Module 49: Legal Issues - Competency, Consent, and Controlled Substances

Competency for Consent

• Definition of Competency: Competency is a legal presumption applied to individuals when they reach the status of adulthood. It grants adults the legal right to negotiate various activities, including executing a will or entering into legally binding contracts.
• Age Threshold for Competency: In the majority of states, an individual is legally considered competent at the age of $18$ years. This presumption remains in effect unless specific evidence is presented to a court that persuades them to declare the individual legally incompetent.
• Legal Incompetence and Guardianship:     * Adults declared legally incompetent via a court order are assigned a legal guardian.     * Healthcare Provider (HCP) Requirement: The legal guardian is responsible for providing HCPs with a copy of the specific court order that grants them the authority to make healthcare decisions on behalf of the incompetent adult.     * Examples of Incompetence:         * Individuals who have sustained a debilitating brain injury (e.g., from a motor-vehicle crash).         * Individuals with a profound intellectual disability.
• Temporary vs. Gradual Incompetence:     * Temporary Causes: An adult may be rendered temporarily incompetent due to the effects of narcotic medication or a serious fall.     * Gradual Causes: Incompetence may develop slowly over time as a result of conditions like dementia.
• Nursing and Provider Responsibilities:     * Nurse's Role: If a nurse has concerns regarding a patient’s level of competency, they must alert the primary care provider.     * Provider's Role: The primary care provider determines if the patient is competent for the purposes of informed consent. If found incompetent, the provider must determine if the "emergency doctrine" applies or if an alternative valid decision-maker is available.
• Legal Continuity and Presumptions:     * Courts typically presume the continuing competency of adults. (Source: Guido, $2020$).     * To overturn this presumption, a healthcare facility must demonstrate that the patient is unable to understand the consequences of their own actions.
• Institutional and State Compliance: Nursing staff and healthcare personnel must be familiar with their specific state’s laws as well as the policies and procedures of their employer.
• Patient Rights: Nurses must recognize that competency affects the delivery of care because patients possess the legal right to decline both medical procedures and general nursing care.
• Diversity and Culture: Cognitive impairment can significantly alter the process of obtaining informed consent.

Consent in an Emergency

• The Emergency Doctrine: In most states, the law assumes an individual's consent to medical treatment when they are in "imminent danger of loss of life or limb" and are physically or mentally unable to provide informed consent.
• Reasonable Consent Assumption: The doctrine is based on the premise that a reasonable person would consent to treatment if they were able to do so.
• Purpose: It serves as a guiding principle allowing HCPs to perform potentially lifesaving procedures when obtaining consent is impossible or impractical.
• Limitations of the Doctrine:     * It does not allow HCPs to implement treatments to which a patient would not reasonably consent.     * Prior Refusal: HCPs are prohibited from providing treatment that the patient previously refused.     * Example: If a patient previously refused a specific procedure based on religious grounds, HCPs cannot implement that procedure even if the patient becomes unconscious and faces a life-threatening situation.

Child Participation in Healthcare Decisions

• General Rule for Minors: For any minor child (defined as under the age of $18$), a parent or legal guardian must provide informed consent for medical treatment.
• Legal Exceptions to Parental Consent:     * The emergency doctrine is applicable.     * The child is an emancipated minor, defined as one who is no longer under parental control and manages their own financial affairs.     * The child resides in a state that recognizes the mature minor status (e.g., $14$- and $15$-year-old adolescents capable of understanding treatment risks).     * A specific court order exists to proceed with treatment.     * The law recognizes the minor's ability to consent to a specific type of treatment.
• Minor Parents: In a majority of states, a minor who is a parent may provide informed consent for the healthcare treatment of their own child.
• Specific Types of Care for Teenagers: Some states allow teenagers of certain ages to seek specific care without parental consent, including:     * Contraceptive services.     * Prenatal care.     * Mental health counseling.     * Diagnosis and treatment of sexually transmitted infections (STIs).     * Treatment for substance abuse. (Sources: American Civil Liberties Union of Ohio, $2014$; Keller, $2020$).
• State-Specific Example (North Carolina): North Carolina law allows all minors over the age of $12$ to consent to contraceptive services, treatment of STIs, and prenatal care. (Source: Keller, $2020$).
• Mature Minor Judgments: In some jurisdictions, minors must convince a judge that they possess the maturity required to make independent judgments regarding medical consent. (Source: Nurse Journal, $2020$).

Clinical Example A: Marvin Martinice

• Patient Profile: Marvin Martinice, a $15$-year-old boy diagnosed with acute myelocytic leukemia.
• Clinical Status: He has emerged from his second remission with an acute onset of fever, joint pain, and petechiae.
• Treatment Options: A bone marrow transplant is identified as one of the few remaining therapeutic options.
• The Conflict:     * Marvin's Stance: He agrees to the transplantation if a donor is found but explicitly does not want to be resuscitated (DNR) or placed on life-support equipment in the event of cardiac arrest. He has consulted with the hospital chaplain and social worker and is comfortable with this decision.     * Parents' Stance: They want an "all-out effort" to sustain his life using all available means until a donor is located.
• Critical Thinking Questions:     * 1. In general, what happens when parents and children have conflicting opinions about treatment?     * 2. Assume you are a nurse involved in Marvin’s care. What is your role, if any, in addressing the difference of opinion between Marvin and his parents regarding available treatment options?

Controlled Substances Act (CSA)

• Definition: The CSA is a federal law regulating drugs by classifying them based on three criteria:     * The substance's medical use.     * The potential for abuse.     * Safety risks.
• Classifications (Schedules): Drugs are organized into five categories called "schedules," numbered from $\text{I}$ to $\text{V}$.
• Abuse Potential: Schedules $\text{I}$ and $\text{II}$ are identified as having the highest potential for abuse.