortionabortion

• Woman’s intentional termination of pregnancy

• The central ethical dilemmas debates is about right– right of life of the fetus– woman’s right to control her own body by

choosing whether or not to carry a pregnancy to term

AbortionAbortion

• Value of self determination needed when -Abortion -EuthanasiaSome believe that life starts at

conception, while others hold that life begins only when fetus is viable outside the womb

Values that took into consideration Values that took into consideration in abortionin abortion

When life beginQuality of life for the un wanted childrenConcern’s about mothers health & lifeOther reproductive issues Contraceptive use C/S decision

opponents of abortionopponents of abortion

• Hold the position that because fetus possesses humanity, it must be accorded all human right including the right to life (pro-life view)

Proponents of abortionProponents of abortion

• Argue that based on autonomy, a women has a right to her own body, and no women should be forced to bear a child that she does not want (pro-choice view)

EuthanasiaEuthanasia

• … Painless death, removal of artificial interventions to cause death, here personal values of the patient & family & nurse may have different view

Active voluntary euthanasiaActive voluntary euthanasia

• Is an act in which the physician both provides the means of death and administration it such as lethal dose of medication

Assisted suicideAssisted suicide

• The pt receive the means of death from someone, such as a physician but activate the process themselves

• Justification by proponents• Relief of pt’s suffering

Active euthanasia/assisted suicideActive euthanasia/assisted suicide

-Illegal -Possible considerations: HCPS non

adherence to pt wishes regarding end of life issue, fear about prolonged suffering, lack of control.

-Natural dying is always the best choice .

Issue related to HIV/ AIDSIssue related to HIV/ AIDS -We should remember that not all cases result

from lifestyle choices. -Treatment pt regardless their values or lifestyle

-Be aware of judgmental attitudes toward persons with HIV

-Risks of exposure HCPs: autonomy and confidentiality in relation to HIV testing and status.

-It is illegal to do the test without written consent -Stigma and discrimination

-Positive health care worker/ mandatory testing: autonomy, confidentiality, nonmaleficence.

ConfidentialityConfidentiality -In order to care: nurses disclosed secret

information -without assuring confidentiality: people hide

important information for Dx and Tx -Especially true situation where there is stigma

-Pt’s trust is sacred, and any breach of confidentiality is violation of this trust.

-Factors override confidentiality: court cases, potential harm for the pt or others .

Thank you for listening