Informed Consent for Mentally Incapacitated Patients

Autonomy and informed consent are core principles in nursing ethics. In informed consent, a patient should give a nod for every medical procedure that is likely to result in irreversible damage to their health. Thus, the nurse must seek the consent of the patient before undertaking the intervention. This consent must also be informed. In other words, the patient must fully understand the nature of the procedure, how long it would take, the people to carry it out, and all the associated risks. The patient should then have time to think about it and give a response that the nurse and the entire medical team should respect. A good example of such a procedure is surgery. The theory of patient autonomy states that the patient has the ultimate decision regarding all interventions that affect them. However, there is contention as to whether mentally incapacitated patient should have autonomy. A patient with a mental disorder may fail to give informed consent if the disability prevents them from making sound judgments, communicating effectively, agreeing to the intervention or understanding the procedure in question (Kruger and Van Staden, 2003). For many mentally incapacitated patients, caregivers refrain from undertaking curative medical interventions due to lack of informed consent or proceed to treat the patient without the consent of the latter due to a belief that the patient is incapable of making a sound judgment. Owing to the above reasons, a caregiver should carry out an objective assessment of mental ability to give informed consent in case a patient shows signs of mental incapacity, rather than violating their autonomy or denying them care.

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Autonomous decisions are made intentionally and with substantial understanding and freedom from controlling influences (Entwistle et. al., 2010). Essentially, the patient should have all the relevant information about a procedure before making any decision. The explanation of the procedure should be in a language that the patient understands. The nurse should give illustrations if that would help the patient to understand it better. It would also be helpful if the patient gets time to consult with their kin and close friends before giving a final answer. Unfortunately, it is commonplace to find a nurse dishing out a pre-filled form for a patient to sign a few hours before an elective surgery. Such practice is blatant abuse of patients' rights to autonomy. It is important to furnish the patient with information regarding the procedure in due time for them to make decisions. This case is simple with mentally fit patients. There are some patients whose mental disability prevents them from reading or understanding a written informed consent form. The nurse should avoid presuming that such patients do not deserve the right to autonomy and proceed with a procedure or treatment.

Beneficence and non-maleficence are complementary nursing ethics to patient autonomy. A common argument is that the nurse can overlook informed consent in pursuit of beneficence. In the context of mentally incapacitated patient, the nurse may argue that any procedure given to the patient is for the benefit of the latter. Further, they would say that withholding such intervention for the sole reason of unavailability of patient consent is an act of maleficence. While all these arguments are true, the patient's decision is supreme. The autonomy of the patient surpasses all rationale to offer any medical intervention. A clinical assessment of the patient with regards to their comprehension and communication is a potential solution to pitfalls that may attract a court case in the unfortunate circumstance of patient complication.

Mental incapacitation comes in many dimensions. A hospitalized patient may have a mental problem that prevents them from communicating with a caregiver. A patient with cerebrovascular accident, for example, may exhibit broca's aphasia that compromises their communication efficiency. However, such patients are in a position to understand any medical intervention provided that a caregiver explains it to them in elaborate illustrations and diagrams. The patient can then give their consent in writing or a simple illustration like signing. Another case is confusion or depression. A depressed patient may portray symptoms that a nurse may confuse with psychosis. However, such patients only need antidepressants to stabilize them. They can then make a decision after their symptoms subside. In a nutshell, there are various conditions that may inhibit the conventional dialogue between the patient and the caregiver. To avoid shortcomings and injurious circumstances, a nurse should exploit all routes through which they can reach the patient and ask for informed consent.

A typical scenario where informed consent from the relatives is of paramount importance is the diagnosis of brain death. Before withdrawing the life support in circumstances where a doctor diagnoses brain death, the nurse should explain the risk-benefit profile of maintaining the patient on medical care to the relatives (Muramoto, 2016). If the relatives consent to the diagnosis of brain death, the doctor can then initiate cardiac death and save the relatives the medical bill of sustaining their kin on life support. Here too, the doctor and the medical team should respect the relatives opinion of calling in a family doctor or an expert in such matters.

Insofar as the nurse wants to seek informed consent for invasive procedures, there are several difficult cases that call for desperate measures. One of those is unconsciousness. In such a case, the nurse in consultation with the surgeon can proceed with the procedure but inform the patient of it after 48 hours once the patient becomes conscious, whichever comes first (Schmidmaier, et al, 2017). Another difficult case is patient overwhelming. In this case, the patient has a sound mind, but the information that the nurse feeds to them is beyond their understanding. Bester, Cole and Kodish (2016) opine that genetic replacement therapy, for example, is not within the comprehension scope of the general public. They, then, think that the caregiver should avoid asking for informed consent in instances where the patient is not capable of understanding the information. It is indeed true that the caregiver can proceed with the intervention without the consent of the recipient as long as they are well within the moral obligation of beneficence. However, it is more prudent to let the patient consult with a second expert and get a better understanding of the principle behind the overwhelming information.

Besides the patient, there are close relatives who can give informed consent on behalf of the patient. Once the patient reports to the hospital, the company in which they come includes next of kin or other close relatives. If the patient is a minor, the parent or a guardian is within the legal right to offer informed consent on behalf of the child. The same case should apply to the mentally ill or unconscious patient. The relatives too, should be allowed to learn about the intervention to what they are consenting to. The nurse should explain the intervention in a careful manner and allow them to consult any experts if they have any. Further, the nurse must respect the decision by the relatives to decline the said procedure.

The clarion purpose of capitalizing on informed consent is the avoidance of legal battles that may ensue with patients who feel demeaned before they undergo a medical procedure. It protects the nurse and the medical staff. It buffers the caregivers against any unexpected legal tussles that the patient of their relatives may launch after the patient is discharged from the hospital. The nurse should explore all the possible avenues in seeking informed consent through carrying out an objective assessment of the patient's mental ability to give consent. In avoiding the hustle of seeking informed consent, the medical staff argues that none of the procedures they are giving is detrimental to the patient. However, patients autonomy supersedes the principles of non-maleficence and beneficence. The results of the mental assessment should then give a nurse the guide to seeking patients consent. If, for instance, the patient is depressed, the nurse should treat the depression and then communicate with the patient afterwards. For patients having a mental disorder caused by brain damage, the nurse should find out if the cognitive function is present and devise a communication method that conforms to the patient's condition. Another way of seeking informed consent is through the relatives who have the legal right to speak on behalf of the unconscious, overwhelmed, or unconscious patient.

References

Bester, J., Cole, C. M., & Kodish, E. (2016). The limits of informed consent for an overwhelmed patient: clinicians' role in protecting patients and preventing overwhelm. AMA journal of ethics, 18(9), 869.

Entwistle, V. A., Carter, S. M., Cribb, A., & McCaffery, K. (2010). Supporting patient autonomy: the importance of clinician-patient relationships. Journal of general internal medicine, 25(7), 741-745.

Muramoto, O. (2016). Informed consent for the diagnosis of brain death: a conceptual argument. Philosophy, Ethics, and Humanities in Medicine, 11(1), 8.

Schmidmaier, G., Kerstan, M., Schwabe, P., Sudkamp, N., & Raschke, M. (2017). Clinical experiences in the use of a gentamicin-coated titanium nail in tibia fractures. Injury, 48(10), 2235-2241.

Van Staden, C. W., & Kruger, C. (2003). Incapacity to give informed consent owing to mental disorder. Journal of Medical Ethics, 29(1), 41-43.