Consent, Capacity, and Competency Issues

a patient with end-stage renal disease has decided not to have dialysis. the family is upset and advises the nurse that they would like to overrule the patient's decision. what is the appropriate response to provide to the family?

a. explain the process of determining a patient's capacity to provide informed consent as well as a patient's right to autonomy if capable of decision-making. educating the family about decision making, capacity, and competence is an important component of health care. patients have a right to make their own health care decisions unless they lack the capacity to do so. advising the family that they can overrule a patient who has capacity is not accurate; nor is advising the family that a patient who lacks capacity can make decisions. suggesting that the family go to court can create unnecessary conflict in the family; a better course of action would be to engage the patient and family in a discussion of the decision.

a patient presents to the emergency department with a torn left quadriceps muscle. the pain is so intense that the patient is unable to answer questions during the examination. a determination is made that the patient needs immediate surgery. what is the first action the nurse should take?

a. immediately administer the ordered pain medicine the priority nursing action is to administer the ordered pain medication and determine whether that will remove the temporary barrier to informed consent. impairments of capacity may be temporary or permanent. examples of temporary impairment include pain, some forms of mental illness, delirium, extreme anxiety, and the effects of medications. such temporary barriers may give the false impression of impaired capacity. the nurse can ask the patient for the surrogate information and keep trying to reach a family member; however, the ordered pain medications should be administered first. this circumstance is not a situation in which the patient would suffer imminent harm (i.e., loss of life or limb) without emergency intervention; thus, emergency privilege or implied consent is not present. preparing for transfer to the operating room is an inappropriate first action unless the situation is an emergency.

the nurse is making a note in the patient's record about preparation for a medical procedure scheduled for 9:00 AM. the nurse notices that no informed consent is in the record. what is the correct nursing action at this time?

a. inform the practitioner that no informed consent form is in the record and then document this action. the nurse should inform the practitioner that no informed consent is in the record and then document this action. the practitioner has the legal duty to obtain informed consent before any medical procedure is performed. however, the nurse can be held liable for professional negligence and battery when the nurse knows, or should have known by checking the patient's record, that the practitioner did not obtain informed consent. merely making a note in the record or telling the nurse manager that no informed consent is present does not resolve the issue. sending the patient for the procedure without an informed consent is inappropriate. the practitioner is responsible for completing the informed consent, and the nurse may witness and sign the consent when directly observing the patient sign the consent. if a consent is not present, the nurse must inform the practitioner before the procedure, and the practitioner is responsible for completing the consent. if the practitioner does not obtain consent, the nurse should inform the unit manager or supervisor.

the preceptor is teaching a new nurse about informed consent. which statement by the new nurse indicated that further education is needed.

b. "capacity is a legal determination made by a court of law." determining whether a patient has capacity to make medical decisions is a clinical decision made by the practitioner, not by a court of law. a finding of competence, not capacity, is a judicial determination that a person is able to manage the person's own affairs and estate. the patient's capacity to make medical decisions is critical to the process of informed consent. when a patient is said to have capacity, it means the patient is recognized as having the ability to make medical decisions. if a person does not have capacity, a surrogate is needed to make decisions on the patient's behalf.

a patient is brought via ambulance to the local emergency department. the patient is found to be unresponsive and in need of emergency surgery to stop bleeding. what should the nurse be aware of?

b. the surgery can proceed without informed consent from the patient in this situation, the surgery can proceed without informed consent from the patient. the standard for emergency treatment without informed consent is whether the patient would suffer imminent harm in the amount of time required to find or appoint a surrogate. in this scenario, time is the essence, and irreparable harm will occur before a surrogate is appointed or a family member is contacted. the nurse cannot act as a surrogate decision maker for a patient.

a patient has been admitted for a surgical procedure and has completed the education process and signed consent. on the morning of the scheduled procedure, the patient reports no longer wanting to proceed with the procedure. what is the best response the nurse can provide?

c. "I will advise your surgeon that you've changed your mind and would like to withdraw your consent." the patient should be told that the practitioner would like to withdraw consent. patients have a right to change their mind and withdraw consent, and the practitioner must be notified. telling a patient that it is too late or inconvenient to change the plan is not appropriate. although a patient may be nervous, providing medication at the point when the patient verbally withdraws consent will complicate the situation.

an adolescent patient is admitted after a car crash. assessment reveals that the patient is in critical condition and requires emergency surgery. what is the nurse required to do in this case?

c. prepare the patient for surgery because consent is not required in an emergency situation. in an emergency situation, consent is not required; it is assumed. although notifying the parents as soon as possible is important, delaying emergency medical intervention in an attempt to gain consent is inappropriate. an adolescent's consent cannot substitute for parental consent, nor is an ethics consultation necessary in an emergency.

a nurses speaking to a 15-year-old patient who was admitted during the previous shift. the patient has been diagnosed with acute leukemia and is scheduled for the first round of chemotherapy. the patient tearfully states, "I don't want to do this. they can't make me do this. I haven't said they could do it." what is the best nursing action in this situation?

d. ask if the patient would like to talk more with the practitioner about the procedure and related concerns and fears. to allay fears and concerns, the nurse should have the patient talk more with the practitioner. having an adolescent patient assent to treatment is good practice. the nurse cannot predict the patient's outcome; therefore, reassuring the patient that it will be okay is inappropriate. asking whether the patient would like to play a video game or watch a movie does not validate the patient's emotions. explaining that the patient may act independently in a few more years also does not validate the patient's concerns.

a confused older adult is admitted for a hip replacement. the nurse reviews the consent form in the patient's record and sees that it has been signed by the patient and the practitioner. what is the first thing the nurse should do?

d. notify the practitioner about concerns regarding the patient's capacity to make an informed medical decision based on the patient's confused state. if the patient is confused and the nurse has concerns about the patient's ability to provide an informed consent, the nurse must notify the practitioner about these concerns. ignoring the issue of the patient's confusion, processing the paperwork and signing the form as a witness, and preparing the patient for surgery without clarifying concerns about the patient's capacity for informed consent are inappropriate actions and could lead to liability for the nurse.

a patient scheduled for a minor procedure is seen by the practitioner and given sedating medication before the nurse has checked the patient's record. upon locating the consent form in the patient's record, the nurse discovers that it has not yet been signed by the patient, only by the practitioner, who reports receiving verbal consent from the patient. what is the appropriate nursing action?

the nurse should advise the practitioner that because there is no signed consent from the patient, preparations for the patient's procedure cannot proceed. a signed consent form is required for all medical procedures. only in emergency cases can one forego consent. the practitioner cannot sign for the patient; nor is a consent acceptable that is signed after the patient has received sedating medications because sedation may impact a patient's ability to understand information and ask questions.