Respect For Patient Autonomy Research Articles

The medical record as legal document: When can the patient dictate the content? An ethics case from the Department of Neurology

Confidentiality of health information is increasingly relevant in the era of electronic medical records. We discuss the case of a hospitalized patient who requested a neurology consultation for an episode he described as an “LSD-like” (Lysergic acid diethylamide) flashback. The patient expressed concern that the episode was a residual effect of past drug use, but subsequently requested that his drug use not be documented. Involved in a custody battle, he feared that if his records were released to the court he could lose custody of his children. Ethical concerns arose with regards to the physician’s competing obligations with a duty to record information accurately and honestly, respect patient autonomy, and maintain patient confidentiality. We discuss the decision of the team to document the patient’s drug use by arguing that the obligation to maintain confidentiality did not supersede the primary role of the medical record as a complete and accurate account, which cannot be altered at a patient’s behest.

Rūpesčio habitus medicinoje: reliacinė bioetikos prielaidų interpretacija

Straipsnyje analizuojamos bioetikoje vyraujančio pagarbos asmens autonomijai principo prielaidos. Remiantis antropologų L. Dumont’o ir C. Geertzo darbais parodoma, kaip pagarbos asmens autonomijai principas yra susijęs su vakarietiška, krikščioniška, individualistine asmens samprata bei iš to plaukiančiu racionalumo reikšmės įtvirtinimu informuoto sutikimo koncepte. Taip pat ginama idėja, kad būtina atsižvelgti į rūpesčio etikos, pabrėžiančios emocijų svarbą moralėje ir paremtos reliacinio asmens prielaida, pasiūlytas įžvalgas. Straipsnyje parodoma, kaip rūpesčio etikoje pasiūlyti normatyviniai rūpesčio idealai gali būti pritaikomi bioetiniame kontekste – konceptualizuojant rūpestį medicinos sferoje galima pritaikyti Bourdieu pasiūlytą habitus konceptą ir išryškinti ne tik tarpasmeninių santykių svarbą moraliniam vystymuisi, bet ir įvairias sociokultūrines bei istorines įtakas, lemiančias tam tikrus mūsų elgsenos modelius.

Ethics of truth telling: A socio-cultural perspective

Accompanied with various opinions across cultures, truth telling is a major debate in bioethics. Many studies have focused on the attitudes towards truth disclosure. We intend to review several relevant research studies, and discuss the issue through a clinical case consultation. It seems that while ‘the right to know’ is emphasised in bioethics, in some cultural contexts, health professionals fear communicating bad news. The patients may not receive information directly, because it is believed that the truth may make the patient feel hopeless and unable to cope with the problem. Nevertheless, some believe that sharing information may strengthen a trusting relationship between the patients and the medical professionals. Extensive efforts are in process in some societies to make patient's rights to know the truth as a natural part of the medical practice. However, in some cases, the principles of respect for patient autonomy require us to accept the patient's refusal to know the truth, with the provision that he/she assigns someone to receive information and make medical decisions on his/her behalf. In conclusion, it is suggested that healthcare professionals should not act on a unique presumption in all cases and they should explore what the real interest of the patient is, in order to respect individual autonomy.

Shared Decision-Making after Implementation of the Chronic Care Model (CCM)—An Evaluative Approach

Background: In paternalistic models, healthcare providers’ responsibility is to decide what is best for patients. The main concern is that such models fail to respect patient autonomy and do not promote patient responsibility. Aim: To evaluate mental healthcare team members’ perceptions of their own role in encouraging elderly persons to participate in shared decision-making after implementation of the CCM. The CCM is not an explanatory theory, but an evidence-based guideline and synthesis of best available evidence. Methods: Data were collected from two teams that took part in a focus group interview, and the transcript was analysed by means of qualitative thematic analysis. Results: One overall theme emerged—Preventing the violation of human dignity based on three themes, namely, Changing understanding and attitudes, Increasing depressed elderly persons’ autonomy and Clarifying the mental healthcare team coordinator’s role and responsibility. The results of this study reveal that until recently, paternalism has been the dominant decision-making model within healthcare, without any apparent consideration of the patient perspective. Community mental healthcare can be improved by shared decision-making in which team members initiate a dialogue focusing on patient participation to prevent the violation of human dignity. However, in order to determine how best to empower the patient, team members need expert knowledge and intuition.

