Public Health

CHAPTER 9 CONSENT

Consent is an ethical imperative of great importance to managers and clinicians. It is clear that patients want to be more involved in medical decision making. The issues that consent raises suggest both a problem and a goal for health services providers.

The concept of consent in medical care evolved to protect patients from nonconsensual touching. Although the ethical and legal dimensions overlap, the legal requirements of consent are the minimum expected. The ethics of consent are grounded in the principle of respect for persons, specifically the element of autonomy, which reflects a view of the equality and dignity of human beings. In addition, the ethics of consent reflect the special relationship of trust and confidence between physician and patient and between organization and patient. This fiduciary relationship is supported by the principles of beneficence and nonmaleficence. The manager's virtues of trustworthiness, honesty, integrity, and candor also support the ethics of consent.

According to the law, failure to obtain consent can support a legal action for battery, an intentional tort. Beyond this, an action for negligence can be brought if the physician breaches the duty to communicate information necessary for the patient to give informed consent.

Paternalism stems from beneficence and is the ethical value that competes with patient autonomy in implementing consent. Paternalism arises naturally from the relationship between physician and patient because psychologically, technically, and emotionally, the physician is in a position of superior knowledge and is expected to help choose the best course of action for the patient. This reflects the ethics of care discussed in Chapter 1. The paternalism inherent in the physician–patient relationship was first described in the Hippocratic oath. Beneficence, nonmaleficence, and paternalism continue to be important and are implicit elements of the practice of medicine. The revisions of the Principles of Medical Ethics adopted by the American Medical Association (AMA) in 1980 moved organized medicine from paternalism toward autonomy and patient rights, themes that continued in the 2001 revision. The AMA's Council on Ethical and Judicial Affairs amplified these themes in its Fundamental Elements of the Patient–Physician Relationship statement. This document and the 2001 Principles of Medical Ethics are reproduced in Appendix B.

Specialized codes that guide biomedical research (e.g., the Declaration of Helsinki) also recognize the importance of consent. The emphasis on patients' rights or sovereignty in documents such as these are ideals toward which managers and organizations should strive.

LEGAL ASPECTS

Legally, consent must be voluntary, competent, and informed. The law presumes that persons unable to give consent in an emergency want to receive treatment. The presumption of wanting treatment can be rebutted if a competent patient declines it or if the person requiring treatment has an advance directive, such as a nonhospital do-not-resuscitate order. In addition, if that person's attorney-in-fact (e.g., someone who holds a durable power of attorney) is present, consent must be obtained. If minors or persons considered mentally incompetent are patients and those who speak for them refuse to give consent, and withholding treatment is not in the patient's best interests, the organization is usually successful in persuading a court to order treatment.

Even in nonemergencies, general consent for treatment is implied by the patient's presence in the outpatient department, for example, which shows the patient's apparent desire to be treated. Noninvasive elective treatment of a routine nature requires only general consent. Special consent is necessary, however, for invasive, surgical, or special procedures, or when the patient is part of an experiment. Consent for the invasive procedures common in intensive care units is problematic, for example, especially because they are often performed as emergencies and patients may not be able, or their surrogates may not be available, to give informed consent.1 Oral consent is legally binding, but staff changes, faulty memories, and prudence dictate that consent is written. The George Washington University Medical Center's general and special consent forms are shown in Figures 7 and 8, respectively.

To be voluntary, consent must be given free of duress. Duress can be subtle and its presence depends on the facts. Threats or force are clearly duress. Persons with diminished autonomy cannot make voluntary choices; military personnel or prisoners are examples. Historically, the military and prisoners were important sources for research involving human subjects. Negative publicity and public indignation have virtually eliminated experimentation in such settings.

Competent consent means that the person has the capacity to understand the nature and consequences of the treatment or nontreatment. The law presumes minor children to be incompetent. In addition, persons whose mental illness or cognitive disability have resulted in a legal determination of incompetence may not decide about medical treatment or experimentation; others must make such decisions for them. Judging mental competence is complex when patients are terminally ill, depressed, or suicidal; expert opinion is required.

Consent must be informed. The law requires full disclosure of the nature of the patient's condition and treatment proposed, available alternatives, and consequences and difficulties that may likely result from treatment or nontreatment. The courts are about evenly split between those holding that patients should receive as much information as a reasonable physician would provide under the same or similar circumstances, and those using a standard based on what a reasonable patient would want to know. A legal criterion used by a few courts—and one oriented to patient sovereignty—is what that specific patient would want to know.

