Refusal of treatment in a clinical setting
Ethical reasoning is defined as the ability to identify, assess, and develop ethical arguments from a variety of ethical positions (GUIDELINES FOR GOOD PRACTICE IN THE HEALTH CARE PROFESSIONS, 2008.) As a student physiotherapist, we are challenged every day to utilise our ethical reasoning. These are instances where we need to ask ourselves the vital question; are we doing a task to satisfy the interests of the hospital or are we doing a task to benefit the interests of the patient? The ethical dilemma I faced recently was one that involved consent to treatment. This prompted me to think about what exactly is consent to treatment is and when it is needed. Is it an absolute necessity.
Consent to treatment is defined as the act of a person giving permission before they receive any type of medical treatment, test or examination (GUIDELINES FOR GOOD PRACTICE IN THE HEALTH CARE PROFESSIONS, 2008.) Consent is a requirement in current hospitals, however even though this is a right that needs to be acknowledged, it is often neglected by modern day healthcare professionals. Due to the fact that many healthcare professionals tend to do what is good for the patient regardless of whether or not the patient consents to treatment.
The above perspective on consent is derived from the fact that informed consent does not afford sufficient clarity or consensus regarding the purpose it serves where the patients level of autonomy is inhibited. As a result, a good sense of ethics and human morals are required when making medical decisions that concern the patient. (Doyal, 1997).
During my current block I treated a patient who underwent a median sternotomy for an aortic valve replacement. The patient had a favorable prognosis and a good premorbid level of function but was on a ventilator to assist his ventilation for his first few treatment sessions. Once ventilated, the patient was restless and was continuously attempting to dislodge his endotracheal tube. Propofol was administered to sedate the patient. (Grap et al., 2012).
Upon arrival to my first session with the patient I realized that the patient was unresponsive and as a result, I was unable to receive informed consent to treatment. After a few treatment sessions the patient was extubated. Once the patient was extubated I attempted to receive informed consent from the patient. I then explained the benefits of treatment and why I was there. Once I was finished with informing the patient, I asked the patient if he consented to the treatment and he refused. This was such a difficult dilemma. What do I do now?
The answer to my question were based on the ethical guidelines set out by the HPCSA. This stated that a person may refuse treatment and such refusal may be verbal or in writing, provided that such refusal does not endanger the health of others. Therefore I had to respect the patient’s right to refuse treatment. (GUIDELINES FOR GOOD PRACTICE IN THE HEALTH CARE PROFESSIONS, 2008).
However at the same time I thought to myself whether or not the patient answered my question with a sound mind seeing that the patient was recently on Propofol that causes side effects such as confusion, delirium and anxiety which could of influenced his decision. (Propofol & Diprivan, 2019) . This is a difficult ethical dilemma due to the fact that I had to use my limited clinical and ethical reasoning to make an informed decision to adhere to what the patient had said or treat the patient regardless of his right to refuse treatment. I then remembered an article I read about this very situation.
According to the article “Autonomy & the Refusal of Lifesaving Treatment” the right of the patient to autonomy and/or to refuse treatment can be overlooked if the patient is not of sound mind and if the treatment can potentially increase the patient quality of life. (Wreen, 1991). Therefore I continued with my treatment regardless of the patient’s decision. Throughout the whole process I felt so conflicted and concerned whether or not i made the right decision. It was a difficult decision but I used my reasoning to make an informed decision as to what I felt was best for my patient.
Later that day I spoke to my clinician about my experience and she agreed with my reasoning and said that I acted in best interest of my patient and acted with good ethical reasoning. This experience has taught me that whenever treating a patient that has recently been given medication that could affect their thinking, I need to use in depth clinical and ethical reasoning in order to make a decision that best benefits my future patients.
References:
Doyal, L. (1997). Informed consent in medical research: Journals should not publish research to which patients have not given fully informed consent with three exceptions. BMJ, 314(7087), 1107-1107. doi: 10.1136/bmj.314.7087.1107
Grap, M., Munro, C., Wetzel, P., Best, A., Ketchum, J., & Hamilton, V. et al. (2012). Sedation in Adults Receiving Mechanical Ventilation: Physiological and Comfort Outcomes. American Journal Of Critical Care, 21(3), e53-e64. doi: 10.4037/ajcc2012301
Health Professionals Council of South Africa. (2008). GUIDELINES FOR GOOD PRACTICE IN THE HEALTH CARE PROFESSIONS [Ebook] (1st ed., pp. 1-8). Pretoria. Retrieved from https://www.hpcsa.co.za/downloads/conduct_ethics/rules/generic_ethical_rules/booklet_3_patients_rights_charter.pdf
propofol, G., & Diprivan, B. (2019). Common Side Effects of Diprivan (Propofol) Drug Center – RxList. Retrieved from https://www.rxlist.com/diprivan-side-effects-drug-center.htm
Wreen, M. (1991). Autonomy, religious values, and refusal of lifesaving medical treatment. Journal Of Medical Ethics, 17(3), 124-130. doi: 10.1136/jme.17.3.124
3 thoughts on “Autonomy and informed consent: An ethical dilemma”
Hi Dylan. Thank you for allowing me the opportunity to read your writing piece.
I think the topic you chose is a main concern especially in ICU when the patients are sedated as I think about this often as well and go through the same dilemma. I think it is important for us as physiotherapy students to judge what is best for the patient and get it across to them so they are aware and understand. I suppose if they are sedated, it is a different story. I like the fact that you described your situation and gave detail about what was going through your mind of whether or not you should have treated the patient when they were sedated. The fact that you acknowledged it shows that you have ethical morals.