Ethical Challenges and Solutions Regarding Delirium Studies in Palliative Care

ContextDelirium occurs commonly in settings of palliative care (PC), in which patient vulnerability in the unique context of end-of-life care and delirium-associated impairment of decision-making capacity may together present many ethical challenges. ObjectivesBased on deliberations at the Studies to Understand Delirium in Palliative Care Settings (SUNDIPS) meeting and an associated literature review, this article discusses ethical issues central to the conduct of research on delirious PC patients. MethodsTogether with an analysis of the ethical deliberations at the SUNDIPS meeting, we conducted a narrative literature review by key words searching of relevant databases and a subsequent hand search of initially identified articles. We also reviewed statements of relevance to delirium research in major national and international ethics guidelines. ResultsKey issues identified include the inclusion of PC patients in delirium research, capacity determination, and the mandate to respect patient autonomy and ensure maintenance of patient dignity. Proposed solutions include designing informed consent statements that are clear, concise, and free of complex phraseology; use of concise, yet accurate, capacity assessment instruments with a minimally burdensome schedule; and use of PC friendly consent models, such as facilitated, deferred, experienced, advance, and proxy models. ConclusionDelirium research in PC patients must meet the common standards for such research in any setting. Certain features unique to PC establish a need for extra diligence in meeting these standards and the employment of assessments, consent procedures, and patient-family interactions that are clearly grounded on the tenets of PC.

Disclosing the Truth: A Dilemma between Instilling Hope and Respecting Patient Autonomy in Everyday Clinical Practice

While medical ethics place a high value on providing truthful information to patients, disclosure practices are far from being the norm in many countries. Transmitting bad news still remains a big problem that health care professionals face in their every day clinical practice. Through the review of relevant literature, an attempt to examine the trends in this issue worldwide will be made. Various electronic databases were searched by the authors and through systematic selection 51 scientific articles were identified that this literature review is based on. There are many parameters that lead to the concealment of truth. Factors related to doctors, patients and their close environment, still maintain a strong resistance against disclosure of diagnosis and prognosis in terminally ill patients, while cultural influences lead to different approaches in various countries. Withholding the truth is mainly based in the fear of causing despair to patients. However, fostering a spurious hope, hides the danger of its' total loss, while it can disturb patient-doctor relationship.

Disclosing the Truth: A Dilemma between Instilling Hope and Respecting Patient Autonomy in Everyday Clinical Practice

Background:While medical ethics place a high value on providing truthful information to patients, disclosure practices are far from being the norm in many countries. Transmitting bad news still remains a big problem that health care professionals face in their every day clinical practice.Aims:Through the review of relevant literature, an attempt to examine the trends in this issue worldwide will be made.Method:Various electronic databases were searched by the authors and through systematic selection 51 scientific articles were identified that this literature review is based on.Results:There are many parameters that lead to the concealment of truth. Factors related to doctors, patients and their close environment, still maintain a strong resistance against disclosure of diagnosis and prognosis in terminally ill patients, while cultural influences lead to different approaches in various countries. Withholding the truth is mainly based in the fear of causing despair to patients. However, fostering a spurious hope, hides the danger of its’ total loss, while it can disturb patient-doctor relationship.

How psychotherapists handle treatment errors – an ethical analysis

BackgroundDealing with errors in psychotherapy is challenging, both ethically and practically. There is almost no empirical research on this topic. We aimed (1) to explore psychotherapists’ self-reported ways of dealing with an error made by themselves or by colleagues, and (2) to reconstruct their reasoning according to the two principle-based ethical approaches that are dominant in the ethics discourse of psychotherapy, Beauchamp & Childress (B&C) and Lindsay et al. (L).MethodsWe conducted 30 semi-structured interviews with 30 psychotherapists (physicians and non-physicians) and analysed the transcripts using qualitative content analysis. Answers were deductively categorized according to the two principle-based ethical approaches.ResultsMost psychotherapists reported that they preferred to an disclose error to the patient. They justified this by spontaneous intuitions and common values in psychotherapy, rarely using explicit ethical reasoning. The answers were attributed to the following categories with descending frequency: 1. Respect for patient autonomy (B&C; L), 2. Non-maleficence (B&C) and Responsibility (L), 3. Integrity (L), 4. Competence (L) and Beneficence (B&C).ConclusionsPsychotherapists need specific ethical and communication training to complement and articulate their moral intuitions as a support when disclosing their errors to the patients. Principle-based ethical approaches seem to be useful for clarifying the reasons for disclosure. Further research should help to identify the most effective and acceptable ways of error disclosure in psychotherapy.