Historically, cases involving Jehovah's Witnesses, a religion that prohibits even homologous (self-donation) transfusions of whole blood or components, have been problematic for hospitals. Potential legal liability for transfusing or not transfusing the patient has resulted in numerous court cases. In early cases, courts often overrode the patient's wishes and ordered transfusion when patients, especially mothers, had significant family responsibilities. These cases showed that judges considered more than liberty rights (autonomy) when important societal interests such as caring for children were present. Developments in bloodless medicine and surgery in the 1960s and 1970s were spurred in the mid-1980s by problems with the blood supply, such as transmission of hepatitis and the human immunodeficiency virus. These developments have caused a rethinking of the use of blood and blood products; transfusion is avoided, if possible. New evidence suggests that transfusion requirements are often overestimated and that there are several modalities to treat Jehovah's Witnesses with acute blood loss, for example.2

The right of competent persons to refuse treatment is well established in the law:

Figure 7. A general consent form.

(From The George Washington University Medical Center. Copyright © 2011. Reprinted by permission.)

Figure 8. A special consent form.

(From The George Washington University Medical Center. Copyright © 2011. Reprinted by permission.)

On the basis of either the common law liberty right to be free from unwanted treatment or by statute, competent adults, incompetent adults who have clearly expressed their wishes, and even older minors with adult-like decision-making capacity can legally refuse unwanted blood transfusions. As for minor children generally, although parents may not deprive their children of necessary care, if the parents have a choice between two or more effective treatment options, the state has no parens patriae interest in mandating treatment entailing the use of blood simply because it is the popular or standard approach. If the child's health problem can be effectively managed without the use of homologous blood, the parents should be free to choose that treatment option without governmental interference.3

An ethic that emphasizes autonomy and respect for persons can significantly affect the patient–caregiver relationship. Fully expressed, patients alone choose the level of involvement they want. In the early 1980s, the President's Commission stated that patient sovereignty with complete participation in the process is a desirable, if not a readily achievable, goal.4 The principle of respect for persons cannot be realized, nor participation achieved, absent truthfulness and the organization's consistent efforts. Autonomy means patients may not agree with caregivers' recommendations and assessments. Sometimes, clinicians and organizations find this concept threatening.

Some patients choose not to participate in decision making. Explicitly or implicitly, they want to remain ignorant of their medical problems and exclude themselves from decision processes. They prefer paternalism and choose to delegate decision making to caregivers to do what they think is best. This relationship between patient and caregivers is neither the one envisioned as ideal by the President's Commission nor that demanded by contemporary patient rights advocates. Autonomy is also violated if the patient is forced to participate, however. Caregivers and managers should consider a decision not to participate to be acceptable and work to make it a reality. Delegating to others the authority to make decisions may be the ultimate expression of autonomy.

More Serious than She Knows5

Lilah is 6-months pregnant with her first child. Her husband, a member of the U.S. Army, is currently deployed to a combat zone. During his absence, Lilah has moved back to her hometown, where she has the emotional support of her tight-knit family and access to basic medical care at a small-town community hospital. Lilah's mother is excited at the prospect of being her daughter's birthing coach. In anticipation of her due date, Lilah has signed releases authorizing the hospital and her obstetrician to share her medical information with her mother.

At her 6-month office visit, Lilah's blood pressure was slightly elevated. This prompted her obstetrician, Dr. Campos, to refer her to the hospital for outpatient testing to rule out preeclampsia, which is a potentially deadly complication of pregnancy. She was released after three hours with a clean bill of health and given instructions to avoid strenuous activity and to watch her diet. When Lilah and her mother returned to Dr. Campos's office three days later for a regularly scheduled ultrasound, the nurse noted that her blood pressure was even higher than before. Lilah told the nurse that she had followed the hospital's discharge instructions and suggested that the rise in blood pressure was caused by anxiety over her husband's safety, since his unit had suffered several casualties recently.

The ultrasound revealed that the baby's growth was unexpectedly retarded. Suspecting that Lilah and her child needed resources beyond the scope of the local hospital, Dr. Campos, immediately referred her to a perinatologist in a large city three hours away. “It's probably nothing serious, but it's better to err on the side of caution,” he assured Lilah. “You and your mother can make a vacation of it. You could stay overnight and shop for the baby after the appointment.”

As the nurse and Lilah completed paperwork in another room, Dr. Campos turned to Lilah's mother and said, “I don't want to cause Lilah additional stress, but this could be far more serious than she knows.”

