Consent to Surgery or Other Procedures, and to Care - Literature review Example

Consent to Surgery or Other Procedures, and to Care Introduction: The role of the nurse, according to Virginia Henderson, in Nicol, Brooker & Meyer,2003, p.3, is “to assist the individual, sick or well, in the performance of those activities contributing to health or recovery (or to a peaceful death) that the individual would otherwise perform unaided if the individual had the necessary strength, will, or knowledge. And to do this in such a way as to help the individual gain independence as rapidly as possible”. Performing this role of nursing in individuals above the age of eighteen constitutes adult nursing (Nicol, Brooker & Meyer, 2003). Adults are a group of individuals that have the capability to take decisions on the medical interventions or care interventions and demonstrate their willingness for a particular medical intervention strategy or care strategy by giving their consent either in writing, oral or by implication. The concept of patient consent stems from the legal and ethical rights of patient autonomy. Patient autonomy implies that an adult patient has the capability and the right to decide on what is done to the body of the individual and it is the duty of the medical and nursing professionals in the health care sector to respect this ability and right of patients to be involved in the decision making process about their own health care (Aveyard, 2002). Many a time there is the wrong assumption that getting the consent of the patient the responsibility of the involved medical professional and that the nursing professionals is just a silent observer of the process. From a legal perspective it is true that the responsibility of consent lies with the medical professional, but the advocacy role of the nursing professional demands that the nursing professional takes an active role in the consent of the patient and is pro-active, when the nursing professionals that patient autonomy is not being given the necessary respect it deserves (McStein & Peden-McAlpine, 2006). Another frequent misconception is that patient consent is required only for intensive medical interventions like major surgeries. Patient consent is required for any aspect that involves the patient and the body of the patient, even if it involves simple procedures considered normal to nursing care, like taking the blood pressure of the patient. Patient consent is an integral component of any medical or surgical procedure and extends into nursing because of the explicit epistemic component of patient autonomy of making informed free choices in the management of their own health care (Kukla, 2007). Informed free choice in patient autonomy brings into the picture the role of providing information to the patient. Patients can choose autonomously only when they are well informed. This means providing full information in a manner that the patient can assimilate. There is a considerable interlinking between knowledge and autonomy in healthcare and the nursing role demands that adult patients are assisted in collecting, understanding and reasoning the required medical information so that their autonomy is enhanced and not compromised (Kukla, 2007). Meaning of Literature Search and Literature Review: Research is a journey that puts existing knowledge to test and enhances it through the additional learning experience that research brings with it. There are different ways of performing research on a given subject. According to Blaxter, Hughes & Tight, 2001, p. 5, “The basic characteristics shared by all of these different kinds or views of research are that they are, or aim to be, planned, cautious, systematic, and reliable ways of finding out or deepening understanding”. For the purpose of a proper understanding of the concept of adult patient consent for surgical and other procedures and nursing care research through literature review of the subject was selected. The reason choice is that literature review provides to insight to the current status of knowledge on the subject, the gaps in the current knowledge and areas that future research needs to concentrate for enhancing the knowledge on the subject (Blaxter, Hughes & Tight, 2001). Finding the required literature to review involves the search for the right literature. Such literature is available at local libraries and in the various medical databases like PubMed, Medline and BioMed. The search for literature thus involves the use of both local libraries and suitable databases on the Internet, finding articles, shifting through the articles for the right articles on the subject and using them in the literature. This process has been employed in securing the articles which are reviewed below in the literature review. Literature Review: 1. Guidelines and Standards for Adult Patient Consent: Reviewing literature available shows that there is ample documentation on the guidelines and standards for consent from adult patients prior to any treatment intervention or care intervention from the health authorities and respective governance bodies. The Department of Health (DoH) makes the securing of consent a fundamental part of good practice and a legal requirement. The scope for the need of consent