how to make a competent person get life saving treatment

by Kyler Price Published 3 years ago Updated 2 years ago

Can competent patients refuse life saving medical treatment?

Competent patients who refuse life saving medical treatment present a dilemma for healthcare professionals. On one hand, respect for autonomy and liberty demand that physicians respect a patient’s decision to refuse treatment.

Will a competent patient ever fully grasp and give consent?

It is equally conceivable that a marginally competent patient will never fully grasp his condition and never give consent. It is presumptuous, however, to expect that a competent patient’s values would change fundamentally following medical treatment.

Is it possible to forcibly treat a competent patient?

The following two cases illustrate the limits and lessons of forcibly treating a competent patient. A 51 year old woman presents with severe urinary bleeding caused by a large tumour in her bladder. The preferred treatment is excision of the entire bladder (radical cystectomy) requiring a urine bag to collect and pass urine.

Can treatment extend a patient's life?

Although treatment may extend a patient’s life, the costs in terms of curtailed lifestyle, for example, may lead a patient to prefer a shorter life under some conditions rather than a longer life under others. This is the common defense for autonomy and respect for a patient’s decision to forego treatment.

Can a competent patient refuse life sustaining treatment?

Should a competent patient have the right to refuse a treatment?

Every competent adult has the right to refuse unwanted medical treatment. This is part of the right of every individual to choose what will be done to their own body, and it applies even when refusing treatment means that the person may die.

What can you do if someone refuses medical help?

What to Do if Your Loved One Refuses to See a DoctorBe transparent and direct. ... Convince them that it's their idea. ... Make it a "double-checkup" ... Make the rest of the day as enjoyable as possible. ... Get someone who is an authority figure to help.

What four areas decide if a patient's treatment decision is competent?

The four key components to address in a capacity evaluation include: 1) communicating a choice, 2) understanding, 3) appreciation, and 4) rationalization/reasoning.

Can you be forced to have medical treatment?

You cannot legally be treated without your consent as a voluntary patient – you have the right to refuse treatment. This includes refusing medication that might be prescribed to you. (An exception to this is if you lack capacity to consent to treatment.)

Can you force someone to take medication?

For the most part, adults can decline medical treatment. Doctors and medical professionals require informed consent from patients before any treatment, and without that consent, they are prohibited from forcibly administering medical care.

What should be done if a patient refuses treatment for a life threatening condition?

Where a competent adult refuses treatment recommended by guidelines, the doctor is bound to respect that refusal. If he does not, the doctor may face disciplinary action by the General Medical Council, plus possible civil and criminal proceedings in battery.

What should a doctor do if a patient refuses life saving treatment for religious reasons?

Three physician experts suggest that to discern when to accommodate a patient's refusal of treatment on religious grounds, doctors should embrace medicine's traditional orientation toward preserving and restoring health.

Is there a way to force someone to go to the hospital?

A person can be involuntarily committed to a hospital if they are a danger to themselves, a danger to others, or gravely disabled. They are considered a danger to themselves if they have stated that they are planning to harm themselves.

Who decides if a patient is competent?

Competence is determined by a judge [1][2][3]. This legal determination is never determined by medical providers.

How do you determine if someone is competent?

To be considered competent, individuals need to be able to:Comprehend information that is presented to them.Understand the importance of such information.Make sound decisions among provided choices.Understand the potential impact of their decisions.

How is competency evaluated?

A competency evaluation is a court-ordered mental health assessment to determine how much a defendant remembers and understands about his or her charges and alleged offense, as well as his or her capacity to understand court proceedings and assist a lawyer in their defense.

What is the morally best approach to life sustaining treatment?

When a patient’s life seems to be nearing its end, it is generally felt that the morally best approach is to try a new intervention, continue all treatments, attempt an experimental course of action, in short, do something. In contrast to this common practice, the authors argue that in most instances, the morally safer route is actually to forgo life-sustaining treatments, particularly when their likelihood to effectuate a truly beneficial outcome has become small relative to the odds of harming the patient. The ethical analysis proceeds in three stages. First, the difference between neglectful omission and passive acquiescence is explained. Next, the two necessary conditions for any medical treatment, i.e., that it is medically indicated and that consent is obtained, are applied to life-sustaining interventions. Finally, the difference between withholding and withdrawing a life-sustaining treatment is discussed. In the second part of the paper the authors show how these theoretical-ethical considerations can guide clinical-ethical decision making. A case vignette is presented about a patient who cannot be weaned off the ventilator post-surgery. The ethical analysis of this case proceeds through three stages. First, it is shown that and why withdrawal of the ventilator in this case does not equate assistance in suicide or euthanasia. Next, the question is raised whether continued ventilation can be justified medically, or has become futile. Finally, the need for the health care team to obtain consent for the continuation of the ventilation is discussed.

