Ethics: Autonomy

*See the 4 box method slide (slide 21)*

*See the 4 box method slide (slide 21)*

*See the 7 step process of ethical decision making in patient care slide (slide 22)*

*See the 7 step process of ethical decision making in patient care slide (slide 22)*

1. Pt understands the situation/condition and relevant medical information 2. Pt appreciates the nature and significance of their treatment options 3. Pt can relate the treatment options to their own values/preferences 4. Pt can evaluate the options and make a reasoned choice 5. Pt can express a consistent choice (i.e. the patient has a stable set of values over time)

5 requirements a patient must meet to have decision making capacity?

No - Don't confuse a constrained range of choices with a lack of autonomy

A doctor has provided a patient with a narrow range of choices regarding their medical care. Has this patient lost their autonomy?

Competence - Health professionals determine if a pt is competent

A legal determination of the capacity a pt has to make autonomous medical decisions?

No - A broad view of autonomy includes the ability to *understand and apply relevant* information* when making clinical judgements; patient autonomy is not an unqualified right to choose.

A patient who has misinterpreted medical information they found online requests an unnecessary and harmful intervention. Does denying their request for this intervention eliminate their autonomy?

Palliative care

A patient with a terminal disease wants to forego care. What should you offer them next?

Respect for autonomy - Patient-physician encounters are better captured by the idea of respect for autonomy than by the abstract principle of autonomy

Acknowledging that a person has a right to hold views, make choices, and take actions, based on their personal values and beliefs?

Sliding-scale strategy - Increased risk requires the patient to demonstrate increased capacity in order for them to be allowed to make a decision

Approach to assessing a patients decision making capacity that allows for standards of competence in decision making to change with increasing risk?

No - This patient has waived consent. Ethically and legally, a patients request to waive the right of informed consent should be respected.

Before being given informed consent, a patient says "you do whatever you think is best doc." Do you still need to give this patient informed consent before proceeding with treatment?

Legal conduct - Something unethical is not necessarily illegal and something illegal may not necessarily be unethical

Conduct that conforms to written law?

Moral conduct

Conduct that is based on judgement of what is right or wrong and conforms to the accepted conventions of people, but fails to provide a clear direction in clinical situations?

Ethical conduct - Ethical conduct has a clinical framework (oaths, credentialing boards, AMA)

Conduct that is based on moral principles and often focuses on *why* something is right or wrong?

No - You do not need to obtain informed consent in emergencies

Do you need to obtain informed consent if delaying treatment might jeopardize a patients health?

Implied consent - Should not be used when informed consent is feasible or if it is known that a particular treatment is not wanted

Doctrine which states that because reasonable persons would consent to treatment in emergencies, physicians can assume that the patient in question would also consent?

Never competent

Exception to informed consent in which the patient is legally determined to be incompetent (cannot make adult decisions), and has a court appointed guardian?

Moral distress - Other factors that can lead to moral distress include lack of time, supervisory reluctance, an inhibiting medical power structure, institutional policy, or legal considerations

Form of distress brought on by knowing what to do but not doing it (i.e. institutional constraints making it nearly impossible to pursue the right course of action)?

Ethical distress

Form of distress that is brought on by not knowing what is the right thing to do?

No - Using patient autonomy to justify unnecessary tests/procedures violates professional integrity

Is it ethical to use the principle of patient autonomy to order a non-beneficial test at the patients request?

Orientation (to time, space, etc) Attention span Immediate recall Long-term memory Calculating ability

Mental status testing may be inadequate to determine decision making capacity. A patient can have deficits in one or more of what 5 areas, but still have decision making capacity?

Event model

Model of informed consent in which consent is gained during a single event, and usually involves the signing of a legal document (i.e. consent form)?

Process model

Model of informed consent in which there is an ongoing discussion between healthcare providers and the patient/family/surrogate which affords the opportunity for education, questions, weighing of risks/benefits, and shared decision making?

Shared decision making - Allows each participant to better understand the relevant factors and allows for shared responsibility in the decision.

Process of communication between patients and physicians in which patients describe their values and preferences, and physicians present prognosis and treatment options in order to reach an agreement on a course of treatment?

Crepe Hanging

Refers to a medical practitioner painting an overly bleak picture for the purposes of protecting themselves from possible litigation?

Informed consent -Informed consent can be thought of as a process of shared decision making between the physician and patient

Refers to a physician creating meaning in the mind of the patient as to what the physician is planning to do (i.e. a procedure/ test)?

Framing

Refers to chunking information into small bites with frequent breaks to verify that the patient is comprehending the information?

Coercion

Refers to intentionally using a credible and severe threat of harm or force to control another?

Autonomy

Refers to self-rule free from controlling interference by others and from limitations, such as inadequate understanding, that prevents meaningful choice?

Decision making capacity - Think about decision making capacity as an ability to make an informed decision (consent or refusal) for a specific task.

Refers to the capacity of a patient to give or withhold informed consent, or the capacity to refuse/accept medical interventions?

Manipulation

Refers to the incomplete or less than truthful presentation of information, such as lying, omitting vital facts, or deceiving the patient?

Persuasion

Refers to the process through which we create, shape, and reinforce the beliefs of another person?

Therapeutic privilege - "It will upset them" is not a reason to refrain from informing a patient

Uncommon *exception to informed consent* where a physician may be excused from giving information to a patient when it would pose a serious psychological threat or medical contraindication?

Decision in favor of a plan Authorization of that plan

What 2 elements of informed consent are considered *Consent elements*?

Decision making capacity Voluntariness

What 2 elements of informed consent are considered *threshold elements (preconditions)*?

Disclosure of material information Recommendation of a plan (from the physician) Understanding of the information and recommendation (by the patient)

What 3 elements of informed consent are considered *information elements*?

1. Receive information 2. Process information 3. Store information 4. Retrieve information - Possible challenges to the capacity to understand include brain injury, dementia, mental illness, delirium, trauma, etc

What 4 abilities must a patient possess in order to have the capacity to *understand*?

1. Respect for persons (patient autonomy) 2. Beneficence (provide a benefit) 3. Nonmaleficence (do no harm) 4. Justice (treat persons fairly)

What are the 4 ethical guidelines?

1. The guidelines are broad and overarching 2. The guidelines are empty of content 3. Meaning is derived from the facts and context of the case 4. The guidelines may provoke conflicting duties

What are the 4 limits of the guidelines we use for ethical decision making?

1. Decision making capacity 2. Voluntariness 3. Disclosure of material information 4. Recommendation of a plan 5. Understanding of the information and recommendation 6. Decision in favor of a plan 7. Authorization of that plan

What are the seven elements of informed consent?

Patient preferences may not be in line with what we consider ethical

What is a major limit to shared decision making?