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Her l. Informedconsent I ts e eyell: In the case above,becausethe patient exprcssedthat shewoulcr riketo haveher aorta repaired her hus- bandcannotgo againstthis aftershclosesconsciousness. The samereasoningholds true if apatientrefusesa procedure or treatnent and then losescolrsciousDess. He has lost so much blood he rsunconscious. There is no family member availableto sign consent.
What should youdo? Thcmanagementof an emergency is different. Becauscwe must inform the patientabout all the optionsof treatment,risksof the options,and risksof not performingthe procedurein a languagethe patientcanunder- stand,theconsentmustbeobtainedby a personqualificdto maketheexDlanation. Forexemple,you arean intern who hasconsultedsurgeryto placea subclavian centralvenousline,Youonlyknow accessmustbeobtained.
On thephonethesurgicalresident says,"Can. Youmustnot bein a position to explainthe risksof proceduresthat you did not decide on. Ifthe patientdevelopsa pneumothoraxandyou do not knowwhy theinternaljugular approachisnot beingused,you cannotadequatelyinform thepatient. You must, at the risk of seeming difficult, tell the surgical residentthat he must obtain the consenthimsell If a complication occurs,you cannot say, "l wasjust gettinga papersigned;I didn't know what it meant.
If you tell the patient that he could havea pneumothorax and might need a chesttube and document this, and the patient still signs consent, then you are not at risk. The patient also cannot say latel "l rvasjust signing a piece of paper. I didn't know rvhat it meant. This is a legitimate form of consent by an authorized surrogate decision maker. Forexample, a 65 year-old r. The head CT shows a ring or contrast-enhancingi lesion consistent with a brain abscess.
The patient remains persistently confused, but is not deteriorating. You need to perform a brain biopsy but there is no family member or health-care proxy who comes to visit hini. His wife is housebound from multiple sclerosisand cannot get to the hospital.
You have hcr on the phone but the nurse is refusing to be the witness for the consent, saying that telephone consent is not valid. As with all forms of verbal communication, oral advancedirectives,and telePhoneconsent are more difficult to prove if contested. However, they are equally valid. If a health-care worker is uncomfortable taking the telephone consent,useanother member of the health- care team to act asyour witness for the consent.
You can educatethe nurse later. You can take consent tbr cardiothoracic surgery over the phone if that is the only way to speakto the surrogate. The real questions about telephone consent are these: Is the personyou arespeakingto reallythe surrogate? Doesthe personknow the paticnt'swishes?
Hence, no matter whatyour personal feeling may be, the fetus doesnot haveany intrinsic 'rights' asa person. So,even though a week-old fetus would be a viable child if the fetus were removed from the uterus, all health-care decision making and ethics are basedon the choicesof the motherand her interests. Ifparents havea child born at 34 weeksof gestationalagein need of a blood transfusion to saveits life, they cannot refuse lifesaving therapy for the child evenifthey are Jehovah'sWitnesses.
The statewould intervene in the interestsof the child. However,if the same child at 34 weeks of gestational ageis still in the uterus, the mother canreluse or accept whatever therapy she wishes without specific regard for the fetus. Hence,a pregnant woman may refusea lifesaving transfusion. Shemay refusea Caesarian sectionto remove the child even if this will put the life of the fetus at risk. The father has no legal right to make an informed consent fbr any pregnancy- relatedissuebecausethe questions concern the body of the mother.
A mother's autonomy overher own body is felt to be more important than the rights of the fetus or of the father. Onlythe mother can sign informed consent for any procedure or treatment during preg- nancy.
Any answerchoice that has 'Ask the father. Ifthe patient hasDown syndrome andhasa family member to make decisions for her then the question will be straightfor- ward-ask for the consent of the parent or guardian.
If there is no parent or guardian, the circumstanceis much more difficult. A third party court designeemust make a decision1, basedon the bestinterestsof the patient even though the patient may neverhur,. This is an advance directive written or formal. An advancedirective cannot even be given by a patient who hasnever had capacity. The same is true of a living will. The next best method of giving consentis "substituted judgment. This is also not possiblefor a person who hasnever been competent.
