Autonomy,privacy and informed consent 4: surgical perspective

This is the fourth article in a four-part series that considers the issues of patient autonomy, privacy and informed consent. The article discusses these issues in the context of surgical patients and their nurses. There is an abundance of references to issues of autonomy and informed consent within the healthcare literature, although there are few empirical studies investigating these issues within practice. The issue of privacy has been somewhat less explored than that of autonomy or consent, particularly in the UK literature. This article reports the findings of a Scottish study that formed part of a multisite comparative study funded by the European Commission. A convenience sample of surgical patients (n = 282) and their nurses (n = 260) participated in the study. Data were collected by means of a self-completion questionnaire for both patients and nursing staff. Results indicated that there are significant differences in patient and staff perceptions on issues of patient autonomy, privacy and informed consent. However, the most marked difference in perceptions of patients and staff were found on the information-giving element of the autonomy subscale. Implications for nursing practice, education and research are highlighted.     

Autonomy,privacy and informed consent 2: postnatal perspective

The nursing and healthcare ethics literature over the past 10 years has focused on issues of patient autonomy and patient rights. Despite the growing volume of literature exploring such topics, there is little empirical work investigating what is actually happening in clinical nursing or midwifery practice in relation to patient autonomy, privacy or informed consent, from the perspective of either patients or staff. This four-part series reports the results of a Scottish study that formed part of a multisite comparative research project funded by the European Commission, investigating issues of patient autonomy, privacy and informed consent. This article, the second of four, explores the issues of autonomy, privacy and informed consent in maternity care. The research questions asked were: (1) What is the perception of mothers' autonomy, privacy and informed consent in Scottish NHS hospitals, from the point of view of both mothers and midwives? (2) Are there differences in the perceptions of mothers and midwives on these issues? Data were collected by a self-completion questionnaire for mothers (n = 243) and staff (n = 170) on postnatal units in both district general and university teaching hospital. Results indicated that there are differences between the perceptions of mothers and midwives in relation to mothers' autonomy, privacy and informed consent. Most differences were found in the information-giving and decision-making elements of autonomy.     

The requirement for informed consent prior to nursing care procedures

AIM OF THE PAPER: The aim of this paper is to examine the extent to which there is a requirement to obtain informed consent prior to nursing care procedures. RATIONALE: The requirement for nurses to obtain consent prior to nursing care procedures is addressed in various nursing policy documents. It is important that nurses understand the legal and ethical rationale behind the principles of informed consent so that the principles are applied appropriately to the particular context of nursing care. ARGUMENT: The ethical and legal rationale behind the concept of informed consent and its relevance to nursing practice are examined. In this paper, it is argued that the function of informed consent is to protect patient autonomy and to promote meaningful decision-making. Given the potential for nursing care procedures to infringe patient autonomy, consent is clearly a relevant concept in nursing. Furthermore, in law, any touching without consent is a potential battery. Informed consent is often associated as a rigid procedure, only relevant to surgical or research procedures. Consent should be obtained prior to nursing care procedures whenever patient autonomy is at stake. However, information-giving should be determined by the needs of the patient and approached in such a way as to facilitate meaningful decision-making. Given the individual nature of infringements to patient autonomy, it is difficult to predetermine all those care procedures that require consent; any list of procedures would fail to be comprehensive. CONCLUSIONS: The principles of informed consent should underpin our approach to nursing care procedures, which should not be mechanistic but determined by the needs of individual patients.     

The meaning of autonomy in Chinese culture: obtaining informed consent for operation

The purpose of gaining the patient's informed consent is ethical, lying in respect for his or her autonomy, and such consent forms the foundation for the performance of clinical medical treatment. In order to respect the patient's autonomy, for example, during decisions about operations, doctors have the obligation to clearly explain that patient's medical condition to him/her. A thorough briefing should be given prior to the obtaining of the patients' consent. In fulfillment of their duties as medical professionals, both doctors and nurses should be involved in clinically informing patients as well as in obtaining their signature for operation and anesthesia. Although informing patients about their physical state is not the responsibility of nurses, it remains absolutely necessary for nurses to understand how people in Asian cultures understand autonomy. This paper begins with a discussion of autonomy in ethics, and then outlines the differences between the Eastern and Western concepts of autonomy, before discussing the obtaining of the signature of consent, a process performed by the nursing staff during clinical treatment, and resulting in the provision of such signatures by patients with the legal capacity to provide them.     