What are the two conditions that a health care provider needs to have to start treatment?

A health care provider needs to have both a medical indication and a consent to start treatment; and she likewise can only continue the provision of treatment when and as long as that treatment is still medically indicated and the patient is continuing to consent to its provision.

What happens if a patient refuses life sustaining treatment?

Similarly, if the patient refusing the life-sustaining treatment is competent, one of the two necessary conditions for treatment discussed above is not fulfilled and hence the patient’s health care providers are not ethically permitted to start the treatment. It may be the case that the patient is refusing the treatment in an attempt to end his life. But even if the refusal is suicidal, that does not mean the health care team is assisting the patient in his suicide. The team simply has no ethical mandate to start the life-sustaining treatment when a competent patient refuses the treatment. For sure, the team members should inform the patient, counsel him, negotiate, and use any other respectful means to get the patient to at least try a life-sustaining treatment that is likely to be effective and unlikely to cause severe side-effects. But if a competent patient persists in his refusal, the health care team has no longer a choice in the matter, must abstain from the refused treatment, and hence cannot be responsible either for the patient’s subsequent death.

What are the two conditions that must be met before a health care professional is morally permitted to provide a treatment?

Firstly, the treatment must be medically indicated. That is, the provider must conclude that given this patient ’s diagnosis and prognosis, treatment X has a reasonable chance of benefitting the patient and is unlikely to cause disproportionate harm.

What is the second necessary condition for initiating a medical intervention?

Secondly, the patient (or the patient’s proxy decision maker in case the patient herself is incompetent) must be informed about her diagnosis, prognosis, and the nature of treatment X, and must then consent to it. In rare circumstances, such as when an incompetent patient with a life-threatening condition is brought to the Emergency Room, the patient’s consent may be presumed. But even then it is this “presumed consent” that fulfills the second necessary condition for initiating a medical intervention.

Why is clinical decision making so complicated?

The clinical decision making process is often rendered more complicated still when and because it is not clear which medical treatments can benefit the patient and which have become futile. To make matters worse, in many such instances the patient is no longer competent to make decisions, has not left a clear advance directive, and family members disagree about which treatments to consent to and which to refuse on behalf of the patient. These different factors then become all mixed-up, yielding an emotionally volatile situation that defies a calm and mutually agreeable resolution.

What is the ethical decision for clinical care providers?

One of the ethically most vexing decisions for clinical care providers is to withdraw a life-sustaining treatment. Many of the hallmark cases in American bioethics involve exactly that type of decision. In the case of Ms. Karen Quinlan [1], which is now half a century old, the treatment forgone was ventilation. Mr. Cinque refused continued dialysis [2]. Mr. Dax Cowart refused further treatment of his life-threatening burns [3]. The husband of Ms. Terry Schiavo wanted the artificial nutrition and hydration stopped after his wife had been in a persistent vegetative state (PVS) for more than two years [4]. All of these cases ended up in court. And when, more recently, a nurse at a California nursing home refused to provide cardio-pulmonary resuscitation (CPR) in accordance with the facility’s Do-Not-Resuscitate (DNR) policy [5], many a commentator was appalled.

What is competency in law?

Competencyis a legal term referring to individuals “having sufficient ability… possessing the requisite natural or legal qualifications” to engage in a given endeavor.2(p257)Unfortunately, this definition is a broad concept encompassing many legally recognized activities, such as the ability to enter into a contract, to prepare a will, to stand trial, to make medical decisions, and so on. The definition, therefore, must be clarified depending on the issue in question. Simply put, competency refers to the mental ability and cognitive capabilities required to execute a legally recognized act rationally.3The determination of incompetence is a judicial decision, i.e., decided by the court. An individual adjudicated by the court as incompetent is referred to as de jure incompetent. After determining that the de jure incompetent cannot make prudent decisions in his or her own best interest, the court will assign a guardian to make decisions on the person's behalf.4,5

Why is incompetency considered labor intensive?

