Ethics Seminar Consent Overview and capacity

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Ethics Seminar ConsentOverview and capacity

• Dr. John R. Isaac
• Associate Professor
• Department of Surgery
• National University of Singapore

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Consent

• Things can and do go wrong in medical practice
• Bad outcome and adverse results occur due to
• Doctors error of ommision
• Doctors error of commision
• Known complication

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Consent

• 37 year old woman who lost her voice after
  thyroid surgery

• You did not inform me of the risks
• You told me it might happen but it is very rare
  now its happenned.
• I would not have consented to the operation if
  I had known of the risks
• You have caused my injury and failed in your
  medical duty of care to inform.

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Consent an Overview

• What is consent
• Autonomous authorisation of a medical
  intervention by individual patients Beauchamp.
  ENCY of Bioethics,
• Complex interaction between patient and Doctor
  and occurs throughout the relationship done
  correctly it strengthens the relationship
• Signature is part of the documentation which is
  part of the whole process
•  

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Consent an Overview

• Medical treatment can only be performed with the
  consent of a competent patient.
• Administering medical treatment without consent,
  would be considered a failure to respect a
  patients autonomy, violating an individuals
  right of self-determination.
• Consent must be freely given with the patient
  understanding the nature, risks, benefits,
  alternatives and limitations of the proposed
  treatment.
•   Catherine Tay

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Consent an Overview

• Consent a complex process
• Reduced to
• Disclosure giving information
• Capacity - patients understanding
• Voluntariness process of decision, free will

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Consent Capacity

• The law emphasises Doctors role not patients
• Ethics takes a balanced view ie considers the
  patients role in the process ie what the patient
  has understood-Doctor must ensure that patient
  understands

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Consent Capacity

• Diminished capacity to understand
• Case 1
• Elderly 85 yrs old
• UTI medication
• Insomnia sedatives
• Patient asked to make important decision

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Consent Capacity

• Diminished capacity to understand
• Case 1
• Confounding factors-illness,drugs
• Is physician aware of patients normal cognitive
  processes has there been a change?

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Consent Capacity

• Diminished capacity to understand
• Case 1
• Await treatment of all illness
• Reassess
• Refer for specialist opinion is needed

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Consent Capacity

• Temporary diminished capacity to understand
• Case
• Patient just told of serious diagnosis
• Anxiety, depression
• Grief reaction may last weeks
• disbelief
• shock
• anger
• acceptance
• Repeat explanations at appropriate time

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Consent Capacity

• Doctor driven diminished capacity to understand
  
• Use of technical terms
• Rapid or cursury disclosure
• No chance to ask questions

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Consent Capacity

• Permanent diminished capacity to understand
• Intelligence
• illness
• Surrogate decision making

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Consent Capacity

• Permanent diminished capacity to understand
• Surrogate decision making
• Dont ask what do you want
• Question family members on what they believe
  would be important for patient
• Try to reconstruct the patients evaluative
  understanding as closely as possible
  substituted judgement
• Preventive ethics approach eg advanced medical
  directive

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Consent Capacity

• Doctor must be sure that patient understands
  disclosure
• S/T Pt and relatives explained everything-sign
• Repeat what I just said demeaning
• Ouestioning the patient stressfull
• Usually rely of visual and verbal clues to assess
• Well crafted consent form - helpful

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Consent Capacity

• Case
• 26, female, just married perforated viscus
• Explained need for surgery
• Declined to consent deferred to husband
  cant understand
• Husband refused to consent wanted to try
  traditional medicine for 24 hours

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Consent Capacity

• Special case - emergency
• 18 yr old -ruptured liver from trauma
• Low BP, drowsy. No NOK
• ?disclosure, ?capacity
• Reasonable to proceed with surgery if
• Delay is detrimental
• Belief that reasonable person would consent to
  intended treatment
• No prior knowledge that patient would refuse
  treatment

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Consent Capacity

• Case 2
• 70 year old with early dementia
• Recently cannot manage personal affairs
• Decision needed on admission to psychiatric
  hospital pt refuses

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Consent Capacity

• Case 2
• Exclude subacute illness, drugs other psyc
  conditions
• Assess decision making capacity examine reasons
  for refusal
• Arrange for specialist psyc assessment
• Arrange for home help

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Consent Capacity

• Special case - paediatric patient
• 16 yr old - Advanced malignancy
• Conventional therapy failed
• Many months of suffering
• Experimental therapy becomes available
• Painful
• Expensive
• Not well studied
• Parents refuse, patient request treatment

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Consent Capacity

• Special case - paediatric patient
• Adolescent patients, pts with chronic illness
• are often very aware and mature
• can complete the consent process
• patients autonomy should be respected by surgeon
  and parents
• When parent child disagreement occurs physician
  should act as goodfaith negotiator

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Consent

• Practiced as a process not a one off event
• Doctor must take a personal meticulous role in
  process to assess patients understanding
• Elicit the patients understanding of illness and
  treatment
• Assist patient in developing cognitive
  understanding of situation
• Assess patients understanding
• Special situations of diminished capacity