1. Practice Issues Related to Patient Self-Determination Chapter 11 April 18, 2013

2. Autonomy and Paternalism
- Self-determination derives from the principle of autonomy.
Autonomy: freedom to make choices about issues that affect our life & make decisions about personal goals.
Self governing implies respect for person, the ability to determine personal goals and decide on a plan of action and the freedom to act on the choices made

3. Paternalism
Acting in fatherly manner where fathers are granted the right and responsibility to use their supposedly superior knowledge and judgment to make decisions on behalf of other family members, role behavior as leadership

4. - In health care area means making the decision on behalf of pt without their full consent or knowledge
- Decisions may reflect the interests of HCPs more than the pt. ( sedated pt if they are agitation/ confusion) so in this way we use medication to make life easier for the staff or for the benefit of the pt?

5. Factors affect patient’s autonomy
Factors threatening patient’s autonomy
- Paternalistic attitudes (dependent role of pt)
- Assumption of pt’s values
- Failure to appreciate a difference in knowledge level regarding health matters
- Focus on technology rather than caring.

6. Factors limiting patient’s autonomy
- Staff are not obligated to accept requests from pt or families that is outside accepted standards of care or contrary to practitioner’s own ethical views.
- Availability of resources
- Economic circumstances

7. Justice considered to be along with autonomy which implies fair, equitable, and appropriate treatment Considers the needs of family and society as well as our own desires. (limited availability and expense → brings such questions) Who deserve the intervention? Who is expected to pay for it?

8. Informed Consent
IC: a process by which pt are informed of the possible outcomes, alternatives, and risk of treatment and required to give their consent freely
-It provides legal protection of patient’s rights to personal autonomy
-It includes the opportunity to autonomously choose or refuse

9. This means
-Pt given the opportunity to autonomously choose a course of action in regard to plans for health care -To choose from available therapeutic alternatives -The choice includes the right to refuse intervention or recommendation about care

10. Ethical and legal elements of informed consent
Ethically valid consent is a process of shared decision making based upon mutual respect and participation -Information -Consent

11. Exception to informed consent include:-
-Emergencies there is no time to disclose information -Waivers by patient who not want to know their prognosis or risk of treatment

12. Emergencies of informed consent
It has been affected by several factors
1)Institutionalization of health care in hospitals associated with their technologies and life- prolonging technique over which people have limited understanding
2)The court influence the shaping the doctrine of IC
3)In home visit IC not necessary because people can control and better understanding of the traditional remedies

13. Ethical and legal elements of IC
-Information (sufficient not as book ) include the nature of health concern and prognosis -Description of all treatment options, even those that the health care provider does not favor or cannot provide -Benefits, risks, and consequences of various treatment including non- intervention

14. How to determine the adequacy of information
-The professional practice standard- the disclosure is consistent with standards of the profession
-The reasonable person standard-disclosure what reasonable person in similar circumstances would need to make a decision
-The subjective standards-what particular person wants or need to know

15. Verification of understandings accomplished through discussion ( ask questions and described their understanding)

16. Consent -Implies the freedom to accept or reject it
-Must be voluntary /without force, coercion or manipulation from health care provider or family

17. The role of the nurse in the IC
Advocate (ensure all criteria met) Act if the nurse believes that pt does not understand implication of any part a- Inform the physician and requesting further information b-Stop the process until it is ensured that the decision can be made autonomously c-Require signature on consent form

18. Witnessing patient's signature implies accountability on the part of the nurse Nurse’s signature attests that pt is giving consent willingly and competently Importance of nursing documentation for their communication with the pt or the physician regarding any questions of any concern related to informed consent ( special circumstances like language, reading or writing ability should be documented)

19. Decision Making Capacity
*Is a medical determination relating only to the issue at a hand
*Ability to take a reasonable decisions which is required in the IC
*If the decision seems unreasonable, however, it is important to explore the pt capacity regarding decision making
*We need here the patient or his surrogate

20. Elements of decision making capacity
-Ability to understand all information -Ability to communicate understanding and choices -Personal values & goals that guide decision -Have the ability to reason & deliberate

21. Decisions about competence
Competence means the ability to take a meaningful life decision which requires a legal actions
Persons are considered competent unless there is a ruling by a judge that they can’t make meaningful decisions
In the case of children usually parents or legal guardian act as surrogate

22. Legal Process for Choosing a Surrogate
-Willing to serve in this role (can make decision in accordance with pt’s wishes) -Should demonstrate care and concern -Decisions made by surrogate should reflect the pt’s values, cultural, and spiritual perspective

23. Advance Directives
Instructions that indicate health care interventions when to initiate, withhold, in the event of inability (loss of decision making capacity).
Designate someone who will act as a surrogate in making decisions

