Informed Consent and Honoring Directives
Published 21 Dec 2016
The patient by name Mrs. Sparza was suffering from a condition affecting her right eye, and she required undergoing surgery. She had given consent to performing surgery on her right eye. Before the surgery she signed the papers for surgery on her right eye, and also gave her children the right to make decisions in her place, in case she was incapacitated. The patient also expressed her intention that in case she was in a permanent vegetative state and there were no signs of her improving, they could remove all the life-supporting systems from her.
The patient changed into her gown and had her vital signs checked. She was then given a muscle relaxant. However, before the procedure is performed, Mrs. Sparza is given a form, which says that surgery is required for both of her eyes. Mrs. Sparza is seen initially refusing for surgery, but is convinced by the doctors. She was seen with tears in her eyes, which suggests that she was not willing for the procedure, but was forced to agree for it. According to the law, informed consent has 4 elements:
- To give consent, the patient has to have legal authority
- The patient should be competent
- Out of their own will, the consent for treatment should come from the patient
- The patient has to be informed about the risks and benefits of the treatment in a manner which they are able to understand
At this point of time, medically, the patient lacks the capacity to give consent for treatment due to medical reasons. Besides, the patient is also incompetent legally to understand the risks involved for treatment and the benefits of the surgery, due to the temporary effects of the medications administered. As the patient is not legally competent to give consent for treatment, the doctors could be held under tort. Doing any procedure without duly consenting the patient is a violation of an inpidual’s right to make informed decisions. The patient has to be informed about the details of the procedures, the options available and the risks and benefits involved. Only if the risks outweigh the benefits, could the procedure be performed in the patient.
If the doctors realized that surgery was also required in the other eye, then it had to be performed under certain guidelines. As the patient is under the effect of the muscle relaxant, she may not be able to give an informed decision. In such a circumstance, the doctors would have to take the consent from the daughter or the son so that they are able to perform the surgery.
The doctors would have to prove in the court that performing the surgery was required as an emergency procedure. If there is an emergency needs to perform the surgery, the doctors can do so, but they have to ensure that some amount of benefit exists. In such a case, consent is not required. In this case, the doctors would have to prove that a medical emergency existed which would require the patient to undergo the surgery. The doctors have two options at this point:
- Inform the relatives of the patient so that consent for surgery is taken
- Go ahead with the surgery and prove that it was a medical emergency.
After the procedure, the patient suffered a heart attack, developed renal dysfunction and subsequently went into coma. The doctors could be held responsible for the complications only if a sufficient risk was present. Before any surgery is performed, the physicians would have to study the patient’s physical fitness and determine the chances of developing any complications. The main objective for this is to ensure that the surgery is beneficial for the patient. The surgery may not be beneficial if the doctors do not conduct a sufficient risk assessment.
If the patient has the risk factors for developing renal failure or heart attacks, then appropriate precautions need to be taken or alternative procedures need to be performed. The doctors could be held for criminal negligence, in case the patient had certain risk factors for complications and did not take any step to protect the patient. However, if the risk factors for myocardial infarction were not present and if the patient has developed this problem, the doctors cannot be held responsible. The doctors can also be held liable in case the doctors performed the surgery negligently and do not take care of the patient after the surgery.
Before the procedure, the patient had given advanced directives regarding her health in case she was permanently incapacitated. The advance care directives have to be considered only if the patient cannot make a reasonable decision about their health and it should not be utilized as a replacement to normal decision making of the patient.
In the US, the states should not deprive any person the right to life, liberty and property. The processes of law should come into picture in case any of these aspects are affected. Hence, in the case of Mrs. Sparza, the processes of law should come in to picture to ensure that she is not deprived of her right to life. Although, she has given advanced care directives, it does not mean that the healthcare personnel or her family member misuse it to bring about her death. In this case, the doctors should carefully look into the case to ensure that she does not unduly suffer even though she has given permission to her children to make a decision on her behalf. It is the duty of the state to protect the inpidual in this aspect.
According to the report, the inpidual does seem to be fully competent and gives a consent or decision about her treatment. She also gives advanced care directives before the procedure. The patient had given consent for surgery on a single eye, but the doctors performed surgery on both eye. The doctors had obtained consent for treatment of the other eye, when the patient was under medication, and was not competent of making a reasonable decision. Was the performance of surgery on two eyes difficult for the patient to cope up with and resulted in her developing complications after the surgery? If this was the case, then the doctors could be held under medical negligence.
With regards to the advanced care directives, the doctors have to ensure that it does not act as a replacement for the patient’s decision. Under the US laws, the doctors could consider that the patient for PAS only if it is proved that the patient is suffering from a terminal illness and cannot survive for more than 6 months. In this case, it cannot be proved that the patient would be surviving for less than 6 months. The patient has been affected with renal failure, which as a reasonable good prognosis if the patient can be treated through dialysis and/or renal transplantation. She is in a coma state and may have a reasonable good chance of survival. The doctors should consider continuing her treatment. In this case, advanced directives may not apply as the patient is not suffering from a terminal illness, and has a good chance of recovering.
The doctors should take into consideration that the children would have an intention of inherited the property of Mrs. Sparza. Hence in such a circumstance, they should be interested in protecting the patient rather than seeking consent for PAS from the children. In case the surrogate does not give a reasonable decision in the best interest of the patient, then it is the duty of the doctors to protect the patient and work in the full interest of the patient. The doctors should also take into consideration the fact that the patient had not given full consent before the procedure for surgery of both the eyes.
She had tears in her eyes suggesting that she was not happy with a few things. This could also mean that the patient had a feeling that she was going to be affected with a life-threatening complication and had an intention to live. The doctors should only permit PAS if the patient gives full consent to it and expresses the need to die with respect. However, Mrs. Sparza cannot be considered a ideal candidate for PAS, and hence the doctors have to take all steps to protect her health and well being.
Required sources:
- Benak, L. D. and Applegate, S. (2006). Informed Consent and Issues Surrounding Lack of Capacity vs. Incompetence. Journal of Forensic Nursing http://findarticles.com/p/articles/mi_m0SHK/is_1_2/ai_n17212505
- EUTHANASIA.com (2007). Information For Research On Euthanasia, Physician-Assisted Suicide, Living Wills, Mercy Killing. http://www.euthanasia.com/
- Johnson, J. C. (1997, August). Handling a request for assisted suicide. http://findarticles.com/p/articles/mi_qa3689/is_199708/ai_n8777366
- Mariner, W. K. (1997). Physician Assisted Suicide and the Supreme Court: Putting the Constitutional Claim to Rest. 87(12). Health Law and Ethics. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1381265&blobtype=pdf