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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

COMPETENCE & CONSENT

Rels 300 / Nurs 330

October 2013

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recommended on line resource
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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what is consent
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

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elements of consent
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)

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what are the foundations of consent
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?

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informed consent the requirement of information
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?

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what is the final goal of disclosing information
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

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consent must be responsible consent must also be voluntary
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]

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case of mary northern
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)

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aid to capacity evaluation joint centre for bioethics univ of toronto
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?

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does mary northern have the capacity to give her informed consent to or refusal of treatment
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:

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additional features of consent
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?

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2 kinds of consent lack of or refusal to consent
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?

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http as01 ucis dal ca dhli cmp documents documents case studies 2 pdf mallette v shulman ontario
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:

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“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!

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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?

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what do you think happened
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

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the law in canada
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

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