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Informed Consent and The Patient Physician Relationship Summary

Informed Consent and The Patient Physician Relationship Summary

Question Description

I’m working on a health & medical question and need support to help me study.

Hello there,

can you please read the following lecture, and write a summary of 500 words.. Please do not rewrite the lecture.

  • Griswold v. ConnecticutIn Griswold v. Connecticut, the U.S. Supreme Court ruled that a Connecticut statute forbidding use of contraceptives violated the right of marital privacy which is included within the penumbra of specific guarantees of the Bill of Rights. The Griswold opinion was delivered in 1965 and noted that zones of privacy are created by several fundamental constitutional guarantees. These metaphorical zones extend outward (penumbras) from the specific constitutional guarantees and are necessary to provide protection for the rights specifically guaranteed under the First, Fourth, Fifth, and Ninth Amendments. A right to privacy is required to protect these other constitutionally guaranteed rights. Per the due process clause of the Fourteenth Amendment, no state shall interfere with or abridge these rights, including the zone of privacy. The Connecticut statute at issue violated the right of marital privacy and was held to be unconstitutional.Over time, in Roe v. Wade, Cruzan v. Director, Missouri Dept. of Health, and Planned Parenthood of Southeastern Pennsylvania v. Casey, the standing of a purported constitutional right to privacy gained and then lost support. Nevertheless, per Griswold, the “penumbras of specific guarantees of the Bill of Rights” may continue to provide a basis for identifying rights of individuals.In re QuinlanIn April 1975, Karen Ann Quinlan was found to be comatose with evidence of loss of higher brain function. She was maintained on a respirator, required artificial nutrition and hydration (ANH), and was supported by twenty-four-hour nursing assistance. The New Jersey Supreme Court ruled in In re Quinlan that treatment served only a maintenance function and prolonged Quinlan’s inevitable slow deterioration and death. Therefore, the interests of the patient, as seen by her surrogate, that is, her guardian, must be evaluated as predominant. The court stated that Quinlan’s parents and family were permitted to render their best judgment regarding whether Quinlan would permit her non-cognitive, vegetative existence to be terminated by natural forces. Thus, the Supreme Court of New Jersey established the right of a competent patient, or in the case of lack of competence, the right of the patient’s guardian, family, or other person appropriately designated to speak for the patient, to withhold or discontinue medical treatment that was deemed nonbeneficial, that is, without the potential to cure or improve the patient’s condition.Cruzan v. Director, Missouri Dept. of HealthIn January 1983, twenty-five-year-old Nancy Cruzan lost control of her car on a road in Missouri and the vehicle overturned. She was in a coma for three weeks and was subsequently determined to be in a persistent vegetative state. When it was assessed that there was no likelihood of Nancy’s regaining her cognitive faculties, her parents requested that hospital employees terminate artificial nutrition and hydration procedures. But the hospital would not honor this request without court approval. In Cruzan v. Harmon, the Supreme Court of Missouri stated that “we do not believe her right to refuse treatment, whether that right proceeds from a constitutional right of privacy or a common law right to refuse treatment, outweighs the immense, clear fact of life in which the state maintains a vital interest.”The Cruzans appealed the decision to the U.S. Supreme Court. In 1990, in Cruzan v. Director, Missouri Dept. of Health, the Court ruled that under certain circumstances, a competent person has a constitutionally protected right to refuse lifesaving ANH. But this does not mean that an incompetent person possesses the same right, as that person is not able to make a voluntary and informed decision to exercise such a right. The Court ruled that the due process clause of the Fourteenth Amendment does not require a state to accept the substituted judgment of close family members in the absence of substantial proof that their views reflect the patient’s preferences and desires. The Cruzan court asserted that “a State may apply a clear and convincing evidence standard in proceedings where a guardian seeks to discontinue nutrition and hydration of a person diagnosed to be in a persistent vegetative state.”The U.S. Supreme Court recognized that this case was the first to specifically concern whether the Constitution grants a “right to die.” The Court stated that a competent person has the constitutional right to refuse unwanted medical treatment, including ANH. This right is established by the due process clause of the Fourteenth Amendment. However, this right does not extend to individuals who are incompetent, that is, do not possess the capacity for medical decision making.Planned Parenthood of Southeastern Pennsylvania v. CaseyIn 1992, in Casey, personal autonomy was balanced against state interests, specifically with the state interest in preservation of life. The Pennsylvania statute under review required among other provisions that a woman be provided certain information at least twenty-four hours prior to an abortion procedure. The Court concluded that the central holding of Roe v. Wade should be retained and reaffirmed. Constitutional protection of a woman’s decision to terminate her pregnancy derives from the due process clause of the Fourteenth Amendment, which declares that no state shall “deprive any person of life, liberty, or property, without due process of law.” However, Casey asserted that it does not follow that the state may not take steps to ensure that a woman’s choice to terminate her pregnancy before viability “is thoughtful and informed.” Casey held that the informed consent requirement, including a mandatory twenty-four-hour waiting period (with the exception of a medical emergency) and notice of the availability of informational materials relating to the consequences to the fetus, was not an undue burden on the right protected by Roe.Informed Consent and the Patient-Physician RelationshipInformed consent requires the following:
    • The patient has the capacity to reason and make judgments.
    • The consent decision must be made voluntarily and without coercion.
    • The patient must have a clear understanding of the risks and benefits of the proposed treatment and treatment alternatives.
    • The patient must have sufficient understanding of the nature of the disease and the prognosis.

