1. Rels 300 / Nurs 330 22 October 2015 THE HEALTH CARE PROFESSIONAL / PATIENT RELATIONSHIP

2. Models of Illness & Medicine ALLOPATHIC MEDICINE = diseases are treated by producing effects that are different from those produced by the illness; the disease is fought HOMEOPATHIC MEDICINE = diseases are treated by inducing effects that are similar to those produced by the illness; substances that produce similar symptoms in healthy people are used 300/330 - appleby2

3. Western Medicine is Allopathic Diseases are seen as invaders or enemies of the person and his or her well-being Medical profession seeks to eliminate disease from the person Persons “have a disease” that is separate from their normal well-being Physicians treat the disease to erase its effects Patients themselves may be expected to be fairly passive in the healing process 300/330 - appleby3

4. Exploring models of the physician- patient relationship Robert Veatch (1972 article); May (1975 article); Childress & Siegler (1984 article); Emanuel & Emanuel (1992 article) Many possible models discussed, including Engineering, Informative or Consumer model Priestly, Paternalistic or Parental model Collegial or Interpretive model Contractual model Covenantal model 300/330 - appleby4

5. Collier & Haliburton’s terms: 1. Engineering model 2. Paternalistic model 3. Contractual model 4. Covenantal model 300/330 - appleby5

6. 1. The Engineering Model Physician is a medical engineer or technician Has particular training and expertise Offers medical services to patients When medical decisions must be made, the physician presents all of the relevant clinical facts and options  Patient then considers his or her own values and comes to a decision  Physician carries out the procedure 300/330 - appleby6

7. 2. The Paternalistic Model Physicians are like a parent or priest who knows what is best for another person Physicians have superior education and clinical judgement; patients have limited medical knowledge and capacity for complex understanding  Patient should not be presented with alternatives that are not in his or her best interests  Patient should be guided in making decisions by the physician who knows best 300/330 - appleby7

8. 3. The Contractual Model Physicians and patients each have responsibilities to the other that simulate a 2-party contract Both parties have obligations to share information and work together towards medical decisions  When there is agreement, a mutual decision can be reached  When there is disagreement, then either party can opt out of the therapeutic contract 300/330 - appleby8

9. 4. The Covenantal Model Physicians and patients have reciprocal and enduring relationships Physicians benefit from educational opportunities, social esteem and regard Patients benefit from the experience and medical expertise of their physicians  Mutual & reciprocal relationships have the potential for long-term benefits in promoting health and minimizing the effects of disease  Covenantal fidelity provides mutual benefits 300/330 - appleby9

10. What role does the patient play? 1. Engineering model – patient is seeking a medical technologist to provide a therapy 2. Paternalistic model – patient is like a dependent child seeking guidance and care 3. Contractual model – patient is a consumer of medical services who is free to enter into and break the contract for medical care 4. Covenantal model – patient is a partner working towards mutual well-being 300/330 - appleby10

11. The Nurse/Patient Relationship Historical (and largely ongoing) context of hierarchical relationships among health care providers, especially within a hospital setting Physicians generally have more power than nurses and may discharge their duties by writing orders that nurses fulfill Where it is the nurse who provides ongoing personal care for patients, the nurse does not have the authority to modify care plans independently 300/330 - appleby11

12. Nurses as ADVOCATES Within the health care team, no one is likely to provide greater continuity of care than the nurse If the nurse is witness to patient dissatisfaction with treatment orders, or confusion or disagreement among the patient’s family, the nurse is uniquely positioned to make the decision-making process explicit Where teamwork is valued, the nurse can make valuable contributions to the ethical process by raising alternative paths & voicing the patient’s concerns 300/330 - appleby12

13. 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 300/330 - appleby13

14. Elements of Consent What are the 3 elements of consent? 1. disclosure of relevant information and its comprehension by the patient 2. patient capacity for responsibility (or ability to come to a decision and live with it) 3. voluntariness (or freedom from force, coercion or undue reward) 300/330 - appleby14

15. 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? 300/330 - appleby15

16. 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) 300/330 - appleby16

17. CAST: Miss Mary Northern; Judge Todd; Judge Drowota; Rev. Sorrow; Nurse 300/330 - appleby17

18. Aid to Capacity Evaluation Joint Centre for Bioethics, Univ. of Toronto For each item, indicate YES, UNSURE, or NO to the questions. Is the patient able to understand: 1. the medical problem? 2. the proposed treatment? 3. the alternatives to the proposed treatment? 4. what refusal of the proposed treatment would mean? 5. the consequences of accepting the proposed treatment? 6. the consequences of refusing the proposed treatment? 7. Is the person affected by depression? 8. Is the person affected by delusions or psychosis? 300/330 - appleby18

19. 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: 300/330 - appleby19