The law and medical ethics include the concept of therapeutic privilege, which permits physicians to withhold information from patients when the physician believes it serves the patient's best interests. States recognize therapeutic privilege in several ways; a general rule is difficult to formulate. Some reference the danger that full disclosure may cause to the patient's physical or mental health; others focus on patient best interests. Such paternalism is supported by the principles of beneficence and nonmaleficence and the virtue of caring. The therapeutic privilege exception is pragmatic and avails physicians of a range of actions. It is desirable that physicians possess the latitude to make such judgments, especially if the alternative is probable harm to the patient. If so, beneficence and nonmaleficence take precedence. Lilah's case is an expression of therapeutic privilege. Dr. Campos is concerned that apprizing Lilah as to the potential risks of her pregnancy may cause further stress and aggravate her condition. Telling Lilah's mother may assuage Dr. Campos's reluctance to communicate vital information to Lilah. Also, it makes her mother more alert to changes that may require emergency attention.

ETHICAL ASPECTS

The premise for a discussion of the ethics of consent is that the ethical standard is significantly higher than the legal standard. This expectation arises from exercising the principles of respect for persons (autonomy) and nonmaleficence—which are based on Kantian deontology (see Chapter 1), natural law, and rule utilitarianism—and is supported by virtue ethics as expressed by virtuous managers acting as moral agents.

The nuances inherent in duress and inducement are important in determining whether consent is voluntary. In these cases, ethical considerations and duties extend well beyond the standard in the law. Can patients suffering from a fatal disease make medical decisions voluntarily? Are patients' decisions free of duress if they fear losing their physicians' friendship and loyalty because they prefer an option the physician opposes? Clinical staff talk about “bad” patients, usually defined as uncooperative patients. Such patients are not intentionally harmed or mistreated, but they may not receive the same attention as “good” or pliable patients. Patients sense this attitude and it affects their volition. Patients are also heavily influenced by family and friends and may make decisions because of them. Similarly, family members may ask clinicians to act in ways that may be unwanted by a patient who is considered incompetent or that, under the principles of beneficence or nonmaleficence, do not serve the patient's interests.

Such considerations suggest that consent may never be entirely voluntary. Some have argued that patients' personal freedom to accept or reject medical treatment has been so reduced that it is only a right to veto unwanted procedures.6 This argument is bolstered by the increasingly complex relationships in medical care and its delivery, all of which preclude simple answers and easy determinations as to the voluntariness of consent. Managerial and clinical staff must understand the difficulties of consent and make all efforts to further patient autonomy and control of medical decision making.

In determining the voluntariness of consent, some groups present special problems. As noted, in the past healthy persons with diminished autonomy, notably military service members and prisoners, participated in experimentation that was nontherapeutic—meaning that it had no direct benefit for them. The consent of persons in such groups is seen as nonvoluntary, and their use as healthy subjects is rare. Voluntariness may also be reduced because inducements are so significant that prudence is cast aside. Money or other incentives may be offered to those who participate in high-risk experimentation; for example, some persons may be persuaded by payments that, for them, are significant. Students who participate in experiments are unique in this regard and may fit into several categories. Often, they are economically disadvantaged. In addition, some faculty encourage students to participate in experiments by exempting them from other, seemingly more onerous requirements, such as research papers or examinations. Occasionally, there is implicit, or even explicit, coercion by faculty who control the students' academic (and sometimes economic) destiny, and who unethically use this position to “encourage” consent and participation in research.

Usually, the ethical aspects of whether one is competent to consent are easier than the ethics of whether consent was voluntary. Competence is assumed in adults. Typically, clinical staff can determine if a patient's mental status is questionable and then seek consultation. Absent evidence of questionable mental status, the organization's policies should include an explicit assumption that patients are autonomous for the purposes of decision making. It is incumbent on managers to assist in this process through staff education and the support provided by appropriate systems and procedures.

The third element of consent is that it must be informed. Some commentary suggests that being “informed” is the only criterion for consent. Because of the complexity of informed consent, whether the patient was adequately informed receives the most attention. Some states have statutes designed to ensure that patients obtain sufficient information to make informed medical decisions. A Virginia law regarding consent, for example, resulted from reports that physicians performed radical mastectomies (even though removal of the malignancy would have sufficed) and that women were not given enough information to make an informed decision.7

Wait a Little Longer, We'll Do It Then

The emergency department at County Hospital has a typical caseload: some true emergencies and urgent medical conditions, but many sniffles and other nonemergencies. The hospital contracts with an emergency medicine group, but administrative activities, including systems, procedures, and personnel, are the hospital's responsibility. The process for obtaining consent is typical: Unconscious patients are treated as their conditions necessitate. Competent patients who are able to communicate sign a consent form authorizing treatment. Parents and other family members are involved as needed and as available.