Because an adjudication of incompetency effectively denies an individual autonomy to make decisions, such court cases become labor intensive. An individual is presumed to be competent unless demonstrated to be otherwise. The standard of proof required for judicial finding of incompetency is that of “clear and convincing evidence.”6This standard of proof, based on evidence presented by licensed health care practitioners and others, is set at a standard between the high level of proof required for criminal convictions, i.e., “beyond a reasonable doubt,” and the lowest standard of “preponderance of the evidence.”7

How to assess a patient's condition?

Making certain that a patient understands his or her condition can be best assessed by open-ended inquiry, for example, “Can you tell me what your medical problem(s) consists of?” or “Why have you been brought to the hospital?” Avoid questions that elicit a yes or no reply, e.g., “Do you understand what your medical condition is?” since an affirmative reply does not clearly convey that the person comprehends the nature of the illness.

Why are psychiatrists asking for psychiatric consultation?

Requests for psychiatric consultation by primary care physicians to assess capacity to make treatment decisions have been increasing.11A retrospective chart review12of consultation requests made to psychiatrists in a municipal general hospital and a university-affiliated hospital found that as many as one fourth of all consultation requests were to assist with deciding issues of capacity. Earlier studies found lower rates of referral to psychiatric consultation services for capacity assessment, ranging from 3.3% to 15%.13–15The increase in consultation requests for capacity assessment suggests that physicians may be uncertain about, and perhaps overwhelmed by, the complexities encountered when addressing issues pertaining to medical decision making.

How to test the capacity to evidence a choice?

Therefore, the capacity to evidence a choice can be tested quite simply by asking patients who have been informed about their medical condition and proposed interventions to respond to what they have just heard. The stability of the choice that they express can be examined by simply rephrasing the same question some time later.26Certainly, patients have the right to change their mind, hence a reasonably justifiable alteration in one's decision does not necessarily constitute an inability to evidence a choice.

Is the ability to understand relevant information more stringent than the ability to evidence a choice?

Although the ability to understand relevant information is more stringent than the ability to evidence a choice, this standard does not factor in patients' abilities to weigh the options before them and understand the implications the decision has for their lives. Toward this end, a higher standard of capacity is employed, i.e., appreciation.

Is capacity subjective?

Unfortunately, this standard of capacity assessment is more subjective than the previously mentioned standards since it involves an assessment of whether the individual can understand the implications of his or her decisions and whether he or she is, in effect, willing to live with the consequences of that decision. Such decisions are, for the individual, quite weighted, involving values assigned to potential consequences and issues related to quality of life. Hence, for one person, the choice of undergoing a procedure that can result in paralysis may be worthwhile over an option of death, whereas for another, death may be preferred over life as a quadriplegic. The assessment of the individual's capacity to appreciate is, therefore, based upon an examination of the ability of the individual to weigh various treatment benefits and risks against personal values and choices. If a patient is able to do so, without impediments from misunderstanding, cognitive deficiency, or psychopathologic states, he or she has capacity. Nonetheless, the subjective nature of decision making at this standard of capacity calls forth an assessment of the ability to rationally decide. Hence, a fourth, and final, standard of capacity assessment is often commonly invoked, i.e., the rational manipulation of information.

Who is Stephanie Cooper?

Stephanie Cooper, MD, MS is an emergency medicine physician at Harborview Medical Center in Seattle and an assistant professor at the University of Washington School of Medicine. Her academic interests are bioethics, humanities, and narrative medicine. She teaches Ethics in the ER, a course that introduces medical students to critical ethical concepts in the context of emergency medicine.

Why is it important to assess decision making capacity?

Assessing decision-making capacity is central to providing medical care that respects patient autonomy, since patients’ consent to or refusal of medical treatment is not valid unless they are capable of making medical decisions [1].

Why is it important to honor the severely burned firefighter's request to withhold treatment?