The weakestform of consentis to act: However, it is thc best method of obtainins consent for doctors treating a person who has never had capacity. A legalguar. In the absence of a family member the guardian is either appointed by the courts or is the administrator of the health carefacility, such asthe medical director. I rg ause ning hich ence 'ator Chapter4: Communications betseen paticnt and physician are highly privileged and this confiden tialit,vcar. Medical information cannot be passedto anyone l ithout thc direct consent of thc patient.
Confidentiality also includes keeping a patient's medicalinformation priyate even from his friends and family unless the patient expressly saISit is okay to releasethe information. The fact that a patient may have a good rclation shipwith his familv and fiiends is absolutely no excuseto assumethat the patient wants his medicalinformation passedon to them.
I have an exccllent relationship with my mother; hon'ever,even though I am a doctor or mavbe becauseofit shedoesnot want me to know herlist of medications.
Shehasno obligation to give me a reasonrvhyshedoesnot want rne to know which mcdications she is taklng. If I call her doctor and sa1 "l just want to help mom vvith hcr mecls.
What is she on? I know you mean well, but I iust can't talk to you about your mother's medical problen. The patient is arake and alert. His wife comesto you demanding inforn. She shorvsher identification card verilying this. What shouldyou tcll her?
For example, the wife becontesinfuriatcd and storms off the floor, threatening to sueyou. You apologize to the patient for upsetting his wife by not speaking. The patient responds "On the contrary, Doctor, you did great.
Although she is still my wife, we arc finalizing our divorce and we do not live together. I expect to be clivorced and rcmarriecl lvithin the next few months. Sheonly wanted information about me to useagainstme in thc divorce proceeding. Thanks for protecting my confidentiality. However, the information can only be transferred if the patient has signed a consent or releaseform requesting the transfer of information. It is the patient who must sign the consent to releasethe infornation, not the health,care provider.
This is how the system guarantees that the patient's medically privileged inforrnation only transfers to those people to whom the patient rvants it to go.
For example, yott receivea phone call from another physician who is rvell known to you in your local community. What do you tcll him? You should tell another physician requesting information to send you the patient's signed releaseform befbre you send him the infonration. Her soncallsyou anclasksyou to givehim the infornation bccausc the family is concerned that the bad news will depresshis mothcr. He is sincerc and genuine in his concern. There is no basisfor informing the family and not the patient.
It is exactlythe oppositc: Maybethe patient wantsher family to know and maybeshedoesn't. It is alwaysthe patient's decision. There is a rare exception in the caseof a patient with a psychiatricdisturbancein rchom to inform if a meclicalcondition might induce a suicide attel1lpt. He shows 'ou proper identification stating that he is a government employee. He is looking for your patient's immigration statusand for his medical condition. What do you tell the investigator?
Ifthe investigator doesnot havea searchwarrant, then you must refusehim access to the files.
You are not under any obJigation to make immigration statusinvestigations of vour patients nor to provide this information to third parties unless it is at the request of thepatient. This right of privacy also coversgeneticinformation. You must keepthe medi calinformation private from a patient's co-workers aswell.
The Tarasofcasc ,in whicha mentally ill paticnt toid thc psychiatristof his intent to harn sonreoDe,is a famousexample of this ln this type of case,thc physician must inform larvenlorcement asrvell asthe potential victim. Other casesin which it is lawfrl. Horvever,all effortsmust first bc made to enlist the patient to inform tr. No lawsuit agai'sta physicia' for brenkingc.
Although the medical record as ap,hysicaloblect rcnrains al. For example, you have a new patient with a complex history r,ho hasbecn tryingto get a copy of her record from her previous doctor. The practice administrator inforns you that thc paticnt is extremely unpreasantand aim. The patient rcturns to seeyou thc tbllowing iav anclasksr.
What tlo ,ou tell her? No one has a right to interfere with this for anyreason. You should tell her that she should be allowed a copy of the chart. A patient doesnot have to give her doctor a reason for requesting hcr own property, and she is entitledto this information whether or not she is "pleasant.
The need for information to take care of patients outweighs the physician'sright to payment. This allows anyone reading the chart to seewhat was originally thereand it ensuresthat medical errors are not being covereclup.
This makesit look asif you arehiding medical errors. If you forget to put in a note or document somcthingand want to add it the next day,you cannot put a note in the chart with the old date.
