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Lecture 3

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PHLB09 – Lecture 3 Agenda:  Competence, decision-making and children  A few words about advance directives  ―Informed Consent‖:  The concept of informed consent  Standards for determining its obtainment  The interests of others Christine Harrison, et al.: “Involving Children in Medical Decisions”  Informed Consent reflects respect for autonomy (of competent adult patients).  What about children?  How ought physicians and HCPs respond to the preferences and wishes of child patients?  Can/should children participate in the medical decisions that affect them?  Adult models of informed consent assume that ―the patient is autonomous and has a stable sense of self, established values, and mature cognitive skills‖ (30).  Do children have the relevant capacities?  Infants aren‘t capable of articulating underlying goals and values and to reason. As children get older, it‘s plausible for them to make small decisions.  How do we decide for children?  Principle of autonomy?  We still think autonomy is important to children because they‘re still going to be adults.  We have to show respect for that developing capacity that they‘re capable of… but how do we find out their autonomy level?  Principle of beneficence?  To secure the patient‘s best interest, let patients decide.  We think it‘s the role of the gov‘t and doctors to protect the best interest (paternalism), but we also have a social role to protect the interests of children.  Is there some combination/balance that is preferable?  What if they should conflict?  Case study: (refer to Involving Children in Medical Decisions reading)  She may have maturity beyond her years, but because she only has 20% chance of living, go through with chemo. The costs/benefits? – Prognosis isn‘t very good, but 20% is still significant, and lung cancer is a bad way to die, what are the chances that it will emerge elsewhere afterwards?  The child is on the cusp of adolescent maturity  Author suggests a family-centered approach, maybe the patient‘s interest will weight a bit more (physician still has primary duty of care to the patient) must assess the child‘s competency level to make certain decisions.  How do we determine the parent‘s competency level? May be clouded by grief, shock, stress, etc.  Challenges: at what point does it become battery (abusive treatment) to the child? 1 PHLB09 – Lecture 3 Family-centered ethic:  ―A family-centered approach considers the effects of a decision on all family members, their responsibilities toward one another and the burdens and benefits of a decision for each member, while acknowledging the special vulnerability of the child patient‖ (30).  Challenges:  ―Triadic‖ relationship between HCPs, parents, and child patient  What if the parents and child disagree  What is the physician disagrees with the parents?  Family-centered approach:  Respect the child—the particular patient to whom HCPs have ―primary duty of care‖  ―Allow the child to exercise choice in a measure appropriate to his/her level of development and experience of illness and treatment‖ (30).  Affirm parents‘ responsibility and take seriously their concerns and wishes  Seek to harmonize the values of everyone involved  What does this really mean, and what does this approach look like in application?  Is harmonizing the interests/values of everyone always possible?  How might this model help inform our decision-making about Samantha‘s case?  Legally:  Parents have the legal authority (generally) to act as the child‘s surrogate decision-makers:  Obligation to decide in the best interest of the child  HCPs who disagree that decision is in the child‘s best interest can appeal to the relevant authorities (31).  The appropriate level of involvement of children in medical decision-making will differ depending on age, decision-making capacity, and potential harms.  The involvement of infants, primary-school, and adolescent minors will differ, but  (When appropriate) each should be given information appropriate to their comprehension  Strong consideration of their preferences (esp. dissent) – find out why Can the ―process” standard of competence help us here? Process standard:  How well does the patient‘s reasoning reflect the patients underlying aims and values?  What is the necessary level of understanding and reasoning?  How certain are we that the patient has met that level?  Standards set in accordance with expected costs/benefits of a decision  Costs/benefits evaluated with respect to a patient‘s known values/aims  When values/aims unknown, we evaluate with respect to to others‘ reasonable assessment of harms/aims  Merits of process standard:  Evaluation involves balancing respecting patient autonomy and protecting patient from harmful consequences 2 PHLB09 – Lecture 3  Can the ―process‖ standard help us determine the appropriate level of a child‘s participation in medical decision-making?  Why or why not?  Considerations:  Children often do not yet have stable underlying aims/values – even if they‘re able to articulate goals and values, might not reflect mature (adult) values  Process standard isn‘t the same to assess children as adults, not necessarily sufficient.  Even when they do (to the extent that they do), paternalism might be appropriate  The parents‘ interests  The physician‘s special responsibilities to children Canadian Medical Association: “Advanced Directives for Resuscitation and Other Life-Saving or Life-Sustaining Measures” Anticipating ‗incompetence,‘ the currently ‗competent‘ can express wishes regarding medical decisions by  Advance directives  Appointing a proxy decision-maker (if no advance directives or person was appointed)  (Or both) How do surrogate decision-makers decide for the formerly competent:  Expressed wishes  (Sometimes—hopefully—as a written advance directive)  Substituted judgment  Ex. family, wife ―I know them, they wouldn‘t have wanted this‖ Ex. Terri Schaivo case  Ex. doctor ―If I were the patient, what would I do?‖  Best interest  Ex. if there‘s no close friends/family  Use the principle of beneficence and balance those  Use the reasonable person standard.  ―The CMA holds that the right to accept or reject any treatment or procedure ultimately resides with the patient or appropriate proxy‖ (33)  Advance directives helpful tools for respecting patient self-determination  If you don‘t follow advance directive or have informed consent, even if acting in best interest, may be battery, assault – barring certain cases. Challenges and possible exceptions:  Advance directive is too specific and does not speak to actual circumstances that arise  Ex. if in total vegetative state, do not resuscitate. But if in transient state, what to do?  Advance directive is too general and too vague to provide proper guidance  Ex. advance directive only stated that didn‘t want to live without reasonable mind, but when old with Alzheimer‘s, they‘re happy because without memories, what to do?  There are reasonable grounds to suppose the advance directive no longer reflects the patient‘s wishes or that the patient‘s understanding was incomplete when written 3 PHLB09 – Lecture 3  If person has both advanced directive and proxy, which trumps the other?  If advance directive is still relevant, then that‘s stronger  If proxy has appointed level of authority, in cases, that‘s stronger.
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