Surrogate Decision-Making: How to Promote Best Outcomes in Difficult Times

Respect for patient autonomy is highly valued in American society and in nursing professional codes of ethics. US law protects the right of patients to self-determination in health care decisions. Advanced practice registered nurses must be able to identify patients who are not competent to make these decisions and the surrogates who will make decisions in their place. Advance planning with patients and providing optimal support for their surrogates are part of individualized, total-patient care and key to promoting best outcomes for patients and their families who are experiencing extremely difficult choices and significant life transitions.

Ethical Aspects Considered in Doctor-Patient Relations: Experiences of Anesthesiologists

Background and objective: Ethical principles guide professional conduct, particularly in establishing the doctor-patient relationship and, therefore, require constant reflection. The purpose of this study is to analyze ethical experiences of anesthesiologists in their interaction with the patient under their care. MethodThis was an exploratory study involving 16 active anesthesiologists at a university hospital in João Pessoa, Paraíba. We collected data through semi-structured interviews and analyzed qualitatively using the content analysis technique. ResultsThe study findings show that the classification of ethical experiences of the study participants regarding the doctor-patient relationship were classified into five categories: respect for the patient, humane treatment, equal treatment, professional secrecy, and respect for patient autonomy. ConclusionWe conclude that respondents recognize the ethical and humanistic values that should guide the relationship with their patients.

Generalism in healthcare: ethical challenges in the 21st century

Healthcare provision in the 21st century heralds a new understanding of the concept of generalism. The underlying themes include empathy and engagement in patient care and an appreciation of limits as generalists, as well as professionalism. Generalism requires the integration of healthcare services as we work across professional and organisation boundaries. The approach respects patient autonomy, especially as patient expectations rise. Patients value a holistic approach to care. Generalism supports cost-effective care across the health system.

The Case Against Cesarean Delivery on Maternal Request in Labor

The ethical obligations of an obstetrician to a patient who requests a cesarean delivery without maternal or fetal indication differ depending on whether the request is made before or during labor. Informed consent is an essential dimension of respecting patient autonomy, and the process of informed consent should be extensive for a cesarean delivery in the absence of maternal or fetal indications during active labor. For this reason, physicians should rarely grant a request for cesarean delivery made during active labor. Although physicians may think that declining a request for cesarean delivery is a violation of patient autonomy, they should also be concerned about the violation of patient autonomy that results if they are unable to adequately complete the process of informed consent during labor.

The Argument about Paternalism Health Care Model

Paternalism in the context of healthcare is constituted by any action, decision, rule, or policy made by a physician or other care-giver, or a government, that dictates what is best for the patient without considering the patient’s own beliefs and value system and does not respect patient autonomy. So it became a health care model widely applied worldwide. This paper is an argumentative essay to discuss the controversy whether to apply the Paternalism in health care or not.

Finnish nurses' perceptions of care of older patients

The aim of the study was to explore how far the perceptions of care of nurses in Finland take into account the preferences of the older patient and the patient's family members and to evaluate related background factors. The data were collected by questionnaire with nurses (n=167) working in a geriatric hospital. The questionnaire contained items about shared decision-making, attitudes to nursing patients, assessment of patients' functional ability and need for care, goal-setting, evaluation of outcomes and discharge planning. This study showed that taking into account the preferences of the patient and the patient's family members regarding the patient's care was challenging for the nurses in practice. About one-third of the nurses reported making the decisions on a patient's care themselves and not respecting patient autonomy in situations where patients are not able to assess their own situation. In addition, the nurses reported asking for the views of patients less frequently than those of family members when assessing and setting patient care goals. In practice, nurses need to be aware of this, during the transition from routine-centred care to patient-centred care.

