151110P - AUTONOMY AND CONSENT TO TREATMENT

Presentation at a Surgical Specialties Grand Round King Fahad Medical City Riyadh on November 10, 2015 by Professor Omar Hasan Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics Committee King Fahad Medical City.

The Patient's Autonomous Right to Consent

• No medical procedures can be carried out without informed consent of the patient except in cases of legal incompetence.
• The patient has the purest intentions in decisions in the best interests of his or her life. Others may have bias in their decision-making.
• The patient is free to make decisions regarding the choice of physicians and treatments.
• Consent can be by proxy in the form of the patient delegating decision making to a proxy or can be prospective by means of a living will.
• Spouses and family members do not have an automatic right to consent for a competent patient. A spouse cannot overrule the patient’s choice.

Conditions of Informed Consent

• Disclosure by the physician
• Understanding by the patient
• Voluntariness of the decision
• Legal competence of the patient
• Explanation of all alternatives
• Recommendation of the physician on the best course of action
• Decision by the patient
• Authorization by the patient to carry out the procedures.
• Consent is limited to what was explained to the patient except in an emergency.

Refusal of Consent

• Refusal to consent must be an informed refusal (patient understands what he is doing).
• Refusal to consent by a competent adult even if irrational is conclusive and treatment can only be given by permission of the court.
• Doubts about consent are resolved in favor of preserving life.

Proxy Consent

• Decision by a proxy can work in two ways: (a) decide what the patient would have decided if able (b) decide in the best interests of the patient.
• The living will has the following advantages:

a.)      Reassuring the patient that terminal care will be carried out as he or she desires.

b.)     Providing guidance and legal protection and thus relieving the physicians of the burden of decision making and legal liabilities.

c.)      Relieving the family of the mental stress involved in making decisions about terminal care.

d.)     The disadvantage of a living will is that it may not anticipate all developments of the future thus limiting the options available to the physicians and the family.

e.)      The device of the power of attorney can be used instead of the living will or advance directive.

f.)       A do not resuscitate order (DNR) by a physician could create legal complications that have not been discussed thoroughly.

Consent for Children

• Competent children can consent to treatment but cannot refuse treatment.
• The consent of one parent is sufficient if the other one disagrees and the treatment is life saving
• Parental choice takes precedence over the child’s choice.
• The courts can overrule parents.
• Life-saving treatment of minors is given even if parents refuse.
• Parental choice is final in therapeutic or non-therapeutic research on children.

Mental Patients

• Mental patients cannot consent to treatment, research, or sterilization because of their intellectual incompetence.
• Mental patients are admitted, detained, and treated voluntarily or involuntarily for their own benefit, in emergencies, for purposes of assessment, if they are a danger to themselves, or on a court order.
• Suicidal patients tend to refuse treatment because they want to die.

Consent for the Unconscious

• For patients in coma, proxy consent by family members can be resorted to.
• If no family members are available, the physician does what he as a professional thinks is in the best interest of the patient.

Discussion Case #1:

A patient was brought to the emergency room by the police after attempting to kill himself by hanging. He was unconscious when first brought in and had a signed suicide note in his shirt pocket saying that he wanted to die. The doctors ignored the note and started resuscitation measures. The patient became conscious after 30 minutes and protested at the medical treatment arguing that he wanted to die. The doctor was thinking of stopping resuscitation measures when the patient’s father and wife arrived and instructed the doctor to continue resuscitation.

Discussion Case #2:

A 40-year old policeman refused surgery to drain a pyomyositis abscess. He still refused surgery after the abscess burst spontaneously. The surgeons sedated him and carried out the surgery without his consent.

Discussion Case #3:

A 42-year old actress pregnant for the first time refused an elective caesarean section because an abdominal scar would ruin her career. She continued to refuse the procedure when labor became obstructed and signs of fetal distress appeared. The obstetrician went ahead to operate on the basis of consent by the husband. The baby was delivered alive and well.

Discussion Case #4:

A conscious and competent patient told nurses on admission to the ICU that he did not want his family to be told anything about his condition. When his condition deteriorated the physicians wanted to consult his family about end of life decisions but he refused to give up his right to confidentiality.

Discussion Case #5:

A surgeon had seen a patient in OPD and had explained the surgical procedure to the patient, benefits and side-effects. The patient gave oral approval. He asked the resident to take the formal consent and have all forms signed. When the patient was wheeled into the OR the consent form was not available and the resident concerned was not on duty

Discussion Case #6:

A nurse told the surgeon that the patient on the OR table had not given anesthesia consent. The surgeon told the anesthetist to take consent quickly so that the surgery can commence.