A historical perspective of informed consent in clinical practice and research

OBJECTIVES: To review the historical perspective of informed consent in clinical practice and research as it pertains to human subjects. DATA SOURCES: Published professional journals, books, case law, and the internet pertaining to the historical development of informed consent. CONCLUSIONS: The history of informed consent is complex. Informed consent as a fundamental principle of clinical ethics has developed within the past 50 years. Full disclosure and shared decision making have not come naturally to clinicians. Consequently, respecting the autonomy of patients and research subjects requires a conscious, sustained effort by clinicians. IMPLICATIONS FOR NURSING PRACTICE: Knowledge of the history of informed consent is important for practicing cancer nurses to ensure they understand the significance of preserving patient autonomy and advocate for the patient and research subject.     

Autonomy,privacy and informed consent 1: concepts and definitions

This article is the first in a four-part series that explores the concepts of patient autonomy, privacy and informed consent in the context of the provision of nursing care. In this first article an overview of the concepts is provided, and some of the difficulties with definitions of these concepts are considered. The dearth of empirical exploration of the operationalization of the concepts of patient autonomy, privacy and informed consent within nursing practice is highlighted. The second, third and fourth articles report a series of empirical studies carried out with patients and staff in postnatal care, in continuing care of elderly people and in acute surgical care within Scottish NHS settings. These studies are part of a concerted effort to address the lack of empirical investigation of the ethical dimension of nursing care provision and clinical nursing practice.     

Clinical pathways to improve patient outcomes

Abstract

A dynamic plan of care should be established for each diagnosis to optimise patient outcomes. There is evidence to support the view that these dynamic plans or clinical pathways improve patient compliance. This pathway would create a relationship between the clinician and patient, increase autonomy, and decrease paternalism. It will delineate frequency, duration, pain, and time to reach the anticipated functional goal of the patient. Informed consent and patient rights have been discussed in the literature as an ethical challenge. A respect for the legal implications of an informed consent must continue, along with an open dialogue about the clinical pathway. The informed consent would transition from a legal document to an active clinical pathway, providing increased autonomy, improved outcomes, and better patient compliance.     

Nurses’ perceptions of informed consent and their related roles in Korea: An exploratory study

Background

Informed consent is based on the Western notion of autonomy that patients have the right to know about their illnesses and make decisions about their health. However, there may be difficulty in accepting informed consent in Eastern cultures based on Confucianism, such as Korea. Even though nurses have no legal binds to informed consent, they have participated in the process of obtaining informed consent as an administrative assistant in Korea and then have had moral distress.

Objectives

The purpose of this study was to investigate nurses’ perception of informed consent and their role in establishing a better process of informed consent in Korea.

Methods

This exploratory study employed in-depth interviews with nurses. Participants were 12 nurses from selected departments (orthopedics surgery, cardiac surgery, and obstetrics & gynecology) from two university hospitals in Seoul and Kwang-ju, Korea. A semi-structured interview guide was constructed from the literature and used to elicit responses.

Results

Content analysis showed that nurses perceived a lot of problems in the process of obtaining informed consent and noted the need to modify this process. Although the role of nurses was found to be insignificant in the process of obtaining informed consent, some nurses wanted to participate in the process in order to advocate for patients and to verify if patients had received the information they needed.

Conclusions

Nurses can take a proactive role in the process of informed consent, as advocator as well as witness. This may be influential in balancing patient autonomy with paternalism, changing the skewed patient–physician relationship to one of mutual respect.     

Autonomy and clinical practice. 2: Patient privacy and nursing practice

This article, the second in a series of three considering issues of autonomy, privacy and informed consent in nurse/patient interactions, focuses on the wider conceptions of patient privacy and confidentiality. Given that patients in institutional care are likely to suffer intrusions into their privacy which would be considered unusual in normal social interaction, it is interesting to note the dearth of literature in this area. Some definitions of privacy are considered in an attempt to begin to raise readers' awareness of the complexity of this notion. It can be argued that privacy is a pertinent notion to consider, both in order to gain a greater understanding of what is meant by the term and in terms of the implications of this understanding for clinical practice.     