involves any treatment or care of people and ranges from simple procedures like dressing of wounds to major surgeries. The DoH explains the need for consent, as a requirement to respect the rights of people to determine on what is done to their bodies. Advanced age or frailty of individuals is no excuse for not seeking the consent of individuals. There are three general points that are essential in making consent valid and acceptable. The first deals with the competence of the individual in that the individual should be capable of taking the decision; the second is that the decision should be an autonomous one without pressure or duress from any other individual and the third concerns the requirement for adequate information to be provided for the patient to take an informed decision. From the perspective of a nursing professional for surgical and other procedures beyond nursing care, the nursing professional has to make sure that the consent received by the concerned professional is valid, prior to any of these procedures, while in the case of nursing care procedures, the nursing professional, is required to obtain valid consent before initiating the procedures (Department of Health, 2001). When dealing with groups of individuals, like people with dementia or any form of cognitive impairment, people with learning disabilities and people with mental illness and in emergency situations like accidents or cardiac arrests, who are not capable of taking decisions on what is done to their bodies, then consent from a family member or next of kin is required. However in such cases it is necessary to know if the individual has provided any advance statement or directive regarding medical or care intervention. The Mental Capacity Act of 2005 provides this cover for consent from another individual for an incapacitated adult for treatment. In any case the guiding framework for providing treatment or care to individuals unable to give consent on their own is that the intervention is essentially in “the best interests” of the individuals (Royal College of Nursing, 2005). From a legal perspective there is no difference if the consent from the patient is obtained on a formal consent form in writing or given orally or implied by willingness indicated. The general guideline for good practice is that written consent is obtained when the intervention is complex or involves significant risk like in major surgical procedures, or side effects like in chemotherapy. For a nursing professional it may not be practical or possible to get written consent for every aspect of nursing care provided. Oral or implied consent is sufficient, like extending the arm for taking blood pressure (Department of Health, 2001). Patients can choose autonomously only when they are well informed and thus they have the right to receive information on their condition and the medical and nursing interventions that could be employed in their state so that they can make an informed choice. Informed choice is the key ingredient in the autonomy of the patient. For a patient to make an informed choice the information provided should be accurate and truthful. In addition this information needs to be presented to the patient in a suitable manner taking into consideration the unique requirements of each individual, so that it is understood by the patient and enhances the competency of the patient to take decisions. Sensitivity to their individuality and respect for their needs and wishes are an essential part of informed choice. Should the nursing professional have any doubts on any issue of informed consent from a patient, competent professional and legal advice has to be sought (Nursing Midwifery Council. 2004). 2. Requirement to be Knowledgeable of Informed Consent: Salient features of the legal aspects of consent that healthcare professionals need to know are that failure to secure informed consent from a mentally competent adult for the procedure intended could lead to the patient bringing on legal action for trespass to the patient. In such legal action harm does not have to be proved, but just the mere touching of the body of the patient without the consent of the patient. On the other side failure to provide the patient with sufficient information about the substantial risks or harm of the procedure could bring about legal charges of negligence for breach of the duty of care in providing information. In this case it is enough that the patient is able to show that not enough opportunity was provided to rethink the consent provided for the procedure. The severity of failure to get consent after due process of informing the patient makes it essential for healthcare professionals to be knowledge about the issue related to informed consent (Dimond, 2006). Acquiring knowledge in matters of patient consent occurs at the time of formal education and essentially during the practice of invasive procedures at the nursing skill laboratories. Informed patient consent prevents charges of battery and abrogation of patient rights during medical intervention and nursing care. Verbal consent is hard to prove and written consent is the best means to addressing issues of battery and patient rights. This makes adequate knowledge and skills for obtaining valid informed patient consent is a requisite as part of the practical input in formal nursing education. Yet not many nursing schools provide adequate practical knowledge and skills in this essential aspect of nursing and where it is provided, lacunae in the ability of the nursing students to evaluate capacity of the patient for providing valid informed consent persists (Redford & Klein 2003). 