A patient’s right to treatment is fundamental, but the right to refuse treatment is much stronger. A patient always has the right to refuse treatment. Department of Health 2001 states that consent to treatment is vital to the provision of healthcare.
DNR orders are very common in the health care environment particularly among the elderly and terminally ill. However, DNR orders can only be considered after discussion with the patient and or relatives and friends close to the patient and should be reviewed at regular intervals (RCN 2001).
Ethical considerations
Decisions about resuscitations pose many ethical issues for those who are involved. The quality of life, diagnosis along with the wishes of the patient should be taken into account (Birtwistle and Nielsen 1998).
The ethical principles of non maleficience, beneficence, autonomy and justice can be used as a guide to help when deciding whether or not to resuscitate. It could be argued health care professionals have a responsibility to resuscitate those patients who have a significant chance of survival and good quality of life (Pera and von tonder, 2005). Even when the patient has involvement of the decision there are also problems in regards to what advice to give.
A DNR order gives the rescuer the permission not to attempt resuscitation based on the patient’s medical conditions (DoH 2001).
The Nursing and Midwifery council (NMC 2008) “The Code” states that registered nurses are “personally accountable for ensuring that you promote and protect the interests and dignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs.” (Section 2.2.)
Communication is essential in ensuring that those who care for the patient are fully informed (Royal College of Nursing). By discussing the DNR order with Mrs K and her relatives will ease stress and any misunderstanding. When a DNR decision has been put in place, it is important to explain why. A DNR decision is based on the quality of life considerations, and if the patient cannot express a view, the opinion of relatives or people close to the patient may be sort with regards to the patient’s best interests (BMA 2007).
The right to refuse consent.
In this case it is down to the health professionals involved to identify whether the patient is independent in the decision making and to find the reason of refusal. The decision should be respected if the patient refused based on an informed and rational decision. However, if the patient is emotional or has not understood the information conveyed or if the health professional believes the patient is mentally unbalanced or incompetent in making a rational decision then it becomes a difficult situation (Pera and Tonder 2005).
According to Dunn 1998 there are four groups which irrationality can seriously affect individuals, one group identified is the elderly. Deterioration in the brain can lead to normal reasoning being affected. In such cases reducing the patient’s autonomy in decision making may be necessary to safeguard the patient.
The principle of non-malifience is one that seeks to avoid intentional harm to others. It also implies to stop or prevent treatment that causes harm to an individual (Rai 2009). In relation to Mrs K she has clearly expressed that she did not want to proceed with the operation. Ignoring her wishes would both undermine her interests and break the trust she maintains with the healthcare professionals. Proceeding in this way may harm the integrity of future decision making.
Conversely not proceeding with the procedure may conflict the professional code and in turn causing the patient more harm. Hip fractures are common among the elderly and refusing treatment will lead to immense pain and discomfort as well as immobility, which can lead to pressure sores (Onslow 2005).
The principle of beneficence is essentially one which requires one to behave to the benefit of the patient, and it is closely linked to non-malificence. It could be argued that the consultant proceeding with the operation will inevitably lead to a better lease of life, which will contribute to the welfare of Mrs K. By having an open discussion with Mrs K it will allow her to voice her opinions and any concerns she may have regarding the procedure, allowing the consultant to attempt to put her mind at ease (Pera and Tonder 2005). That way the benefits and drawbacks can be balanced, enabling the consultant to come to a just decision on how to proceed.
The respect for the wishes of a patient is the crucial point to the issue of consent (Hope et al 2008). Deciding whether a patient is autonomous is important in whether to be influenced by a patient’s view. Looking at the case, it could be argued that Mrs K’s dementia prevents her from being autonomous. She does not appear to have plans free from the interference by others. It could be argued that over riding her refusal does not conflict with the principle of respect for autonomy, since she is not autonomous.
Family members should not be shared information regarding mentally competent patients without their consent. The patient decides with whom and what information to share. Where there is a lack of capacity within the patient, it is usual to assume they would want those close to them to be informed, unless there is clear evidence against this (Rai 2009). The health professionals in this case have not done that.
Consent provides lawful justification for treatment, if valid consent is not given any treatment which involves touching the patient would amount to battery. In order for Mrs K to give valid consent she must have the mental capacity to understand the information given to her. Consent is an agreement made voluntarily, without deceit by a mentally competent person to an action that without consent would be a violation to that person. With reference to the case study it is important to establish whether Mrs K is mentally competent to make discussions, to understand the information given to her and to consent to the operation.
As the case study indicates that Mrs K is elderly and has advanced senile dementia and shows a clear objection to the procedure, the Nurse and Consultant would have to consider whether Mrs K is competent enough to understand the information given to her. It should never be assumed that a person lacks capacity because they have dementia. Obtaining consent depends on the competency and capacity of the person with dementia to understand the information given, and to make an informed decision regarding their treatment of care (DoH 2001).
According to the Department of Health guide to consent to treatment 2001 if the practioners can demonstrate that operating is in Mrs K’s best interests then consent can be placed in their hands. The only interests which should be taken into account when deciding on treatment is the patients best interests. It is no lawful to balance these against the interests of family or health professionals.
References
Beauchamp, T.L and Childress, J.F. (2009) Principles of Biomedical Ethics (6th ed.) Oxford: Oxford University Press
Buka, P. (2008) Patients’ Rights, Law and Ethics for Nurses: A practical guide. London: Hodder Arnold
Dunn, C. (1998) Ethical issues in mental illness England (Guildford): Ashgate Pubblishing Limited
Fletcher, N., Holt, J., Brazier, M and Harris, J. (1995) Ethics, law and nursing. Manchester: University Press
Kitwood, T. (1997) Dementia reconsidered: the person comes first. Buckingham: Open University Press
Leathard, A and McLaren, S (Eds.) (2007) Ethics: Contemporary challenges in health and social care. Bristol: Policy Press
Mason, J.K., McCall Smith, R.A and Laurie, G.T. (2002) Law and Medical Ethics (6th ed.) London: LexisNexis
Pera, S.A and van Tonder, S. (Eds.) (2005) Ethics in Health Care (2nd ed.) Landsowne: Juta & Co
Rai, S.G (ed.) (2009) Medical Ethics and the Elderly (3rd Ed.) Oxford: Radcliffe Publishing