Patient autonomy in physical restraint

Despite initiatives to raise the awareness of patient autonomy among healthcare providers, the use of physical restraints on frail or confused older patients continues to be a common practice in many healthcare settings. This paper examines the relationship between patient autonomy and the use of physical restraints by drawing on the literature contradicting its efficacy and the assumption that its use is necessary to protect the welfare of patients. It argues that the paternalistic use of physical restraints without patient's informed consent is morally unjustified and is an unequivocal violation of their autonomy. The duty to respect individual autonomy should be extended to a duty to respect the autonomy of older people who are being restrained. Only in this way can their human dignity and quality of life be enhanced.     

Informed consent in theory and practice: legal and medical perspectives on the informed consent doctrine and a proposed reconceptualization

The theoretical, legal, and medical doctrines of informed consent are analyzed. The elements of informed consent include disclosure of information, competency, understanding, voluntariness, and decision-making. The doctrine is ground in deference to individual autonomy and recognition that the exercise of self-determination in matters of health is a liberty interest honored by our history and traditions. The exceptions to informed consent including emergency, incompetency, therapeutic privilege, and waiver are especially important in critically ill patients and reflect a balancing of autonomy values and society's interest in the promotion of health. Legal decisions inevitably are based on atypical physician-patient encounters and focus on a particular problem or procedure rather than on overall medical care. In addition, they often reflect an artificial view of the doctor-patient relationship. Medical decision-making is a complex, evolving pursuit of a diagnosis and proper treatment regimen. Moreover, patients are not always interested in the role assigned to them by law. A reconceptualization of informed consent doctrines utilizing sliding scale standards based on variables pertinent to each individual patient is suggested.     

Medical informed consent: general considerations for physicians

Medical informed consent is essential to the physician's ability to diagnose and treat patients as well as the patient's right to accept or reject clinical evaluation, treatment, or both. Medical informed consent should be an exchange of ideas that buttresses the patient-physician relationship. The consent process should be the foundation of the fiduciary relationship between a patient and a physician. Physicians must recognize that informed medical choice is an educational process and has the potential to affect the patient-physician alliance to their mutual benefit. Physicians must give patients equality in the covenant by educating them to make informed choices. When physicians and patients take medical informed consent seriously, the patient-physician relationship becomes a true partnership with shared decision-making authority and responsibility for outcomes. Physicians need to understand informed medical consent from an ethical foundation, as codified by statutory law in many states, and from a generalized common-law perspective requiring medical practice consistent with the standard of care. It is fundamental to the patient-physician relationship that each partner understands and accepts the degree of autonomy the patient desires in the decision-making process.     

Autonomy, privacy and the implementation of the principle of "informed consent" with regard to nursing intervention from the view point of the aged

The aim of this study was to describe patient autonomy, privacy and the implementation of the principle of informed consent in the care of elderly patients in facilities experienced by themselves. This study is part of the BIOMED 2 project "Patients' autonomy and privacy in nursing interventions" supported by the European Commission. Interview data (n = 95) were collected among elderly people in German facilities for geriatrics and in nursing homes. The results showed there was a lack of opportunity by the elderly people to make self-determined decisions. The principle of "informed consent" was hardly realised. The participants felt their privacy was not respected in multi-bedded rooms and in situations of dressing and eliminating. One can proceed on the assumption that the lack of information, the need of help and the fixed organizing structures of the facilities are the reasons why elderly people play a rather passive role as patients. It might be possible to improve the autonomy of elderly people if the nurses as an advocate supported them to make self-determined decisions. The implementation of the principle of informed consent with regard to nursing interventions would promote both autonomy and respect of privacy. Furthermore, one can assume that the autonomy and quality of life of elderly people could be promoted if the organizing structures of the facilities were more flexible.     