3. Adult Patient Consent in Surgery Procedures: Prior to surgery an assessment of the patient is required involving a number of investigations to confirm diagnosis, assess the fit ness of the patient for surgery and rule out any problem that may interfere either with the anaesthetic process or the surgical procedure itself. Since it is the responsibility of the involved health professionals to provide the required information on these preoperative assessment tests such information is normally provided to the patient to secure the required consent, but studies show that the concentration of the effort is on the meeting the consent norms, rather than on actually ensuring that the patient is properly informed. This leaves some patients not knowing what tests they were about to undergo, unsure of the necessity for the tests ordered for and unsure of what the tests for. In essence this shows that some patients have only a vague idea of the pre-operative tests they were about to undergo underlying the fact that the enough concern in patient understanding was not shown in explaining the pre-operative assessment tests prior to getting their consent for the tests (Jolley, 2007). Patients awaiting surgical procedures can be deemed to have given informed consent only when full disclosure is made about all the pertinent information, which includes a full understanding of the benefits and risks and the surgical procedures. Literature suggests that patients were more frequently informed on when to eat and drink and what would be done during the surgical procedure and less on the possible risks of the surgical procedure and the how to support bladder and bowel functions. Nursing staff confirm the deficiency in information provided to surgical patients and this raises concern on the information provided to adult patients undergoing surgical procedures at each phase of their care (Scott, et al, 2003). 4. Adult Patient Consent in Nursing Care: Nursing care involves several simple and not so simple every day procedures. The impracticality of getting written or verbal informed consent for every procedure has led to nurses using implied consent. There is evidence to suggest that there is misuse of this provision. Implied consent has the involved crucial component of information giving and this is more in breach than in practice, leading to patient compliance rather than patient consent for procedures in their lack of protestations to the nursing care forced on them. Nurses need to be more knowledgeable about the implications of information giving in informed consent and the difference in patient consent and patient compliance (Aveyard, 2002). Thus we see nursing professionals failing to observe the requirement of information giving in securing implied consent for care procedures. Nursing professionals increase their information input, when adult patients refuse consent for procedures. This creates the impression that nursing professional tend to abuse their power over adult patients in coercing consent from them for procedures that the nursing professionals believe that the patients need. There is evidence of unease among nursing professionals providing care for patients unable to give care. In such a combined journey of patient and nursing professional, the nursing professionals, who need to take the lead in the care of their patients tend to falter and fall back on refusing to provide care, rather than seeking the means to provide care by the provisions of informed care in patients not capable of giving informed consent (Aveyard, 2005). Perceptions of the adult patients of autonomy and informed consent need to be understood by nursing professionals, while getting informed consent for nursing care professionals. However evidence suggests that nursing professionals are not knowledgeable on the manner in which to evaluate a situation from the perspective of the patient. This could lead to difficulties in providing nursing care to the patients, particularly in elderly patients with a different perspective of quality of life, which may arise from generation differences. Greater emphasis needs to be given to the values of the patient, on what they respect, and what they believe constitutes good nursing care than the perspective of the nursing professional. This may mean that the nursing professional spends more time with each patient, but this would give greater respect both for the autonomy of the patient and the rights of the patient to consent to nursing care (Leino-Kilpi, et al, 2003). Discussion: The Department of Health, the Royal College of Nursing and the Nursing and Midwifery Council have clearly provided the guidelines for informed consent and the standards that should be maintained for quality in surgical and other procedures and nursing care. These standards and guidelines not only set the course for getting informed consent