Early one afternoon, a conscious, middle-aged man who had been in a car accident was brought in. He was diagnosed with internal injuries that required immediate exploratory surgery. He was asked to sign the consent form but refused because, as a Christian Scientist, receiving medical treatment violated his religious beliefs. He asked for a Christian Science practitioner.

(Darr 215-224)

Darr, Kurt. Ethics in Health Services Management, 5th Edition. HPP, 7/2011. VitalBook file.

The citation provided is a guideline. Please check each citation for accuracy before use.

CHAPTER 10 DYING AND DEATH

Dying and death are intrinsic to human existence. As with abortion, the ethical questions involved often prompt emotional responses from the public and many health professionals. Ethical issues in dying and death arise in ways such as treating neonates with severe disabilities who are unlikely to survive, and caring for children or adults who are terminally ill and unable to be autonomous.

Technology is at the heart of the matter. Since the 1970s, renal dialysis, mechanical ventilation, cardiac medications, and intensive care units (ICUs) have made it possible to postpone the end of life. Similar developments allow neonates who would have died in the 1980s to survive. A great deal has been written about the questions such technology raises, but there are few widely accepted courses of action. Sometimes an ethical dilemma occurs when a person asks the health services organization to assist in achieving pain-free death.

Adding complexity to these ethical issues is that many are poorly developed in the law. Deliberately shortening a patient's life raises important ethical and legal questions. Juries are reluctant to convict perpetrators, even when violent means have been used to end the painful life of someone terminally ill.

Chapter 9 noted that in the early 1980s, the President's Commission for the study of Ethical Problems in Medicine and Biomedical and Behavioral Research recommended a physician–patient relationship that maximizes patient sovereignty, with the patient fully participating in the decision process. Often, by the time crucial medical decisions must be made, the patient can no longer participate effectively, however, and may not be competent. If available, advance medical directives are helpful, but families and caregivers may disregard them. A medical ethic dedicated to preserving life and staving off death controls, and it is typical that the technological imperative results in expending all efforts, many times with marginal results. The economic, emotional, and psychological costs are obvious.

Managers may feel uneasy discussing dying and death. They may think that decision making at the end of life is clinical, a situation in which they play no role. Certainly, physicians are the lead actors in these dramas, but the effect of such issues on the organization requires that managers are knowledgeable about them and participate in developing and implementing policies and procedures. Managers must also be involved in the work of relevant committees.

In the mid-1980s, a distinction was drawn between treatments that were life prolonging and those that were life sustaining. Since then, however, the two concepts have merged and are simply called life-sustaining treatments. Life-sustaining treatment is “any treatment that serves to prolong life without reversing the underlying medical condition. Life-sustaining treatment may include, but is not limited to, mechanical ventilation, renal dialysis, chemotherapy, antibiotics, and artificial nutrition and hydration.“1

DEATH DEFINED

Historically, death was defined as the stoppage of blood circulation and the cessation of circulation-dependent animal and vital functions, such as respiration and pulsation. New technology proved this definition inadequate. Table 3 summarizes definitions of death. Definitions based in law and theology provide limited guidance for contemporary clinicians.

In 1968, a Harvard Medical School committee defined irreversible coma, which solved some problems but created others. The Harvard criteria were accompanied by a report stating that only a physician can determine the patient's condition, and that when the condition is found to be hopeless certain steps are recommended:

Death is declared and then the respirator is turned off. The decision to do this and the responsibility for it are to be taken by the physician-in-charge, in consultation with one or more physicians who have been directly involved in the case. It is unsound and undesirable to force the family to make the decision.2

This quote is noteworthy because of changes in society's attitudes and perceptions that have occurred since 1968, including emphasis on patient autonomy and natural death statutes, family involvement in decision making, and establishment of institutional ethics committees (IECs). These changes have reduced the physician's primacy in decision making.

Table 3. Definitions of death

Concept of death (Philosophical or theological judgment of the essentially significant change at death)

Locus of death (Place to look to determine whether a person has died)

Criteria of death (Measurements physicians or other officials use to determine whether a person is dead—to be determined by scientific empirical study)

1. Irreversible loss of flow of vital fluids (i.e., the blood and breath)

Heart and lungs

Visual observation of respiration, perhaps with the use of a mirror

Feeling of the pulse, possibly supported by electrocardiogram

2. Irreversible loss of the soul from the body

Pineal body (?) (according to Descartes)

Respiratory tract (?)