Informed Consent: Ethical and Legal Considerations for Advanced Practice Nurses

The ethical principles of self-determination and autonomy govern the practice of informed consent. A patient’s right to shared decision-making and assent prior to invasive procedures, therapeutic interventions, and research projects is protected by law. Foundational nursing roles of communication, education, and patient advocacy compel advance practice nurses to formulate methods that safeguard patients’ rights. Legal implications of informed consent may vary, leaving nurse practitioners juxtaposed between judicial and ethical responsibilities. The goal of this study is to examine legal and ethical components of informed consent and to assist nurse practitioners in developing proactive practice strategies related to informed consent.     

医患双方对医疗知情同意书意见的调查

目的探讨医患双方对医疗知情同意书的意见,以期为修改医疗知情同意书提供参考依据。方法收集不同等级医院的医疗知情同意书进行分析。采用自制的调查问卷对某医院100名医生和100名患者进行医疗知情同意书意见的调查。结果医患双方在医疗知情同意书的性质、过程、签署及改进方面的差异均有统计学意义(均P<0.05)。结论临床现行医疗知情同意书仍有许多方面不能达到医生及患者的要求,且绝大部分的医生及患者均认同知情同意书应采取全国统一格式。     

Perceptions of autonomy,privacy and informed consent in the care of elderly people in five European countries: comparison and implications for the future

This article discusses nurses' and elderly patients' perceptions of the realization of autonomy, privacy and informed consent in five European countries. Comparisons between the concepts and the countries indicated that both nurses and patients gave the highest ratings to privacy and the lowest to informed consent. There were differences between countries. According to the patient data, autonomy is best realized in Spain, privacy in the UK (Scotland), and informed consent in Finland. For the staff data, the best results tended to concentrate in the UK. The conceptual and methodological limitations of the study are identified and discussed. Implications of the results are divided into three areas: nursing practice, education and research. In practice, the analysis of patients' values and the ethical sensitivity of nurses are important as part of ethically good care. In nurse education, students should learn to recognize ethical problems, generally and particularly, among vulnerable groups of patients. Multicultural international research is needed in this area. This is the last of a set of five articles published together in this issue of Nursing Ethics in which the results of this comparative research project are presented.     

Informed consent to breaking bad news

Informed consent to breaking (or waiving) bad news is an important yet neglected topic. It is distinct from informed consent to diagnosis and to treatment, and may be logically and ethically sound, provided patients are competent and that no considerable harm may be caused to others by breaking or waiving bad news to patients. This requires a differential assessment procedure in order to balance patient autonomy, benefit and justice towards others, preferably exploring patients' values, expectations and needs with them, so that an acceptable decision can be made on whether to act on their consent to breaking or waiving bad news, or to ignore it and act on informed consent by proxy. Future study should attempt to provide a detailed characterization of procedures for attaining informed consent to breaking or waiving bad news, and to test their success in establishing ethically sound health care.     

The right to information and the autonomy of the hospitalized elderly

It was carried out a study with the aim to analyse the autonomy of hospitalised elderly, based on the comprehension about their rights of information and the informed consent on proposals of diagnosis and therapeutics. The results showed patient's lack of information, dissatisfaction on the degree of information. It was also verified that the patient's family frequently acts as information intermediary between the health team and the patient. Therefore, autonomy process of decision making was compromised, as well as the informed consent of the elderly.     

两种手术知情告知方式对输尿管结石激光碎石术患者焦虑情绪的比较

目的 比较两种手术知情告知方式对输尿管结石激光碎石术患者焦虑情绪的影响。方法 80例接受输尿管结石激光碎石术的患者被随机分为对照组(40例) 和实验组(40例) ,对照组采用传统方式口头告知手术过程、并发症及术后注意事项,实验组则结合使用多媒体材料(解剖图片、PPT、手术Flash动画及视频录像等)进行相同内容的手术知情告知。分别在手术知情告知签字前、签字后和手术后第二天采用焦虑自评量表进行焦虑情绪的评估和比较。结果：知情告知签字前两组患者的焦虑测评结果无明显差别(P>0.05),签字后和手术后两组患者的焦虑症状评分均进一步下降,但实验组的下降程度与对照组比较具有显著性差异(P<0.05)。结论：结合使用多媒体方式进行手术风险知情告知能显著减患者围手术期的焦虑情绪,提高患者对医生的信任度,避免医疗纠纷,值得进一步推广。