Honoring the severely burned firefighter’s request to withhold treatment allows him to die from his underlying disease and injury. From a clinical perspective, one could argue that providing medical treatment in this case simply prolongs death rather than preserves life. Mr. Worther is seeking pain medication only, not prescription of a lethal medication. By honoring his request to withhold life-sustaining treatment, we are honoring the autonomy of a patient with decisional capacity who understands the risks of treatment refusal. Providing some patients a dignified death may be just as critical as saving the lives of others [11].

What is the capacity to refuse treatment?

Determining capacity to consent to or refuse treatment is a clinical judgment based on the patient’s cognitive and physical functioning and the complexity, risks, and possible repercussions of the medical treatment at hand [1]. It is an essential skill for emergency physicians, who frequently must delicately and accurately walk the tightrope between medical urgency and ethical imperative. Assessing decision-making capacity is central to providing medical care that respects patient autonomy, since patients’ consent to or refusal of medical treatment is not valid unless they are capable of making medical decisions [1].

Can a comatose patient be intubated?

Certainly, a comatose patient, a severely demented patient, or an intubated, head-injured patient lacks decisional capacity. Under the “emergency exception,” immediate intervention can proceed without informed consent in order to prevent death or serious disability.

Rapid Response

Morris described a case when a decision had to be made, before his patient regained consciousness from a Caesarean Section, to perform an emergency laparotomy to explore the abdomen for possible life-threatening haemorrhage; but the patient’s husband refused to give consent to the treatment.

Life-saving treatment may be given without consent under the doctrine of necessity

What does the court consider when deciding an individual's right to refuse lifesaving treatment?

The courts, in deciding an individual’s right to refuse lifesaving treatment, even if there is a possibility of a cure, consider the competency of the individual as to whether an individual has knowingly and validly chosen such a right, and whether there is a compelling state interest that justifies overriding the individual’s decision.

What should a physician do in an emergency situation?

However, a physician should respect the refusal of treatment from a patient who during the emergency situation is capable of providing consent.

What is the significance of Powell v. Columbian Presbyterian Medical Center?

2d 215 (N.Y. Sup. Ct. 1965), it was found that the court authorized blood transfusions for a member of Jehovah’s Witnesses who was in a critical state and had refused pleas of her husband and family and hospital staff that she sign authorization for blood transfusions. Nevertheless, while considering the state’s interest in preserving life in blood transfusion cases that can cure the patient’s condition, the court should examine the facts that blood transfusions are not without risk and can result in adverse complications affecting the patient due to impure blood transfusion.

Can a patient refuse life-sustaining treatment?

The competent adults irreversibly sustained by artificial life support and enduring physical and mental pain and suffering had the right to terminate treatment. Under such circumstances, the patient’s right to refuse or terminate life-sustaining treatment would override competing state interests in preserving life and the exercise of the right would not amount to suicide.

Can a doctor ignore the mandates of their own conscience?

The medical professionals are not to be forced to ignore the mandates of their own conscience in treating a patient by withholding certain type of medical treatment which run counter to the procedure, such as the administration of blood transfusion in treatment for leukemia. Also, a patient under no circumstance shall order a doctor to provide treatment that would result in his/her death. The courts have compelled patients to accept the treatment they wished to reject under situations where the administration of lifesaving treatment is considered necessary and only partial treatment has been authorized.

Is a minor child dependent on a patient?

Where there are minor children dependent upon the survival of the patient, the medical control of one’s body is relative. Therefore, the need of protection of innocent third parties arises and where there are such minor children dependent on the patient, the court will not recognize the patient’s right to refuse medical treatment even ...

Can a court order a lifesaving treatment?

Under a compelling state interest, the court may order a lifesaving treatment to an individual where the evidence shows that such individual has a good chance to live if the operation is performed and will die otherwise. In Superintendent of Belchertown State School v. Saikewicz, 373 Mass. 728 (Mass. 1977), the court found that there is a general right in all persons to refuse medical treatment in appropriate circumstances.

What is the dilemma of refusing lifesaving treatment?

What is the dilemma of non-consensual treatment?

