Advance Care Directive

An Advance Care Directive (‘Living Will’) is a written statement regarding someone’s wishes for their future health care. An Advance Care Directive can be made by anyone who has the capacity to do so. An Advance Care Directive is only used if, at some point in the future, the person becomes incapable of making health care decisions for themselves (due to illness or injury) (Advance Care Directives, 2014).

Health care professionals are required to respect patients choices and gain consent (or, at least, assent) prior to providing treatment or care. They are also required to respect patient confidentiality. Based on what you have learned in this unit discuss the ethical issue of informed consent in relation to the following:

What are the features of a valid (legal) consent; and how does this relate to an advanced care directive?

Why does it matter ethically speaking that a patients choice be respected?

Are there any expectations to the requirement to respect patients choices?

Is Paternalism ever ethically justified in the provision of heath care?

What is the role of the HCP in relation to advocacy for a patients wishes and in particular when an advance care directive is present?

What are the legal and professional frameworks that guide a health care professionals practice in Australia?

Introduction

 Medical practice is complicated today than ever because of the increased factors that have been impinging the physician patient relations. In the modern world, the patients are either well informed or ill informed about their health condition. The healthcare professionals are mandated to respect patient’s choices, and obtain consent from these patients when delivering care. Patient confidentiality must always be respected (Gergen, 2011). Informed consent refers to the process where patient’s gives permissions for the treatment to take place after being informed about the treatments procedure; the benefits as well as the risks associated the   treatment. This process is intertwined with many ethical issues. Additionally, there many barriers associated with the informed consent process, which includes communication barriers, cultural barriers and the religious dogmas between the service users and the service providers (Chong, Aslani, & Chen, 2013).

In this context, the ethical issues surrounding the informed consent will be discusses and the HCP roles when delivering care for patient with advanced healthcare directives. The two perspectives that will be discussed in this paper are the registered nurses and physicians perspectives. This will help empower the healthcare provider bearing in mind those patients demands are changing continuously throughout the illness course, and according to their changes in the patents mental and physical capacities. This paper will be drawn on relevant codes of conduct, theories, ethics laws and practice, principles and values of informed consent.

Features of valid and legal consent

 The valid consent is more to a mere form where patients can append their written signature. For the consent to be valid, the following elements should be included, and understood by the patients. These elements include procedures that are to be carried out, benefits of the treatment, risks and alternative treatment available (Aasen, 2014). All information related to the patient’s circumstances must be specific, without any invalidating factors. This is particularly important in patients under advance care directive. An advance care directive refers to the process where a patient records their wishes when they are unwell to understand their medical health complication and treatment options available. This is a form where the patient communicates their wishes. ACD is not similar valid legal consent, and the two legal documents roles are different and should not be used interchangeably (Hamrosi, Raynor, & Aslani, 2014).

 There few circumstances where this could pose ethical dilemma for the HCP. For instance, there have been many questions about end of life care attributed to the advancement in technology. There are cases where many patients are not willing to subject their relatives to prolonged suffering through prolongation of his or her life even where there is little hope (Heggland, et al., 2013). The best way to maintain control is this through use of ACD to record patient’s preferences as guided by the physician and the loved ones. However, the law supports the ACD directives as stipulated by the Patient Self Determination Act of 1990. However, the advance care directives are  valid at common law  if  the following conditions have been met; to start with the  patient capacity at the time of advance  care directive is done  is stable and the patient can communicate effectively (Randall, 2008).  The patient must have the capacity of weighing the information and make an informed choice between risks and benefits. The directives must be made voluntarily and of high specificity. There are no legal ramifications that the directives should be done in writing and under witness, but these are vital are necessary as they indicate that the directives have been done under the requirements (Korhonen, Nordman,  & Eriksson, 2014).

Respecting patient choices

 Informed consents and ACD are meant to value patient autonomy. This principle of autonomy is associated with the ability of patients to make their own choices about the healthcare treatment that they will receive. The main principles that arise when addressing patient’s autonomy are privacy, confidentiality, and fidelity and patients freedom of choice (Krishna, Watkinson, & Beng, 2014).

Several criticisms have been done about the principle of respecting patient’s autonomy. This is especially on the fact that patients must be informed about the healthcare treatments even if it would make the patient stand back from undertaking treatment. There are also concerns that respecting patient choice would impair clinical recognition. Beuchap and Childress illustrates that autonomy principle fails to protect the competent patients, but those who lack confidence, and are unsure or have conflicting priorities (Barlem, & Ramos, 2014).