    The components of informed consent need to be primary inputs in the development of healthcare institution policies. Informed consent requires disclosure of information that includes the following:

    • The patient’s clinical status and the diagnosis
    • The characteristics, risks, and benefits of proposed treatment, including estimates of the probabilities of those risks and benefits
    • Alternatives to proposed treatment, including the potential outcomes of no treatment
    • The relationship of proposed treatment to the patient’s life goals and the likelihood of the patient’s achieving those goals
    • The physician’s recommendations
    • An assessment of the patient’s understanding of the information presented

    Institution-wide training of medical staff and selected administrative staff may be needed. Ideally, such training has been included in preprofessional education curricula and continuing education programs. Emphasis should be placed on the benefits of an effective informed consent process in the following:

    • Upholding the patient’s right of self-determination
    • Enhancing the physician-patient relationship and optimizing healthcare outcomes
    • Improving patient satisfaction
    • Reducing risk to the healthcare institution and the individual provider

    Patient Rights and Patient ResponsibilitiesPatient rights, as made available to patients at their specific healthcare institutions, generally include the following:

    • The right to be treated with respect, consideration, and dignity
    • The right to receive communication in a language you can understand
    • The right to receive respectful and compassionate treatment without discrimination as to race, religion, age, gender or gender identity, national origin, disability, or source of payment
    • The right to receive emergency care if needed
    • The right to receive care in a clean and safe environment
    • The right to receive complete and understandable information from your physician regarding your diagnosis, prognosis, risks and benefits of treatment, likely outcomes of treatment, and alternatives to proposed treatment
    • The right to provide written informed consent and participate in healthcare decision making
    • The right to create an advance directive and appoint a healthcare proxy or surrogate decision maker
    • The right to refuse treatment and be told of the effects such refusal may have on your health
    • The right to choose or refuse to participate in medical research
    • The right to privacy and confidentiality of communication and all information and medical records pertaining to your care
    • The right to access your medical records
    • The right to add information to your medical records
    • The right to spiritual services
    • The right to participate in your discharge planning and receive a written discharge plan
    • The right to receive an itemized bill and an explanation of all charges

    Patient ResponsibilitiesThe patient-physician relationship is a reciprocal interaction in that each party has inherent responsibilities. Many health care institutions include a “Patient Bill of Rights and Responsibilities” in their packages of materials for incoming patients and inform their patients that patient responsibilities are corollaries to patient rights. In general, if you are a patient, you are responsible for the following:

