[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]
Informed Consent and Decisional Capacity
In 1914 Judge Benjamin Cardozo made the pivotal argument that “every human being of adult years and sound mind has a right to determine what shall be done with his own body”. The meaning of patient ‘consent’ in the practice of medicine expanded by the 1950s to ‘informed consent’ (with the patient still in a passive position in the decision-making) and since the 1970s to ‘informed choice’ (with the patient more actively participating in shared decision-making).
Informed consent is “an autonomous authorization by individuals of a medical intervention or of involvement in research” based upon adequate disclosure by the physician of the nature of the intervention, its risks and benefits, as well as of alternatives with their risks and benefits (Beauchamp and Childress, Principles of Biomedical Ethics). Informed consent is a communication process. Informed consent as an ethical dimension of patient care focuses on the protection of a patient’s right to self-determination (with legal protection for the physician being a secondary purpose).
Consider the following encounter –
Most caregivers are able to recall the components of truly/fully informed consent. This diagram calls attention to how few decisions/orders in ‘the plan for today’ involve shared decision-making and opens discussion of the choices other than shared decision-making by (1) identifying the factors that influence a medical team’s choices and (2) testing a medical team’s ability to give justification for each of the four choices for involving patients, surrogates, and family members in decision-making. This diagram also opens discussion about the significance of decisional capacity in determining whether to involve patients, surrogates, and family members.
A person with decisional capacity makes and communicates a decision that is based on a consistent comprehension of the decision’s benefits, risks, costs, and consequences for others. A person with decisional capacity is responsible for her decisions and actions. A person may not have the capacity to make decisions at all levels of complexity or consequence. Procedures should be explained to patients without decisional capacity in terms they can comprehend. The nearer a patient is to full decisional capacity, the more consideration should be given to the patient’s views. Prior to reaching the age of majority (i.e., the threshold of adulthood), a person is presumed not to have decisional capacity unless there is evidence to the contrary.
The attending physician is responsible – through discussion with the patient and with appropriate consultation – to assess a patient’s decisional capacity. If a patient is assessed not have decisional capacity, a substitute for the patient (i.e., a surrogate) is necessary. A surrogate’s decisional capacity must also be assessed by the same criteria (i.e., consistent comprehension of medical facts and communication of choices that reflect patient wishes/interests) plus attention to compromising conflicts of interest.
A surrogate’s minimal contribution to the compromised patient’s care is to advocate for management that is in the patient’s best interests. A surrogate’s optimal contribution to the compromised patient’s care derives from being sufficiently familiar with the patient’s values to express the patient’s wishes and expectations.
Informed Consent and Decisional Capacity
In 1914 Judge Benjamin Cardozo made the pivotal argument that “every human being of adult years and sound mind has a right to determine what shall be done with his own body”. The meaning of patient ‘consent’ in the practice of medicine expanded by the 1950s to ‘informed consent’ (with the patient still in a passive position in the decision-making) and since the 1970s to ‘informed choice’ (with the patient more actively participating in shared decision-making).
Informed consent is “an autonomous authorization by individuals of a medical intervention or of involvement in research” based upon adequate disclosure by the physician of the nature of the intervention, its risks and benefits, as well as of alternatives with their risks and benefits (Beauchamp and Childress, Principles of Biomedical Ethics). Informed consent is a communication process. Informed consent as an ethical dimension of patient care focuses on the protection of a patient’s right to self-determination (with legal protection for the physician being a secondary purpose).
Consider the following encounter –
An intern had written for the nurse to obtain several urine samples, including one for a drug screen. When the nurse asked for the urine sample, he told the patient what tests would be conducted. When a drug screen was mentioned, the patient did not consent to the drug screen. So the nurse did not send that sample. The nurse told the intern the patient would not consent. The intern told the nurse, “I don’t care that he doesn’t give consent, go back in there and get the urine and send it. I will deal with it later.” The nurse did not go back and collect/send the urine. His supervisor advised him to write a note stating, “Patient did not consent to urine drug screening.” Both the supervisor and the nurse felt the intern’s response and course of action were inappropriate. The supervisor spoke with the attending who stated he would follow-up with the intern.The following diagram delineates four distinguishable choices – covering a spectrum from shared decision-making to no involvement – common to patient care re whether, when, and to what extent patients, surrogates, and family members share in decision-making.
Most caregivers are able to recall the components of truly/fully informed consent. This diagram calls attention to how few decisions/orders in ‘the plan for today’ involve shared decision-making and opens discussion of the choices other than shared decision-making by (1) identifying the factors that influence a medical team’s choices and (2) testing a medical team’s ability to give justification for each of the four choices for involving patients, surrogates, and family members in decision-making. This diagram also opens discussion about the significance of decisional capacity in determining whether to involve patients, surrogates, and family members.
A person with decisional capacity makes and communicates a decision that is based on a consistent comprehension of the decision’s benefits, risks, costs, and consequences for others. A person with decisional capacity is responsible for her decisions and actions. A person may not have the capacity to make decisions at all levels of complexity or consequence. Procedures should be explained to patients without decisional capacity in terms they can comprehend. The nearer a patient is to full decisional capacity, the more consideration should be given to the patient’s views. Prior to reaching the age of majority (i.e., the threshold of adulthood), a person is presumed not to have decisional capacity unless there is evidence to the contrary.
The attending physician is responsible – through discussion with the patient and with appropriate consultation – to assess a patient’s decisional capacity. If a patient is assessed not have decisional capacity, a substitute for the patient (i.e., a surrogate) is necessary. A surrogate’s decisional capacity must also be assessed by the same criteria (i.e., consistent comprehension of medical facts and communication of choices that reflect patient wishes/interests) plus attention to compromising conflicts of interest.
A surrogate’s minimal contribution to the compromised patient’s care is to advocate for management that is in the patient’s best interests. A surrogate’s optimal contribution to the compromised patient’s care derives from being sufficiently familiar with the patient’s values to express the patient’s wishes and expectations.