If you forgot to put a note in the chart documenting a patient's condition yesterday, ,youcannot write a note today with yesterday'sdate on it. In other words, you canl]ot,back- date'notes. Your notes must alwaysbear the current date and time. There is no ethical or legaldistinction between withholding and withdrawal of medical treatrnent.
For example, a year-old man with diabetes and hl. He is equivocal about spending the restof his life on dialysis,but he agreesto start. The patient is not depressedand is fully alert. Six months after starting dialysis,he comesto realizevery clearly that he absolutelydoes not wish to continue. You have no doubt that the patient has full capacityto understand the implications of this decision.
Although there may be an enotional distinction between withholding dialysis and stop- pingit after it has started,there is no ethical distinction between the two. It is n. If I hlre you to repair my house, but after a few days I deciclethat I don't like the work you are doing, I havethe right to tell you to stop working on my house. You cannot say, "Sorry, once we startajob we finish it whether the owner likes it or not. The patient has theright to stop treatment.
For example, an elderly man with COPD progressesto the point of needing mechanical ventilation on a chronic basis. He tells you, alier long consideration, that he just does not want to live on a ventilator. What should you tell hirn?
He sayshc will gerbetter"r;;;;;; to-tb. He sayshewantsthe ventirarorrn. Overall, this caservill be ,h" ";;i.: Shehasthecapacityto understandthatshewill ai. Vhatdoyou tellher? She problcms. For example, an HlV-positive,lehovah,s Witness who is now pregnant needs atransfusion to live and haye a deprcssedandisfuuyalert. A at lc bi!!!! Yon cannot transfuse! The situatior. The fact that the patient is pregnantdoesno1alter the ansrver.
Theprevailingconsensusis that personhoodbeginsaftcr birth. Until delivered,the fetus isconsidcredanother part of thc mother's boclv. Another wrong ansrverwould be uaitinguntil the paticnt is no longer consciousand then transfusingher.
Theanslversto all of the examplesdescribedin this scctionare clearbecausein eachcase thepatientis an adult rvith the capacitl,to understandhis or her nredicalproblems. If the casedescritresdeprcssionin the patientthenyou shouldchoosepsychiatricconsultation,or choosea trial of cither belravjoral therapv or antidepressantntedication asthe ansrvcr. Patientshavethc right to try therapyfor a while ald thcn stop it if it doesnot suit then].
This is true even if it means they will clie from stopping dialysis, mechanical vcntila tion, HIV medications,or blood transfusions. The typc of treatnlent does not change the answer. A CBC or cardiac bypass is ethically antl lcgally indistinguishable. Therefore,in a scnsc,treatinga paticr.
Thereis no distinction betweenwithholding anclwithdrarving care. If you are doing sonc thing the patient does not ''ant,you cannot sa,v, "We11, sorry, but I already started, and I rcallvhaveto continuc. The aclvance directiveis a by procluct of the successof nredical thcrapies such as the mechanical vcn tilator that can kccp a patient alive when in the past he would have cliecl. Becauseof thcse therapies,doctorsarenorv in the position of trying 1qictcmine u,hateachpatientwantcd for himself in terms of his health carc.
Thc advancedirectivcis part of the conceptof autonomy. The advancedirectiyetellsthc physicianrvhatthe paticnl'swishesaresothat the lcssaccurateforms of dccisionmcLking,suchassubstitutedjudgn.
End-of-Lifelssues J 27 ical l b e Ling tor ntt no!! F Health-CareProxv The ttvo most comnon forms of aclvancedirectives are the living will and the health carc pror: The conceptof a,durablc,,powerofattorDey is critical becausethe word "durabre" means it remains in effect evenafter the patient roses decision-making capacity becauseof medical illness.
Other forms of legal proxics, such as a finar. The health carc prorT is a person chosenspecificallyby the patient to 'lake health-caredecisionsfor her in the evcnt that she cannot make decisions for hcrseH T'hesedecisions are limited to health care,not finance. Advance directive docunents ntay also have written instructions to give boundariesto care. For cxample,. However, the main focus of the proxy is to designate a person of "agent" who speaksto the physician regarding consent issuesfor aI treatments and tests,aswell asdiscussesissuesof withdrawing and withholding treatment.