24. **Patients should be encouraged to express their wishes about tube feeding, breathing machine, CPR, or dialysis
**verbally or
**writing
**Include how long to stay on an intervention if no improving
**Presence of clearly advance directive can alleviate stress on family and clinician dealing with end of life concern

25. Types of AD’s
Living wills: legal document that gives direction to health care provider to withhold or withdraw life support intervention
Durable power attorney : allow a competent person to act on behalf of the patient in making health care decisions
No particular legal form but, the designation must be in writing, 2 witnesses other than the designated surrogate
Authority does not become effective until it has been determined that person loss capacity for decision making

26. Patient Self-Determination Act
Health organizations should provide written information to adult pt regarding their rights to make health care decisions, such decisions include the right to refuse treatment and to write advance directive for guiding decisions when they become incapacitated

27. Nursing Role in Advance Directive
*Ensuring that pt have an opportunity to complete advance directive and following through with pt wishes as expressed through these directives. *Explore pt and family understanding of the information received *Informing other health team member of the presence and content of advance directive *Increase public awareness about advance directive through pt and community education research

28. Choices Concerning Life and Health.
1. Choices regarding recommended treatment - Noncompliant pt (challenging), or make unhealthy choices - Complementary therapies: massage, healing touch 2. Controversial choices - Abortion - Reproductive rights - Active euthanasia - Issues related to HIV/AIDS 3. Confidentiality

29. *Many people who come into our care are suffering from ill effect of such thing as overeating, tobacco, drug , work related stress *Our job to deal with present health concern (change toward healthier living) *Pt not willing to follow the treatment plan *Unhealthy life practice are part of the whole person and should be taken into consideration in plans of care

30. The notion of compliance relates to paternalistic view, that the health care provider know what is best for pt, and that if pt follow these direction, they well get well But we should remember that pt have a right to refuse interventions, and they have a right to seek therapies that not included in institution

31. Issues related to use of complementary therapies (CT)
1. People have the right to use modalities other than conventional medicine to address their health needs. 2. Nurses need develop some knowledge of such therapies. Be nonjudgmental in decision regarding all modalities being used. 3. CT should not be discounted, council the pt to explore the validity of claims made about particular therapy. 4. In research: whether informed consent will needed to acknowledge CT 5. Expert CT nurses: need to know what CT are within their scope of practice. Nurse should be disclose and document of their use

32. Controversial choices
- The value of pt self-determination support two controversial issues: abortion and active euthanasia. - Affected by ethical and religious opinion and debate.

33. Abortion
- Mother’s right to control her body and her life ( right to choose) in contrast to right of unborn fetus to chance at life (right to life). - Values involved: believe when life begins, QOL, unwanted children, mother’s life and health. - Who has rights &whose rights take precedence.

34. Abortion
*Woman’s intentional termination of pregnancy *The central ethical dilemmas debates is about 1-right of life of the fetus 2-woman’s right to control her own body by choosing whether or not to carry a pregnancy to term

35. Abortion
Some believe that life starts at conception, while others hold that life begins only when fetus is viable outside the womb

36. Values that took into consideration in abortion
When life begin
Quality of life for the un wanted children
Concern’s about mothers health & life
Other reproductive issues
Contraceptive use
C/S decision
Eugenics:
the study of or belief in the possibility of improving the qualities of the human species

37. Opponents of abortion
Hold the position that because fetus possesses humanity, it must be accorded all human right including the right to life (pro-life view)

38. Proponents of abortion
Argue that based on autonomy, a women has a right to control her own body, and no women should be forced to bear a child that she does not want (pro-choice view)

39. Euthanasia
… Painless death, removal of artificial interventions to cause death, here personal values of the patient & family & nurse may have different view

40. Active voluntary euthanasia
Is an act in which the physician both provides the means of death and administration it such as lethal dose of medication

41. Assisted suicide
-The pt receive the means of death from someone, such as a physician but activate the process themselves
-Justification by proponents
-Relief of pt’s suffering

42. Active euthanasia/assisted suicide
- Illegal - Possible considerations: HCPS non- adherence to pt wishes regarding end of life issue, fear about prolonged suffering, lack of control. - Natural dying is always the best choice.

43. Issue related to HIV/ AIDS
- We should remember that not all cases result from lifestyle choices. -Treatment pt regardless their values or lifestyle -Be aware of judgmental attitudes toward persons with HIV - Risks of exposure HCPs: autonomy and confidentiality in relation to HIV testing and status.

44. It is illegal to do the test without written consent
- Stigma and discrimination
- Positive health care worker/ mandatory testing: autonomy, confidentiality, nonmaleficence.

45. Confidentiality
- In order to care: nurses disclosed secret information - without assuring confidentiality: people hide important information for Dx and Tx - Especially true situation where there is stigma

46. Pt’s trust is sacred (the state of being holy ), and any breach of confidentiality is violation of this trust.
- Factors override confidentiality: court cases, potential harm for the pt or others.

47. The End