However, respecting patient choices is important because it indicates that patient’s dignity is respected. This is important also because it discourages inappropriate paternalism, thus protecting the patient from unwanted interventions that they would consider burdensome other than of benefit. Additionally, respecting patient autonomy improves beneficence. This is because the patient is informed about the treatment benefits, risks and costs, and the patient is allowed to make informed choices that benefit them. The issue of non-maleficence is addressed as patient is adequately informed to enable them make decisions that makes patient avoid causation of harm. The harm caused by the treatment must disproportionate the treatment benefits. The distribution of risks and benefits as well as the treatment cost must be of justice (Cole, Wellard, & Mummery, 2014).

 Nevertheless, patient wishes may not be respected all the time. This is especially if the patients  traditions or beliefs about treatment are proven to be inconsistent, untrue or inadequately informed.  In this contest, the HCP will be mandated to make decisions that are in best intention of the patient. This process is referred to as paternalism, which will be discussed later. The expectations to respecting patient choices include that patient mental capacity must be stable enough to make decisions independently. An informed patient must do the decisions voluntarily (Binder & Lades, 2015).  

Paternalism in healthcare

 The concept of paternalism begun with the Hippocratic ideals where he argued that the healthcare provider decisions must be aligned to patients best interests. For some reasons,   patient’s medical decisions may not be respected to ensure that the option picked is to benefit the patient (Lathrop, Cheney, & Hayman, 2013). For instance, an oncologist makes a decision for a patient scheduled for mastectomy in our healthcare facility. This is was because the patient laboratory findings indicated that the patient’s body was not in a position to recuperate. Despite the patient wishes, the healthcare provider supremely controlled the treatment process (Smith et al.,2015).

Paternalism can be categorized as hard or soft, narrow or broad, impure and pure. Soft paternalism occurs when the HCP believes that they make decisions, which would be done by the patient if the patient had the strength and capacity. The hard paternalist is done by the HCP when they believe that the patient could have been mistaken or confused, and thus not in a capacity to make their decisions. This is justifiable if the treatment choice made is advocated and accepted by the HCP as indicated by evidence-based research (Mccullough, 2010).  

From the HCP perspective, most physicians prefer shared decision-making process. Research indicates that the older physician are more likely to practice paternalism that the younger. Physicians in the   surgical department are the least likely to practice paternalism as compared to physicians in the acute settings (Sjostrand, Eriksson, Juth, & Helgesson, 2013). However, as a registered nurse, I feel that paternalism should not be practiced, unless it is the only choice left. This is because it acts as false signal that the nurse knows about the person’s desires or their wishes. In my perspectives, these patients should be advised to write their ACD, or have their relatives make medical choices for them, as some choices could interfere with the patient’s psychological status, and diminish their self-esteem and morale (Lin, Huang, Chiang, & Chen, 2012).

 The healthcare facility should gear their efforts towards a patient centered care. In most cases, the patient may be critically ill and unable to give consents. This is advisable for the healthcare providers to provide the patient with ACD, which can be conducted in presence of the patient relatives. This will mitigate the chance that the HCP will pressurize the patient to make independent decisions, which makes them feel overwhelmed. However, the healthcare provider must intervene to ensure that the patient does not go along with the family’s decisions, but they are allowed to make their own preferences (Baykara, Demir, & Yaman, 2014).

The HCP professional frameworks bind them in determining the patient best treatment based on their knowledge, experience, and judgment. In a case where a patient rejects treatment at the expense of the patient’s life, the HCP are bound by the ethical principle of beneficence (Wortley et al., 2015). The most vital aspect of the HCP frameworks is to establish a mutual relationship with the patients, and to maintain trust between them. This is important because it helps the patient understand that doctors will empathize with them, thus facilitating patient centered as well as a holistic care. In some cases, treatment modification can be done to ensure that the principle of non -maleficence is maintained. It is important for the HCP to value cultural competence to ensure that the care provided is just and holistic (Suzuki, Ota, & Matsuda, 2014).

HCP advocacy role in decision-making process

 The professional and ethical frameworks guide the HCP role in healthcare. The HCP delivery of care should be based on knowledge, experience, and sound judgment (evidence-based practice). The codes of ethics are set of principles that help HCP in delivering quality care. The main ethical issues in day-to-day ethics include treating patient with dignity, respecting the patient, fair treatment and supporting patient treatment preferences (Bradford, Caffery,  & Smith, 2015). This is accordance to the four ethical principles, which include autonomy, beneficence, justice, and non-maleficence. The ethical rules also guide the HCP in decision-making process, which includes veracity, confidentiality, fidelity, and privacy. The ethical theories that help in ethical decision-making processes are the theory of HCP accepting the consequences of their actions (consequentialism), basing the decision making process on set of principles (deontology) and applying decision-making processes based n the most prominent consequence theory (utilitarianism) (Valentine et al., 2013).

