AEB - Ethics and Advanced Directives

Consent

a person’s voluntary agreement to a proposed medical treatment or procedure after receiving and understanding relevant information. Essential for patient-centred care.

Capacity (competence)

ability to make a specific healthcare decision at a particular time where patients can understand the treatment decision with any necessary support given.

Voluntariness

making decisions freely (even if unwanted) without undue pressure or influence.

Disclosure

relevant information needed to make an informed decision is provided, including treatment options, expected benefits, and risks of treatment OR no treatment.

Understanding

patient comprehends the information provided sufficiently to make an informed decision, given the opportunity to ask questions, have time, and get advice.

Material risk

risks that a reasonable person would find significant in deciding whether to have a treatment of procedure, and therefore should be disclosed.

Decision

patient chooses whether to accept or refuse proposed treatment after considering the information. Can at changed at anytime and should be revisited if circumstances change.

Authorisation

generally the patient provides consent for the healthcare professional to proceed with treatment. Can also be down by a substitute decision maker if capacity is lacking.

Autonomy, information, enactment, documentation

What are the 4 aspects of consent?

Documentation

recording the consent process and decision in the medical record, including relevant information discussed, the patient's decision and any specific conditions or limitations.

Proactively disclose information

identify the typical risks, benefits and alternative for the treatment and provide supporting materials to understand this. Phase 1 in framework for consent.

Ensure understanding

communicate information clearly, check patient understanding, and explain any terms. Phase 2 in framework for consent.

Reactively respond

invite questions and concerns; respond thoroughly to patient and their priorities. Phase 3 in framework for consent.

Implied consent

consent inferred from a person’s actions, e.g. holding out arm to take blood pressure.

Sanctity of life

ethical principle that human life has inherent value and should be respected and protected. BUT not absolute requiring delivery of futile treatment.

Non-beneficial care

treatment unlikely to achieve its intended clinical goal or provide meaningful benefit. Generally clinicians are not obliged to be offer.

Proactive duties

doctors must provide information a patient would reasonably want to know, even if not specifically asked, such as risks, benefits, and alternative treatments.

Reactive duties

doctors must respond to the specific needs, concerns, or questions of the individual patient, providing information that is important to the particular patient.

Understand, retain, weigh information and make, communicate decision

Describe the 5 steps of capacity assessment.

Duty of care

ethical and legal responsibility of clinicians to provide reasonable professional care in the patient’s best interests.

Minimum obligations

idea that certain treatments should always be provided, regardless of the clinical situation of patient’s goals.

Ordinary treatment

treatment that offers a reasonable hope of benefit without excessive burden; traditionally viewed as something that should be offered.

Extraordinary treatment

treatment involving excessive expense, pain or burden, or offering no reasonable hope of benefit.

Best interests

decision-making standard used to determine what treatment or care is appropriate for a patient, particularly when they lack decision-making capacity.

Shared decision-making

clinicians with patients or substitute decision-makers should both contribute to determine appropriate care.

Futility

treatment is unable or unlikely to achieve its intended goals. Highly contested.

Proportionality

expected benefits are weighed against the treatment’s risks, burdens, and harms.

Quality of life assessment

considers the likely quality of life following treatment based on the patient’s values.

Futility, proportionality, quality of life assessment

What are the 3 grounds by which clinicians may not offer treatment as best interests are not met.

Autonomy

a person’s right to make decisions about their own healthcare based on their goals, values, and preferences.

Informed consent (and refusal)

an ethical and legal process through which a patient gives valid permission for a specific healthcare intervention.

Substitute decision making

process where another person makes healthcare decisions for someone who lacks decision-making capacity.

Expressed interests

previous expressed wishes of a competent patient, especially acceptance and refusal of specific treatments should be prioritised. ACD applicable.

Substituted judgement

decide according to what the patient would have wanted, based on known preferences, goals, and values.

Best interests assessment

decide based on patient’s circumstances and likely benefits, while prioritising shared decision making.

Expressed interests, substituted judgement, best interests assessment

What are the 3 key basis of substitute decision making?

Person responsible

person authorised to make certain healthcare decisions for a person who lacks capacity. Formally appointed enduring guardian > spouse or partner > unpaid carer > relative or friend.

Supported decision-making

providing assistance that enables a person to make their own decisions and remain in control of their life, as outlined by the UN.

Terri Schiavo case

ethical and legal contest over end-of-life decisions following patient with irreversible brain injury and persistent vegetative state following cardiac arrest.

Messiha case

case establishing doctors are not required to provide life-sustaining treatment when it is deemed futile and contrary preferences of patient of substitute decision maker.