from adult patients, but also make providing the required information in manner that could be understood by the patient as a crucial component of informed consent. The legal consequences for healthcare professionals in failing to comply with the quality and standards required in informed consent makes it essential that healthcare professionals are knowledgeable about the standards and guidelines for informed consent and use them in their daily interaction with adult patients (Dimond, 2006). Yet, from Redford & Klein 2003 comes information that in nursing schools inadequate practical knowledge and skills in this essential aspect of nursing is imparted and where it is provided, lacunae in the ability of the nursing students to evaluate capacity of the patient for providing valid informed consent persists. Formal informed consent is a necessity in any major medical procedure like surgical procedures with the patient clearly informed of what is going to happen and the benefits and the risks of the procedure clearly informed prior to getting the informed consent. Even in pre-operative assessment testing the focus is more on getting the patient to provide the consent rather than on providing the critical component of information giving in the consent process (Jolley, 2007). This scant attention to providing information including the risks and benefits of the surgical procedure extends to the securing of consent for the surgical procedure, which is a clear breach of the rights of the patient to know what is going to happen and the consequences (Scott, et al, 2003). Moving on to nursing care Aveyard 2002, and 2005, gives a clear picture of the lacunae in getting informed consent for nursing care by the nursing professionals. Implied consent is the usual accepted mode for consent among nursing professionals for the routine nursing care activities. However information that is the crucial element even in implied consent is neglected with greater emphasis on the power of nursing, making it more patient compliance. This same concept is extended to situations when the patient refuses consent. The patient is browbeaten into consent through the input of information giving oriented towards the procedure. Leino-Kilpi, et al, 2003 point out that such attitudes among nursing professionals arise from the lack of importance given by the nursing professionals to the values of the patient, on what they respect, and what they believe constitutes good nursing care and more importance to the perspective of the nursing professional. Conclusion: In the informed consent process for surgical and other procedures and nursing care the crucial element of providing required information in a manner that the adult patient understands is observed more in breach than in practice by the healthcare and nursing professionals. This indicates scant respect for the legal and ethical rights of the patient that stem from patient autonomy. Correcting this attitude is essential for the informed process to be observed to provide the quality and standards expected in surgical and other procedures and nursing care. Literary References Aveyard, H. 2002, ‘The requirement for informed consent prior to nursing care procedures’, Journal of Advanced Nursing, vol. 37, no. 3, pp. 243-249. Aveyard, H. 2002, ‘Implied consent prior to nursing to nursing care procedures’, Journal of Advanced Nursing, vol. 39, no. 2, pp. 201-207. Aveyard, H. 2005, ‘INFORMED CONSENT PRIOR TO MURSING CARE PROCEDURES’, Nursing Ethics, vol. 12, no. 1, pp. 19-29. Blaxter, L. Hughes, C. & Tight, M. 2001, HOW TO RESEARCH, Second Edition, Buckingham: Open University Press. Department of Health. 2001. ‘Seeking consent: working with older people’. Dimond, B. 2006, ‘Colostomy: getting patient consent to treatment for surgery’, British Journal of Nursing, vol. 15, n0. 6, pp, 334-335. Jolley, S. 2007. ‘An audit of patients’ understanding of routine preoperative investigations’, Nursing Standard, vol. 21 no. 22, pp. 35-39. Kukla, R. 2007. ‘How Do Patients Know?’ The Hastings Report, vol. 37, no. 5, pp. 27-35. Leino-Kilpi, M Valimaki, M Dassen, T Gasull, M Lemonidou, C Anne-Scott, P Schopp, A Arndt, M & Kaljonen A. 2003, ‘CARE OF ELDERLY PEOPLE IN FIVE EUROPEAN COUNTRIES: COMPARISON OM[PLICATIONS FOR THE FUTURE’, Nursing Ethics, vol. 10, no. 1, pp. 58-66. McStein, K & Peden-McAlpine, C. 2006, ‘The Role of the Nurse as Advocate in Ethically Difficult Care Situations With Dying Patients’, Journal of Hospice and Palliative Nursing, vol. 8, no. 5, pp. 259-269. Nicol, M. Brooker, C & Meyer, J. 2003, ‘Adult nursing: setting the scene’, in NURSING ADULTS: The Practice of Caring, eds. Chris Brooker & Maggie Nicol, Elsevier Health Sciences: Oxford, pp. 3-22. Nursing Midwifery Council. 2004, ‘The NMC code of professional conduct: standards for conduct, performance and ethics’. Redford, D. S. & Klein, T. 2003, ‘Informed Consent in the Nursing Skills Laboratory: An Exploratory Study, Research Briefs, vol. 42, no. 3, pp. 131-133. Royal College of Nursing. 2005, ‘Informed consent in health and social care: RCN guidance for nurses’. Scott, P. A. Taylor, A Valimaki, M Leino-Kilpi, H Dassen, T Gasull, M Lemonidou, C & Arndt, M. 2003. Autonomy, privacy and informed consent 4: surgical perspective. Read More