    • Providing accurate and complete information regarding personal identification, current and past illnesses, hospital stays, medications, and other matters related to your health
    • Providing a copy of your advance directive if you have one
    • Becoming knowledgeable about your healthcare and your treatment plan
    • Asking questions of your healthcare provider or nurse if you do not understand your treatment plan or what is expected of you
    • Actively participating in healthcare decisions
    • Following your healthcare provider’s instructions and the agreed-upon treatment plan
    • Telling your healthcare provider if there is a change in your condition or if problems develop during treatment
    • Telling your healthcare provider if you believe you cannot follow through with your treatment
    • Providing accurate information regarding health insurance or other sources of payment and paying your bills in a timely manner
    • Treating all healthcare staff, other patients, and visitors with respect and courtesy
    • Following all institution or office rules and safety regulations
    • Assisting in maintaining a quiet environment and respecting the privacy of others
    • Keeping appointments, being on time, or cancelling on a timely basis

    Patient AbusePatient abuse represents a breach of the duty of professional ethical conduct and includes physical abuse, verbal abuse, and failure to act on behalf of a patient.As examples, per the California Welfare and Institutions Code, physical abuse includes

    • Assault
    • Battery
    • Assault with a deadly weapon
    • Unreasonable physical constraint
    • Sexual assault

    Use of psychotropic medication for a period beyond that for which the medication was ordered pursuant to the instructions of a physician or surgeonPer the California Welfare and Institutions Code, neglect means “the negligent failure of any person having the care or custody of an elder or a dependent adult to exercise that degree of care that a reasonable person in a like position would exercise.” Neglect includes

    • Failure to assist in personal hygiene, or in the provision of food, clothing, or shelter
    • Failure to provide medical care for physical and mental health needs
    • Failure to protect from health and safety hazards
    • Failure to prevent malnutrition or dehydration

    Manifestations of neglect include malnutrition, dehydration, poor hygiene, pressure ulcers or bedsores, and delirium.The World Health Organization states that elder abuse constitutes a violation of human rights and includes physical abuse, sexual abuse, psychological abuse, abandonment, and neglect. Regarding prevention of elder abuse, WHO recommends public and professional awareness campaigns, caregiver support interventions, caregiver training on dementia, residential care policies, and mandatory reporting of abuse to authorities.Persistent Vegetative StateThe term persistent vegetative state (PVS) was first used in 1972 to describe the condition of severely brain-damaged patients in whom coma has progressed to a state of wakefulness in the absence of detectable awareness. A person who is conscious demonstrates wakefulness (arousal; level of consciousness) and awareness (awareness of the environment and of self). Thus, a person in a coma is unconscious, as the person is neither awake nor aware. A person in a PVS may be awake at times, but he is not aware of self or environment, and such a person is also characterized as being unconscious.Advance DirectivesAn advance directive is a legal document by which an individual specifies personal desires and preferences regarding healthcare decision making in circumstances in which the person is not able to speak on his or her own behalf. An advance directive provides a formal record of one’s wishes in situations requiring medical decision making, in the case in which a person, having previously had the cognitive capacity to make one’s preferences known, has lost such capacity, temporarily or permanently. If one has not created a formal advance directive, one’s medical treatment is determined by the medical standards of the community. The two main components of a person’s specifications or orders are the procedures one wants to avoid and the quality of life that one will find acceptable.Physician Orders for Life-Sustaining Treatment (POLST)Physician orders for life-sustaining treatment (POLST) forms supplement a patient’s advance directive, which designates a surrogate decision maker. A POLST form specifically details medical orders and informs emergency personnel regarding which treatments a person wishes to be performed during a medical emergency. The advance directive and POLST form are included in a patient’s medical record. POLST documentation guides medical decision making for patients who are likely to die within the next twelve months.Healthcare Decision-Making Capacity and Legal CompetenceCapacity refers to a person’s present level of decision-making capability. Capacity is decision-relative and the context needs to be specified. The question regarding decision-making capability becomes, “Does the patient have the capacity to perform a particular decision-making task, at a particular time and under specified conditions?”In contract, competence is a legal construct. In most jurisdictions only a court can determine whether a person is incompetent. Thus, when legislatures draft competence statutes, they may determine the type and degree of clinically assessed lack of capacity that will allow a judge to declare an individual legally “incompetent.”In critical care and end-of-life decision making, a patient’s capacity to make medical decisions is evaluated based on four key criteria:

    • The ability to understand risks and benefits
    • The ability to apply risks and benefits to one’s own situation
    • The ability to make a reasoned decision consistent with one’s beliefs and values
    • The ability to express a preference and communicate that decision

    Surrogate Decision MakingA surrogate decision maker or healthcare proxy is identified in a person’s advance directive as the individual who will assert the person’s rights and interests in the area of healthcare decision making if the person has become unable to speak on her or his own behalf. The surrogate is the living embodiment of the judgments or choices the person would make if she were capable of doing so and the surrogate executes the terms of the person’s advance directive.Substituted Judgment versus Best Interests StandardIn substituted judgment, a surrogate decision maker establishes the healthcare decisions the patient would have made if the patient were competent to make a decision. These conclusions can be based on the patient’s desires and preferences expressed in previous verbal statements or the surrogate’s knowledge of the patient’s beliefs and values. The surrogate is speaking for the patient and “substituting” the patient’s judgment regarding the clinical circumstances and medical decision making required by those circumstances.If no advance directive exists and the patient’s preferences and desires have not been communicated to family or friends, the best interests standard is utilized. In such circumstances, the hospital medical team, supported by input from the hospital ethics committee and the patient’s close relatives and/or close friends, will make medical decisions based on the patient’s best interests. The basis for a best interest decision is what a reasonable person would choose after considering all the options and alternatives.Hospital Ethics CommitteesHospital ethics committee members may include medical and nursing staff, social workers, hospital chaplains, legal and risk management personnel, and representatives from the community, including bioethicists, religious leaders, and interested parties. A typical hospital ethics committee holds regular monthly meetings and convenes during the month as needed to consult on specific cases. The function of the hospital ethics committee is not to direct care but rather to provide recommendations for care. An ethics consultation is typically called when treatment decisions involve circumstances such as the following:

    • Consideration of a patient’s capacity for decision making
    • Determination of an appropriate surrogate decision maker
    • Family conflict regarding medical treatment
    • Withholding or withdrawal of life-sustaining treatment
    • Other assessments of medically nonbeneficial treatment

    Medical Futility/Nonbeneficial TreatmentMedically futile or nonbeneficial treatment is defined as treatment that does not provide appreciable improvement to the patient as a whole. For example, treatment that maintains a patient in an unconscious state but does not result in other improvement in the patient’s condition, or treatment that does not reduce a patient’s total dependence on intensive medical care, should be determined to be medically futile or nonbeneficial after an agreed-upon duration.Palliative CarePalliative care refers to treatment directed toward improving the quality of life of patients with serious illnesses. The palliative care model incorporates total pain management and additional methods for reducing the symptom burden of the patient’s disease. Palliative care specialists assist chronically ill patients in obtaining appropriate pain control. Regarding management of complex symptomatology, the palliative care model includes a focus on nonmotor components of chronic disease such as fatigue, lack of restful sleep, depression, anxiety, urinary urgency, and constipation, all of which contribute substantially to loss of function and impaired quality of life. As well, palliative care also addresses psychosocial issues concerning the patient, the patient’s caregivers, and family members.Physician-Assisted SuicideAs examples of state laws permitting physician-assisted suicide, Oregon and California statutes require certification by both an attending physician and a consulting physician that the patient has an incurable and irreversible terminal disease. The attending physician must refer the patient to a mental health specialist, if indicated, to determine whether the patient is not suffering from impaired judgment owing to depression or other psychiatric disorder and has the capacity to make medical decisions for himself or herself. The patient must make two oral requests to receive a prescription for an aid-in-dying drug, a minimum of fifteen days apart, and a written request. The written request must be signed and dated, in the presence of two witnesses, only one of whom may be related to the qualified individual or be entitled to a portion of the individual’s estate upon death.

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