Observation of breath (?)

3. Irreversible loss of the capacity for bodily integration

Brain

Unreceptivity and unresponsivity

No movements or breathing

No reflexes (except spinal reflexes)

Flat electroencephalogram (to be used as confirmatory evidence)

All tests to be repeated 24 hours later (excluded conditions: hypothermia and central nervous system depression by drug)

4. Irreversible loss of consciousness or the capacity for social interaction

Probably the neocortex

Electroencephalogram

Adapted from Veatch, R.M.S. (1976). Death, dying, and the biological revolution: Our lost quest for responsibility (p. 53). New Haven: Yale University Press. Copyright © Yale University Press. Used with permission. This table has been modified using material from the 1989 second edition.

Note: Death is defined as a complete change in the status of a living entity characterized by the irreversible loss of those characteristics that are essentially significant to it. The possible concepts, loci, and criteria of death are much more complex than the ones provided here. These concepts are simplified models used to define death. It is obvious that those who believe that death means the irreversible loss of the capacity for bodily integration (3), or the irreversible loss of consciousness (4), have no reservations about pronouncing death when the heart and lungs have ceased to function. This is because they are willing to use loss of heart and lung activity as shortcut criteria for death, believing that once the heart and lungs have stopped, the brain or neocortex will necessarily stop, as well.

Note: In the table, (?) signifies uncertainty.

Near the time that the Harvard criteria were developed, a Virginia court issued one of the first rulings accepting brain death.3 The case raised issues of consent, appropriate criteria and process for determining death, conflicts of interest, beneficence, nonmaleficence, and organizational philosophy and managerial ethics. The physicians involved tried to use a brain death standard but failed to meet the Harvard criteria because there was no electroencephalogram to verify brain activity and the respirator was turned off before the patient was pronounced dead. Despite the lapses, the court made legal history by accepting a determination that the patient was dead using a brain death criterion.

The National Conference on Uniform State Laws developed the Uniform Determination of Death Act (UDDA) in 1980 in cooperation with the American Medical Association (AMA) and American Bar Association (ABA). The AMA and ABA officially approved the UDDA in 1980 and 1981, respectively.4 It provides alternative definitions of death. One uses the traditional definition—that is, irreversible cessation of pulsation (circulatory and respiratory functions); the other uses whole brain death. By 2008, a version of the UDDA had been enacted in 50 states and the District of Columbia.5 The uniform act states:

An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards.6

The UDDA has been endorsed by the National Kidney Foundation, the North American Transplant Coordinators Association, and the American Nephrology Nurses' Association.7

Brain death, as shown in the preceding UDDA definition, or some variation, as stated below, is now a commonly used alternative criterion for death:

The three cardinal findings in brain death are coma or unresponsiveness, absence of brainstem reflexes, and apnea. The clinical examination of the brainstem includes testing of brainstem reflexes, determination of the patient's ability to breathe spontaneously, and evaluation of motor responses to pain.8

Definitions vary slightly, but the concept of whole brain death—defined as irreversible cessation of all functions of the brain, including the cortex and the brainstem—has been endorsed by the AMA, the ABA, and the American Academy of Neurology. Efforts continue to make the clinical determination of brain death more precise and standardized.9 Use of the whole brain death concept is law in 46 states.10,11

As scientific developments permit increasingly sophisticated assessments of a patient's condition, especially prognosis, brain death criteria may be superseded by those that incorporate psychosocial factors. Prominent among the criteria proposed is the capacity or potential capacity for social interaction. This definition raises ethical issues and jeopardizes persons with no capacity for typical social interaction (e.g., persons with significant cognitive disabilities). A definition that includes a lack of the potential for typical social interaction was applied when infants with mental retardation, such as Baby Boy Doe, were allowed to die. Federal regulations since the 1980s specifically prohibit applying quality of life criteria to infants with disabilities who have life-threatening medical conditions, but there is evidence that quality of life criteria are commonly, if implicitly, used in decision making for other types of patients.