Medical Uncertainty and Physician Innovation

Uncertainty pervades medical practice. Rapid scientific advances and substantial patient heterogeneity in both treatment responses and value preferences make it impossible for even the most knowledgeable practitioner to confidently identify the “right” option for every patient. Uncertainty is particularly acute when a physician deliberately deviates from generally accepted practices in an attempt to improve patient care. Unlike drug and device manufacturers, innovative physicians are not subject to mandatory public regulation by the FDA or any other government agency. The question of how to regulate physician behavior thus largely falls to the tort system. Innovation by definition involves a departure from customary practice, so adherence to custom in defining the legal standard of care essentially requires physicians to solely bear the liability costs of novel interventions. This regime protects patients from unnecessary risks associated with untested treatments, but may also unduly deter physicians from tailoring individualized treatment plans that address patients’ particular needs and circumstances. This Article proposes a fiduciary framework for regulating medical uncertainty and physician innovation. The proposed approach mandates close scrutiny of the decision-making process but deference to the substance of medical decisions. Under this model, a physician should be held liable for failing to act in her patient’s best interests, taking into account the patient’s unique clinical condition and value preferences. Within these constraints, however, patients should have the freedom to choose – and assume the associated risks and uncertainties – from among a range of reasonable alternatives. If a physician satisfactorily discharges her fiduciary disclosure duties, she should be shielded from liability for providing an innovative treatment that rationally advances the patient’s interests. This legal scheme strikes a desirable balance that respects patient autonomy, minimizes unnecessary risk, and encourages medical progress.

Considerations in Starting a Patient with Advanced Frailty on Dialysis

Nephrologists have focused on the uremic syndrome as an indication for dialysis. The elderly frail renal patient approaching ESRD represents a complex biologic system that is already failing. This patient phenotype exhibits progressive geriatric disabilities and dependence interspersed with shrinking periods of stability regardless of whether dialysis is started. Consequently, the frail renal patient faces challenging treatment choices underpinned by ethical tensions. Identifying the advanced frail renal patient and optimizing the shared decision-making process will enable him or her to make well informed choices based on an understanding of his or her overall condition and personal values and preferences. This approach will also permit nephrologists to fulfill their ethical obligations to respect patient autonomy, promote patient benefit, and minimize patient harm.

Nudging and Informed Consent

Libertarian paternalism's notion of “nudging” refers to steering individual decision making so as to make choosers better off without breaching their free choice. If successful, this may offer an ideal synthesis between the duty to respect patient autonomy and that of beneficence, which at times favors paternalistic influence. A growing body of literature attempts to assess the merits of nudging in health care. However, this literature deals almost exclusively with health policy, while the question of the potential benefit of nudging for the practice of informed consent has escaped systematic analysis. This article focuses on this question. While it concedes that nudging could amount to improper exploitation of cognitive weaknesses, it defends the practice of nudging in a wide range of other conditions. The conclusion is that, when ethically legitimate, nudging offers an important new paradigm for informed consent, with a special potential to overcome the classical dilemma between paternalistic beneficence and respect for autonomy.

Guidelines support the return of incidental genomic findings

Guidelines support the return of incidental genomic findings

Patient Right and the Socio-Cultural Challenges to Informed Consent in Nigeria

The notion of informed consent to medical treatment is a fundamental precept in law. It recognizes autonomy and the right to personal inviolability, irrespective of nationality, socio-economic situation and ideological orientation. A full realization of autonomy in the Nigerian legal system is severely constricted by sociological and cultural factors. Of particular concern is the impact of oppression which may arise from socialization. A sustained focus on improving patient right through informed consent without addressing the impediments posed by the social environment from which a patient operates, will nuance informed consent in Nigerian health care but may not fully realize patient autonomy. A serious commitment to respecting patient autonomy may be realized through a collective effort of the State, the medical profession, the community, and patients in order to remove the impediments to full exercise of autonomy.

Artificial Nutrition and Hydration in Catholic Healthcare: Balancing Tradition, Recent Teaching, and Law

Roman Catholics have a long tradition of evaluating medical treatment at the end of life to determine if proposed interventions are proportionate and morally obligatory or disproportionate and morally optional. There has been significant debate within the Catholic community about whether artificially delivered nutrition and hydration can be appreciated as a medical intervention that may be optional in some situations, or if it should be treated as essentially obligatory in all circumstances. Recent statements from the teaching authority of the church have attempted to clarify this issue, especially for those with a condition known as the persistent vegetative state. I argue that these recent teachings constitute a "general norm" whereby artificial nutrition and hydration are considered obligatory for most patients, but that these documents allow for exception in cases of complication from the means used to deliver nutrition and hydration, progressive illness, or clear refusal of such treatment by patients. While the recent clarifications do not constitute a major deviation from traditional understanding and will rarely conflict with advance directives or legal statutes, there may be rare instances in which remaining faithful to church teaching may conflict with legally enshrined patient prerogatives. Using the Texas Advance Directives Act as an example, I propose ways in which ethics committees can remain faithful to their Roman Catholic identity while respecting patient autonomy and state law pertaining to end of life health care.