 The HCP role in their practice is to support the patient’s decision-making about their treatment preferences. This is normally done using advance care directives, and it is the role of HCP to facilitate the initiation of ACD. This is due to the unique bond that exists between the patient and their caregivers. Their roles in advocacy for ACD are to reflect ethically if the patient’s beliefs and values support or are against patients. The HCP must be adequately be informed about the ethics of care, patients medical care status, and other socio-demographic dynamics that could influence the decision making processes (Tee et al., 2013).  

For example, an elderly patient signs an ACD declining all treatment because the patient does not want to burden the family members. In scenario,’s where the   family disagrees on medical matter such as turning of life support machine, the HCP must educate the family on the importance of respecting patient dignity, and encourage them to support the ACD (Brodtkorb et al., 2014).  In this context, it is the nurse’s role to enter into discussions with the patient to discuss their values, beliefs and to make them understand the context of the status. The nurse role as an advocate of ACD is to teach the patient to express their ideas and wishes. The HCP are legally bound to ensure that the care provided is consistent with the client’s preferences, and is entitled to ensure that there is effective communication of the patient’s ACD to the other HCP team (Terlazzo, 2015).

Code of conduct for HCP in Australia

 The Australian Health Practitioner Regulation Agency (AHPRA) outlines the legal frameworks and code of conduct for HCP in Australia. The summary of these legal frameworks and code of conduct provisions is that HCP must provide evidence based care, which shared decision-making processes. The HCP is expected to maintain their professional performance, and ethical conduct to minimize patient risks. Additionally, these codes of conduct are framed under the principles and frameworks of the United Nations “Universal declaration of Human rights, International covenant on Economic, social and cultural rights, and the international covenant on civil and political rights.” The provisions are also according to the World Health Organization’s constitution, which involves Health and Human rights (AHPRA, 2013).  

The code of ethics are supported by the National competency standards for RN, NP and enrolled nurses as well as the code of professional conduct  for nurses in Australia. The codes are complementary to those of international council of Nurses (ICN), which stipulates that the nurses must deliver quality care to all. They must respect patient autonomy, value kindness and remain culturally competent.  Additionally, the nurses must value the socio-economical sustainability of a patient to ensure that health and patient’s wellbeing are promoted. The purposes of these legal frameworks and code of ethic is to guide the nurses with a reference point from where they can base their ethical decision-making (Mccullough, 2010). 

Conclusion

Ethical decision-making process is complex and challenging. This is especially in advance care directs which is one of the good clinical practice feature. From the health ethics analysis, ACD carries significant ethically moral force and respect. There are legal binding directives but should not limit patients treatment preferences. The code of ethics includes quality nursing care, respect patient decision, value the patient diversity and the culture of safety. The informed choices about ACD must be done according to the ethical management frameworks.

References

Aasen, E. (2014). A comparison of the discursive practices of perception of patient participation in haemodialysis units. Nursing Ethics, 22(3), 341-351.

AHPRA. (2013).  Codes, guidelines, policies.

Barlem, E., & Ramos, F. (2014). Constructing a theoretical model of moral distress. Nursing Ethics, 22(5), 608-615.

Baykara, Z., Demir, S., & Yaman, S. (2014). The effect of ethics training on students recognizing ethical violations and developing moral sensitivity. Nursing Ethics, 22(6), 661-675.

Binder, M., & Lades, L. (2015). Autonomy-Enhancing Paternalism. Kyklos, 68(1), 3-27.

Bradford, N., Caffery, L., & Smith, A. (2015). Awareness, experiences and perceptions of telehealth in a rural Queensland community. BMC Health Services Research, 15(1)

Brodtkorb, K., Skisland, A., Slettebo, A., & Skaar, R. (2014). Ethical challenges in care for older patients who resist help. Nursing Ethics, 22(6), 631-641.

Chong, W., Aslani, P., & Chen, T. (2013). Shared decision-making and interprofessional collaboration in mental healthcare: a qualitative study exploring perceptions of barriers and facilitators. J Interprof Care, 27(5),

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