ADVANCE MEDICAL DIRECTIVES

When the federal Patient Self-Determination Act (PSDA) of 1989 took effect December 1, 1991, efforts to achieve patient participation in and control of their healthcare decisions gained a significant impetus. PSDA requires that hospitals, nursing facilities, hospice, home health agencies, and managed care organizations that participate in Medicare and Medicaid give all patients written information about their rights under state law to accept or refuse medical or surgical treatment and to formulate advance medical directives (AMDs). Adult patients must also be given the provider's written policies about implementing these rights. Medical records must document whether a patient has executed an AMD. Providers must also educate their staffs and communities about AMDs. Despite PSDA and the fact that all 50 states have laws authorizing some type of AMD (e.g., living wills, healthcare agents, medical powers of attorney),12 problems continue in operationalizing patient involvement in decision making about AMDs; relatively few patients execute them. It is estimated that only 20% of Americans have AMDs.13 As few as 5% of individuals older than age 65 may have AMDs.14 A Maryland study found that about one-third of respondents had AMDs; those over 65 were more likely than younger adults to have an advance directive.15

The Joint Commission on Accreditation of Healthcare Organizations requires accredited hospitals to address the wishes of patients relating to end-of-life decisions. Adults must be given written information about their right to accept or refuse medical or surgical treatment, including forgoing or withdrawing life-sustaining treatment or withholding resuscitative services.16 The decisions that patients should consider in their AMDs include specific types of life-sustaining treatment that they want used, withheld, or withdrawn. Examples include cardiopulmonary resuscitation (CPR), elective intubation, mechanical ventilation, surgery, dialysis, blood transfusions, artificial hydration and nutrition (AHN), diagnostic tests, antibiotics, and other medications and treatments, as well as future admission to the ICU. Patients tend to choose more restrictions on treatment as diseases progress.17

Living Wills

The living will was developed long before passage of the PSDA so that persons unable to participate in decision making could guide caregivers. The words living and will seem contradictory. Wills are the legal mechanism by which a deceased person's wishes as to disposition of real and personal property are known. Living wills allow persons unable to communicate with caregivers to express their wishes about the extent of treatment they want. Living wills allow persons to specify what is done for and to them and to control the technological imperative, regardless of its potential benefit. Absent state legislation or case law, living wills have no legal status; patients must rely on the willingness of caregivers to follow the directives in them. Generic living wills are useful in states without specific legal requirements.

State Statutes

Interest in living wills and public reaction to cases in which seemingly excessive treatment was provided led to rapid enactment of state laws recognizing the patient's right to control treatment processes. These laws are variously known as living wills laws, advance medical directives, natural death acts, or death with dignity laws. In early 1983, 14 states had such laws; by 1985, there were 35 states and the District of Columbia.18 In 2009, all states and the District of Columbia had a medical directive law.19 The Virginia Advance Medical Directive form is shown in Figure 9.

Generally, these statutes recognize a patient's right to direct physicians to withhold or withdraw life-sustaining treatment. When statutory requirements are met, the directives are legally binding on caregivers. The laws tend to be drafted narrowly and apply when a physician has determined that the patient who signed the declaration is terminally ill and has no prospect of recovery. Some statutes require that the directives must be reaffirmed when patients know they are terminally ill. Some include penalties against caregivers and the organization if directives are ignored. In addition to statutes, state court decisions affect how the laws are interpreted and their effect on use of life-sustaining treatment.

Figure 9. An example of an advance medical directive.

(Retrieved April 4, 2011, from www.vsb.org//sections/hl/VA-2010-Basic.pdf)

These laws solve some of the issues of control (autonomy), patient role, and, to an extent, organizational and provider efforts to comply with the patient's wishes. Even when there is an AMD, caregivers may not comply. Fragmentation of care among several providers and organizations further complicates patients' use of AMDs and poses a special challenge to managers in the organization to which the patient has been transferred. For example, an AMD in a nursing facility medical record may not accompany the patient to the hospital, especially in an emergency. A study of older patients hospitalized for acute illnesses found that in 75% of cases the medical record did not indicate that physicians had consulted the patient's living will or designated proxy before making treatment decisions, including whether to resuscitate. The problem was attributed to several factors: nursing facilities failed to transfer the information, patients were not asked or did not volunteer the information, and the hospital staff failed to ask or to ensure that such documents were part of the record. Once documented in the hospital medical record, AMDs influenced treatment decisions in 86% of cases involving patients who were judged incompetent.20

There are other problems with AMDs, including determining mental status and whether the patient comprehends the effect of what is being done and establishing the presence of a terminal illness. Of course, ethical issues arise for organizations when the patient has not met statutory requirements or there is no statute or AMD.

(Darr 235-245)

Darr, Kurt. Ethics in Health Services Management, 5th Edition. HPP, 7/2011. VitalBook file.

The citation provided is a guideline. Please check each citation for accuracy before use.