Over the past few weeks I have learnt that sometimes you have to have the “risk vs benefit” mindset especially in ICU when patients need that extra care compared to a ward patient. If you do not do chest physio and movements on them today, this can cause secondary complications in the chest (infections, retention of secretions) and muscle weakness/stiffness/decreased range. Sometimes you have to think outside the box and explain nicely to the patient who you are, why you are there, what the aim is and possible complications that could arise if no treatment is done and not just rush into the treatment with them. When the patient was extubated, did you explain to the patient as stated above or did you go on with the similar treatment process as when they were sedated? Did the patient mention why he refused treatment? This reminds me that having a different approach to patients now and then is key.
To make your piece a bit more stronger, you could maybe add the bill of rights such as freedom of expression and equality rights of the patient. Here is the link https://www.gov.za/documents/constitution/chapter-2-bill-rights and then you can connect this link to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307558/ which gives you more detail of why consent is important (as this was one of your questions you asked in your piece). This will give your piece a different perspective.
You need to add “need to be*” in paragraph 2 line 4
You also added “therefore” a bit too much in your last paragraph so it sounds repetitive – you can maybe re-read it and replace it with “hence”, “thus”, “as a result”, “for that reason”
In addition, do not forget to add your references wherever you extracted information from a source for your final piece.
Good luck and all the best for your final piece. You got this!
Erin
Hi Dylan
Thank you for allowing me to read your piece and for sharing your writing. I enjoyed reading your work and I could immediately resonate with it, as I am also currently working in an ICU setting, where I work with sedated patients on a daily basis. You made me think about this ethical dilemma in a very different light and I thank you for that. This is something I could go and reflect more on.
Even though I did enjoy your writing and explanation of the scenario, I felt that your content and argument was lacking a bit. But I hope I can assist you and help you improve and strengthen it with the following comments:
In the first paragraph you ask the question whether consent is absolutely necessary. I think you could maybe look at what literature says about this as well as what the law says with regards to this, seeing that the Constitution is based on the Bill of Human Rights. You could perhaps refer to the bill of human rights as well, to give the reader more knowledge as to what exactly the patient’s rights are with regards to this situation.
At the end of your writing you also mentioned that this is a grey area and further ethical consideration is required. I feel it would strengthen your argument if you explained what your belief on the matter is. Would you argue that is right or wrong to treat a patient without getting consent or perhaps what are the exceptions on the rule? You could also look at what literature says regarding similar situations, looking at the implications of such decisions (treating a patient without consent). You could then compare the two (treating and not treating) and argue for the side which you believe to be right.
I also think it would benefit your piece if you added a few sentences to explain how you would address similar situations in the future and why? Is there perhaps anything you would change or put in place to help you with these ethical decisions?
Writing (Grammar):
Here are some grammatical error I picked up:
Paragraph 2:
“neglecting” – neglected
add a , after professionals (before ‘due to’)
Paragraph 3:
“would of” – would have (last sentence)
Paragraph 4:
“patient” – patient’s
add “that” after ‘fact’
“interests” – interest
You left out the “p” in patient (acient)
“secretions on the lungs” – secretions in the lungs
Add full stop (.) before “Even though”
Also don’t forget to give your writing a title. It is currently blank, you can see this by scrolling through the blog posts.
References:
Another reason as to why your piece is lacking, is due to no references. References help to strengthen ideas and back the arguments and statements that you make, so it will definitely benefit your writing if you perhaps find external sources regarding this topic and add them to your writing.
You should have in-text referencing as well as a reference list if you add references.
Apart from these few adjustments that can be made, I think your piece has a lot of potential and with these adjustments it can be a very strong writing piece. I enjoyed your topic that you chose and your writing was easy to read.
I hope you find these comments helpful and I look forward to reading your final post.
Good luck and all the best for the rest of block.
Janine
Hi Dylan
Thank you for sharing your piece. I enjoyed reading it and the detail you provided when describing what happened.
You raise a very important ethical topic, as I’m sure this happens to many therapists. I have not yet experienced this dilemma in a clinical setting but I’m sure that I will, especially in my ICU block; I think I will also have similar questions and concerns that you have.
I understand your point about it being a grey area,as how would one know/assume that this patient did not want treatment, as you were acting in his best interest. I would probably have done the same , whilst thinking I am doing what is best for the patient. If I was in this patient’s position, I would want treatment, especially if I understood the benefits of the treatments, compared to the complications which may arise from not receiving treatment. Did you try explaining the risks versus benefits to the patient of receiving/ not receiving treatment? His reason may be a lot deeper than simply refusing treatment.
You have mentioned both sides of the argument in your piece but try to support your arguments with literature; maybe the patient’s best interest versus refusing treatment. Check what the constitution says regarding this grey area of consent to treatment, in order to answer your question about the right to consent and ethical guidelines.
I part I found most interesting, was that you first treated the patient, then you learnt that the patient did not want treatment, as I think many of us would also just treat the patient if they were unconscious and intubated, resulting in us being faced with the same dilemma of when to treat and when not to.
If you were to be presented with this same situation again, would you react differently?
Spelling/grammar suggestions:
3rd paragraph, 1st line- ‘during my current block,’
3rd paragraph, last line- would have consented
last paragraph, 1st line- ‘this is a difficult’ and ‘patient’s right’
last paragraph, 3rd line- patient (you omitted the ‘p’)
last paragraph, 4th line- you repeated yourself with ‘accumulation of secretions’
3rd line from bottom- even; lower case
Add a reference to the definition of ‘consent’
This is a vital topic for us students and qualified therapists, which I think if explored a bit deeper, using literature, could be a very compelling piece.
Good luck and all the best
Zara