Who should decide?

Article Abstract:

Critical care nurses are often faced with the situation of caring for a patient who is dying and who can no longer make decisions. The issues of who is to make decisions for the patient, and the responsibilities of the nurses and doctors, are extremely important. A competent person has the right to refuse medical care, including life-sustaining treatment, based on the principle of autonomy. Patients who have expressed their wishes regarding treatment before losing their capacity to decide still have this right. Problems arise, however, when the patients have not indicated their preference, and the principle that applies is that of beneficence, the duty to help others. When a patient is incompetent, a surrogate must be found, usually someone in the patient's family. Cases where the patient is intermittently incompetent are even more difficult. In most cases, the next of kin is made surrogate, because this person is most likely to have the good of the patient at heart, and knowledge of the patient's wishes and values. Also, the family is recognized as a social unit. In some cases surrogates may be challenged if there is evidence of abuse, or disagreement among competent family members or with the patient's wishes. In some cases the state may appoint a guardian. Decisions by the surrogate should be made on the basis of substituted judgment (based on the patient's preferences) and the patient's best interests. The decision of the United States Supreme Court on the Cruzan case stated that a competent patient has a protected, fundamental, but not absolute, right to refuse treatment; however the state also has an interest in protecting lives, and may require clear and convincing evidence of a patient's wishes. An oral statement may not be sufficient. Nurses need to know the law in their respective states, and become comfortable with the issues by making these discussions routine. Finally, if nurses make these preparations for themselves, they will feel more comfortable when facing these issues with others. (Consumer Summary produced by Reliance Medical Information, Inc.)

Cases, Nurse and patient, Nurse-patient relations, United States. Supreme Court, Living wills, Durable power of attorney, Critical care medicine

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Ethics consultation: skills, roles, and training

Article Abstract:

Medical ethics has evolved over the past several years into a recognized clinical discipline with an academic base. Many hospitals now have ethics consultants to help promote ethically sound decision making in difficult situations involving physicians and patients or their families. Ethics consultants, distinct from ethics committees, need skills to identify specific ethical considerations in complicated medical cases. They need to be good negotiators, acting as patient advocates as well as a professional colleagues. However, they should not try to be nor should they be pressured to be legal counselors, quality reviewers, or psychoanalysts. As ethics consultants gain visibility, some difficulties arise, such as reimbursement issues, liability, what type and level of education best prepares the individual for the role, and what certification is required. One important task of the ethics consultant is to help educate the physician in ethical decision making. The ethics consultant is likely to play a more active and important role in the clinical setting in the future. (Consumer Summary produced by Reliance Medical Information, Inc.)

Training, Study and teaching, Medical consultants

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Informed consent and the need for delegalization

Article Abstract:

Informed consent is a concept with varying meanings and uses. But generally the word 'informed' means understanding and knowing, not just being told something, and the word 'consent' means acting of one's own free will without being forced. The concept of informed consent is not the answer to complex medical and scientific problems such as participation in research programs or withdrawal of life-support measures. The story is told of an elderly, mentally incompetent woman. The court held that the hospital was obligated to force-feed her, despite sworn statements by her daughters that the woman had repeatedly said she did not want her life prolonged by artificial means. The author states that the combination of medical technology and the legal system has relegated human privacy and morality to a minor role in such situations. The concept of informed consent should be 'delegalized'. The legislatures should, by statute, provide an area of decision-making that is private, in which physicians and patients can make decisions without the interference of the legal system. (Consumer Summary produced by Reliance Medical Information, Inc.)

Informed consent (Medical law), Informed consent

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