Class session 20 refusal to treatment
- 1. Class Session 20 Refusal of Treatment Mrs. Samia Almusalhi 20 21 22
- 2. • Patient has the right to accept or refuse treatment. • Nurses must be aware that even though a patient has the right to refuse medical care, this refusal must be an "informed refusal.“
- 3. Patient Self-determination Act • As a result of the Cruzan case, Congress passed the federal Patient Self-Determination Act (PSDA) of 1990. This law mandated that every hospital, nursing home, healthcare agency, and health maintenance organization (HMO) that receives Medicare and Medicaid funds must provide adult patients with a statement of rights under state statutory law to make health choices, including the right to refuse treatment and to execute an advance directive.
- 4. Patients' Bill of Rights • Following the presentation of the PSDA, individual states (if they had not already done so) created or modified their own patients' bill of rights (Patients' Bill of Rights, 1999). Nurses should review the relevant bill of rights available at the healthcare institution or by state law. • is a list of guarantees for those receiving medical care. It may take the form of a law or a non-binding declaration. Typically a patient's bill of rights guarantees patients information, fair treatment, and autonomy over medical decisions, among other rights.
- 5. Informed Consent • Informed consent is the process by which a fully informed patient participates in choices about his or her health care. • The essential· parts of this decision -making process include discussions about: • (1)the nature of the medical decision or procedure; • (2) reasonable alternatives to the recommended intervention; • (3) the relevant risks, benefits, and uncertainties related to each alternative; • (4) assessment of patient understanding; and • (5) the acceptance of the intervention by the patient.
- 6. • For the consent (or refusal) to be valid, the patient must be competent to make the decision, and the consent (or refusal) must be voluntary. It is important that the patient understand the healthcare provider's reasoning process for the recommendation. The discussions should be carried out in lay terms.
- 7. Assessment of Patient's Competence • In most cases, it is clear whether a patient is able to comprehend the information and is therefore considered to be competent. However, in some situations, it is not so clear. Patients in a healthcare setting are often extremely anxious and fearful. This should not be confused with a person's ability to make reasonable decisions. • There are a number of different legal standards in which a person's legal competence could be judged. However, generally an assessment should be made of the patient's ability to: (1) understand the situation (i.e., does the patient knows where he or she is and why he or she is in the hospital); (2) understand the risks associated with the procedure; and (3) communicate a decision based on that understanding.
- 8. • When a patient's competence is unclear, a psychiatric consultation may be helpful. • Again, just because a patient refuses treatment does not in and of itself mean the patient is incompetent.
- 9. • If the patient is demonstrated to be incompetent to make healthcare decisions, a surrogate decision maker must speak for the patient.
- 10. • When an adult never had the mental capacity to make medical decisions, the right to refuse medical treatment becomes complicated. Some states have case law on the policy of replaced judgment, which utilizes all the facts and circumstances to come to a decision on how the incompetent person would decide if he or she is competent.
- 11. • Ideally, the policy of replaced judgment uses the surrogate decision maker's knowledge of the patient's beliefs, ethics, and any decisions or conversations the patient may have had prior to the incompetence and then uses that to determine how the patient would have decided. • This is more difficult to apply when the patient has never achieved a state of competency, as the preceding case demonstrates.
- 12. Minors • With respect to minors, the decision maker is presumed to be the parent or guardian. • The exceptions to informed consent laws, allowing minors to consent to drug and alcohol treatment or mental health treatment without parental consent, • It do not extend to a right of the minor to refuse the same treatment that has been consented to by the parent. The courts would look to whether the minor was able to make an informed decision to refuse.
- 13. • The Florida Appellate court stated the parental right to place a minor child in a drug treatment program without the minor's consent. • The applicable state statute provides for the parent to apply to the courts for involuntary placement .
- 14. What would be done if parent refuse lifesaving treatment for their children? • A parent's refusal of lifesaving treatment for their child may be overruled by a court order. • The court will look to whether the parent is acting in the best interest of the child. • Institutional polices should include the involvement of the ethics committee and legal counsel to determine legal review.
- 15. What is nurse role when patient singed Informed Refusal? • Although the patient has the right to refuse medical treatment, the nurse's duty to the patient does not end at documenting "patient refuses.“ 1. The nurse has a legal duty to ensure that the patient's decision to refuse treatment is an informed one. 2. Patient teaching on the risks of refusing treatment is an essential element to the patient's right to refuse. 3. A nurse who documents in the medical record "patient refuses treatment" has not completed the duty allocated to the patient. The documentation must reflect the teaching that was presented to the patient and that the patient refuses with an understanding of the risks.
- 16. Example • In Hackathorn v. Lester Cox Memorial Center, a nurse was liable to a patient for the burns he received from a heating pad despite the nurse's attempts to assess his back. • The patient was admitted for a herniated disk. The nurse documented that she asked the patient to "roll over" so she could assess his back for heating pad burns. He refused several times. When the pad was removed, he had several serious burns that required treatment, and it caused a delay in surgery for the herniated disk. • The nurse claimed causal negligence by the patient for his own injuries (based on his refusing the nursing assessment).
- 17. • The court found that the nurse did not complete her duty by informing the patient of the risk of heating pad burns and the need for periodic assessment. • Furthermore, the nurse could not prove (through documentation) that the patient was even capable of rolling over for a back assessment upon her request. • Therefore, the patient's refusal was not "informed" and did not contribute to his own injuries. • The nurse should have documented that the patient was educated on the benefits of complying and was physically capable of complying with the nurse's request, yet he refused with knowledge of the risks for burns.