Choosing a Leadership Style (Marquis & Huston, 2012)
DISPLAY 5.3 Guidelines for Informed Consent
The person(s) giving consent must fully comprehend 1. The procedure to be performed
2. The risks involved
3. Expected or desired outcomes
4. Expected complications or side effects that may occur as a result of treatment 5. Alternative treatments that are available
Consent may be given by 1. A competent adult
2. A legal guardian or individual holding durable power of attorney 3. An emancipated or married minor
4. Mature minor (varies by state) 5. Parent of a minor child 6. Court order
The information must be in a language that the patient can understand and should be conveyed by the individual who will be performing the procedure. Patients must be invited to ask questions and have a clear understanding of the options as well.
Informed consent is obtained only after the patient receives full disclosure of all pertinent information regarding the surgery or procedure and only if the patient understands the potential benefits and risks associated with doing so.
Only a competent adult can legally sign the form that shows informed consent. To be considered competent, patients must be capable of understanding the nature and consequences of the decision and of communicating their decision. Spouses or other family members cannot legally sign unless there is an approved guardianship or conservatorship or unless they hold a durable power of attorney for health care. If the patient is younger than 16 years (18 years in some states), a parent or guardian must generally give consent.
In an emergency, the physician can invoke implied consent, in which the physician states in the progress notes of the medical record that the patient is unable to sign but that treatment is immediately needed and is in the patient’s best interest. Usually, this type of implied consent must be validated by another physician.
Nurses frequently seek express consent from patients by witnessing patients sign a standard consent form.
In express consent, the role of the nurse is to be sure that the patient has received informed consent and to seek remedy if he or she has not.
Informed consent does pose ethical issues for nurses. Although nurses are obligated to provide teaching and to clarify information given to patients by their physicians, nurses must be careful not to give new information that contradicts information given by the physician, thus interfering in the physician–patient relationship. The nurse is not responsible for explaining the procedure to be performed. The role, rather, is to be a patient
advocate by determining their level of understanding and seeing that the appropriate person answers their questions. At times, this can be a cloudy issue both legally and ethically.
LEARNING EXERCISE
5.5
Is It Really Informed Consent?
Y
ou are a staff nurse in a surgical unit. Shortly after reporting for duty, you make rounds on all your patients. Mrs. Jones is a 36-year-old woman scheduled for a bilateral salpingo-oophorectomy and hysterectomy. In the course of conversation, Mrs. Jones comments that she is glad she will not be undergoing menopause as a result of this surgery. She elaborates by stating that one of her friends had surgery that resulted in “surgical menopause” and that it was devastating to her. You return to the chart and check the surgical permit and doctor’s progress notes. The operating room permit reads “bilateral salpingo- oophorectomy and hysterectomy,” and it is signed by Mrs. Jones. The physician has noted “discussed surgery with patient” in the progress notes.You return to Mrs. Jones’s room and ask her what type of surgery she is having. She states, “I’m having my uterus removed.” You phone the physician and relate your information to the surgeon who says, “Mrs.
Jones knows that I will take out her ovaries if necessary; I’ve discussed it with her. She signed the permit.
Now, please get her ready for surgery—she is the next case.”
A S S I G N M E N T:
Discuss what you should do at this point. Why did you select this course of action? What issues are involved here? Be able to discuss legal ramifications of this case.
Informed Consent for Clinical Research
The intent of informed consent in clinical research is to give patients adequate information, through a full explanation of a proposed treatment, including any possible harms, so they can make an informed decision.
Studies, however, repeatedly suggest that participants often have incomplete understanding of various features of clinical trials and issues associated with written informed consent are common.
Medical Records
One source of information that people seek to help them make decisions about their health care is their medical record. Nurses have a legal responsibility for accurately recording appropriate information in the client’s medical record. The alteration of medical records can result in license suspension or revocation.
Although the patient owns the information in that medical record, the actual record belongs to the facility that originally made the record and is storing it. Although patients must have “reasonable access” to their records, the method for retrieving the record varies greatly from one institution to another. Generally, a patient
who wishes to inspect his or her records must make a written request and pay reasonable clerical costs to make such records available. The health-care provider generally permits such inspection during business hours within several working days of the inspection request. Nurses should be aware of the procedure for procuring medical records for patients at the facilities where they work. Often, a patient’s attempt to procure medical records results from a lack of trust or a need for additional teaching and education. Nurses can do a great deal to reduce this confusion and foster an open, trusting relationship between the patient and his or her health-care providers. Collaboration between health-care providers and patients, and documentation thereof, is a good indication of well-provided clinical care.
If it is not documented in the health-care record . . . it did not happen.
The Patient Self-Determination Act
The PSDA, enacted in 1991, required health-care organizations that received federal funding (Medicare and Medicaid) to provide education for staff and patients on issues concerning treatment and end-of-life issues.
This education included the use of advance directives (ADs), written instructions regarding desired end-of-life care. Most ADs address the use of dialysis and respirators; if you want to be resuscitated if breathing or heartbeat stops; tube feeding; and organ or tissue donation (MedlinePlus, 2016). They also likely include a durable power of attorney for health care, which names your health-care proxy, someone you trust to make health decisions if you are unable to do so (MedlinePlus, 2016).
The PSDA requires acute care facilities to document on the medical record whether a patient has an AD and to provide written information to patients who do not. However, despite mechanisms within most health-care institutions to provide this information, the AD completion rate remains low and many patients do not understand what is included in the AD or whether this is something important they should have.
The reality is that many people do not express their wishes about end-of-life treatment before a crisis situation exists and then they may be unable to do so. This problem prompted Cooper, Chidwick, Cybulski, and Sibbald (2015) to develop a five-question checklist to elicit an incapable patient’s perspective on
treatment based on the wishes and values he or she expressed while capable. The goal was to ensure that basic legal obligations were met for patients who were no longer able to advocate for themselves. Findings from a 2-year pilot project suggested that the use of such a checklist gave nurses a way to fulfill their professional roles as patient advocates in end-of-life care, when many patients and families were most vulnerable (see Examining the Evidence 5.1).
LEARNING EXERCISE
5.6
Mrs. Brown’s Chart
Y
ou are a nurse in a multiphysician office that treats oncology patients. Mrs. Brown, a patient seen by Dr.Watson in your office, was recently diagnosed with invasive cancer. She started radiation treatments last week. Her husband attends her radiation treatments and office visits with her and seems to be very devoted.
They both are very interested in her progress.
Although they have asked many questions during the last two office visits and you have given truthful answers, Dr. Watson’s interactions have sometimes been a bit short and you felt that Mr. and Mrs. Brown may have left with unanswered questions. In addition, Dr. Watson has not shared much with them yet about Mrs. Brown’s prognosis as he continues to refine his differential diagnosis.
Today, when you walk into Mrs. Brown’s exam room, you find Mr. Brown reading her electronic record on the computer tablet that was inadvertently left on the counter in her room. The look on his face is one of feeling overwhelmed and confused.
A S S I G N M E N T:
Identify several alternatives for action that you have. Discuss what you would do and why. Is there a problem here? What follow-up is indicated? Attempt to solve this learning exercise on your own before reading the sample analysis that follows.