The dilemma posed by non-consensual treatment is not new. Although courts in the United States and in the UK have supported a physician’s duty to treat incompetent patients against their express wishes, jurists have balked when asked to impose treatment on competent, adult patients. In exceptional cases, however, the courts permitted non-consensual treatment for the protection of third parties, usually fetuses or minor children. In those cases where patients appeared competent and no third party interests were at stake, it was necessary to establish that either a patient was temporarily impaired or unduly coerced or influenced at the time he or she made a decision to refuse treatment. This supports the underlying theme in Western bioethics: namely, that a competent, adult patient can refuse treatment even at risk to themselves 3,4

What are the rights of patients in Israel?

Patients enjoy a wide range of rights including national healthcare, the right of informed consent, privacy, confidentially, and respect for dignity.

Is marginal competence moral?

Once the conditions for marginal competence and significant improvement are satisfied, there is a moral obligation to treat patients against their will, and no grounds for respecting a patient’s less-than-informed refusal. Marginally competent patients are not unique to Israel and the dilemma they pose for ethicists, together with the lessons gleaned from the Israeli case, should engage healthcare professionals wary that respect for autonomy may sometimes cause avoidable harm.

Does treatment extend life?

Although treatment may extend a patient’s life, the costs in terms of curtailed lifestyle, for example, may lead a patient to prefer a shorter life under some conditions rather than a longer life under others. This is the common defense for autonomy and respect for a patient’s decision to forego treatment.

Does treatment improve a patient's condition?

Secondly, treatment must “significantly improve” a patient’s condition . Finally, there must be reasonable grounds to suppose that, after receiving treatment, the patient will give “retroactive consent”. Although each of these conditions exhibits certain logic, a number of difficulties arise in practice.

Can a competent person be treated in defiance of their wishes?

Largely limited to incompetent patients, there are very few instances where one might imagine treating a competent person in defiance of his or her express wishes. In fact, the moral principle of respect for autonomy, together with statutes protecting patient rights, expressly forbids coerced treatment.

When should a physician elicit patient goals of care?

Physicians should elicit patient goals of care and preferences regarding life-sustaining interventions early in the course of care, including the patient’s surrogate in that discussion whenever possible.

What is the best professional judgment of a surrogate?

In the physician’s best professional judgment a decision by the patient’s surrogate clearly violates the patient’s previously expressed values, goals for care, or treatment preferences, or is not in the patient’s medical interest.

When should a surrogate make decisions?

Explain that the surrogate should make decisions to withhold or withdraw life-sustaining interventions when the patient lacks decision-making capacity and there is a surrogate available and willing to make decisions on the patient’s behalf, in keeping with ethics guidance for substituted judgment or best interests as appropriate .

Can a surrogate make decisions on behalf of a patient?

There is no surrogate available and willing to make decisions on behalf of a patient who does not have decision-making capacity or no surrogate can be identified. In the physician’s best professional judgment ...

Is it ethical to withhold life sustaining interventions?

Decisions to withhold or withdraw life-sustaining interventions can be ethically and emotionally challenging to all involved. However, a patient who has decision-making capacity appropriate to the decision at hand has the right to decline any medical intervention or ask that an intervention be stopped, even when that decision is expected to lead ...

The case at hand

Last month at an American Academy of Psychiatry and the Law (AAPL) meeting, Ramaswamy Viswanathan, a doctor at SUNY Downstate Medical Center, presented the case of a 76-year-old patient, previously diagnosed with depression, type-1 bipolar disorder, and alcohol use disorder, who'd been admitted to SUNY after a suicide attempt.

When should physicians intervene?

An evaluation deemed that the SUNY patient did not have the competence to make his own decisions about treatment, so Viswanathan reached out to the patient's 27-year-old grandson. But the patient and his grandson had been estranged for years, and the patient refused to let his grandson make treatment decisions.

Why did the patient change his mind?

The patient said "family pressure" led him to agree to the internal pacemaker, but Viswanathan said there may also have been other factors at play, Hlavinka reports.

What should physicians do?

After hearing the case, most physicians agreed with Viswanathan's course of action. That said, Appelbaum noted that each case should be viewed individually.

5 myths physicians believe about patient experience

Excellent patient experience is a critical piece of modern medicine, reflected clearly in outcomes. And more than amenities, clean rooms, or quiet during night, the factors that most inflect patient experience all relate to communication and coordination among the care team—factors that physicians are in a unique position to influence.