The proT speaksfor the patient. Becausethe patient chooses the prorT as her representative,the proxy overrules all other decision ntakers. Therc is a strong presumption that the proxy knows the patient's wishes. The proxy is not there to give his personal opinion as to what he thinks should be done for tl.
The proxy is there to communicate the patient,s originalwishcsin order to ensurethat they arecarriedout.
The pror: The proxy is also like a waiter. The patient tells the waiter lvhat kind of food he wants to eat what kind of medicines and testshe rvants. The proxT praccsthc order ir. The prory is not there to alter. The proxy makcs dccisionsbasedon rwo paranteters: Theprox,voutweighsall othcr potcntjal dccisionmakcrs,including thc family. For example, a year-old nar arrives at the emergency department febrile, shortof breath, and confused.
Many family men. The physician 'lvantsto perform an emergency lumbar puncture, which the patient's wife and siblingsare refusing. His year-old granddaughter r,valksup r'vith a health-care prorylbrm signedby the patient designating her asthe proq'. Sheinsiststhat you dotheiumtrar puncture stating that washer understanding ofthe patient's wishes. Therestof the family, including the wife, refusesthe lumbar puncture stating that theyknorv the patient's wishesbetter.
What do 1'oudo? You cannot tell ivhoin a family knows the paticnts wishesbest unlessthe patient is awaketo tell 1'ou. The prox,vdesignationis thc patient's wa. In the absenceof an advancc directive there is a list of relative importance in terms of surrogatedecisionnakcrs.
You should start first with the spouse,then parents,then adult children,then siblings,tl. This is an approximation only. When the family is split and there is no proxy, you nrust reterto lhcclhic. LivingWill A living will is a written form of advance directive that outlines the care that a patient l,ould want for herself if she were to lose the ability to communicate or the capacity to undcrstandher medicalproblen.
The etiologyof the lossof decision-makingcapacityis irrelevant. A living will can range from being an extremely precise document outlining the exact typesof care that a patient wants or does not want all the way to being a vague, useless documentthat makesnonspecificstatementssuchas "no heroic care.
I oes that mean a yentilatoror chemothcrapy,or dialysis,or bloocitcsts,or all of thcnr, or none of thenr? For instance,a living will that says"No intubatior, no cardiopulmonaryrcsuscitatron,no dialysis,and no blood transfusions" is vcry Lrsefuland allotvs fbr easyfollowinq. For example, a year-old woman ts admitted with metastatic cancer Jeaclingto a changein mcntal status secondaryto hypercalcenria. Shehas a lir. I alsodo not wish to reccivedialysis. Blood tcstingand antibioticsareacceptable.
In the cascabove' follon' the directio' of the living will ancrcarry out the patient's wishes. A livi'g rvill woulcl overrurethe wishesof the fanrily beca,sctrrc riving will conmunicates the patieDt'so. As a nlatter of autonon ,, the patient! Thc rnajorissue'ith the useof a living will is that it is very difficult, ur advanceof trre'r- ness,to be celtain which medical treatmer. NoCapacityandNoAdvanceDirectives Here is u'hat is vcry ciear atrout withholding and withclrarval of caredecisions: End-of-LifeIssues I 5 l ot -lo at of tS a IO Llnfortunately,the 'ast majority of patients, e'en at oldcr age a'd with life-threatening illnesses,do not havea formal advancedirective.
Decision making ca' be rmLchmo.. Ifthe family is united and in agreement,then there is 'o difficulty llith making decisions for the patient.
The main issueagain comes to clemonstratjng tlte bestevidenccof lctowing the patier. Forexample, a 64 year-old man suff-ersa severeiltracrallial bleed leavir]s him conatoseand paralyzed. His wife, sister,and four chjldren arc in the horpital. Theycome to seeyou bccausethey are unanimously asking that you remove the endotrachealtube and lcavethe patient to die. The patient repcatedlymadc this rvishknown to his family. What shoulclyou do? The patient has the right to refuseit.
For example, a year old wouran has been aclmitted to a nursing homc with adyanceddementia. Shehasdifficulty maintaining oral intake sufficient to survive. Thenursinghome wantsto placea nasogastrictutrefor-fecding. The husbandand the son expresslystatethat the patient slid she.
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