Competence to Consent (Clinical Medical Ethics series)

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While physicians must always respect the autonomy of their patients, in practice, many forces may obstruct and limit the ability of patients to express their preferences. In clincal ethics, respect for patient preferences takes place within a therapeutic relationship, that is, when some health problem prompts a patient to seek help from Forgot Password? What is MyAccess? Otherwise it is hidden from view. Forgot Username? About MyAccess If your institution subscribes to this resource, and you don't have a MyAccess Profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

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Davis AT Collection. Davis PT Collection. Murtagh Collection. About Search. Enable Autosuggest. Which choice? A study of GPs' attitudes towards patient autonomy in the management of low back pain. Fam Pract. Clinician Integrity and Limits to Patient Autonomy. Limits of patient autonomy. Physician attitudes and practices regarding life-sustaining treatments and euthanasia.

Arch Intern Med. Making decisions: patient autonomy in general practice. In: Practical Ethics for General Practice, editor. Oxford: Oxford University Press; Informed consent -- why are its goals imperfectly realized? N Engl J Med.

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Doyal L. Ethico-legal dillemmas within general practice: moral indeterminacy and abstract morality. In: General Practice and Ethics, editor.

Dowrick and L. London: Routledge; Ladd RE. Patients without choices: the ethics of decision-making in emergency medicine.

Principles of Medical Ethics

J Emerg Med. Palliat Med. Factors influencing families' consent for donation of solid organs for transplantation. The study including the biostatistics methodology was also reviewed and approved by the health research and knowledge management sub-component of the KZN Department of Health. Approval was also obtained from the CEOs or medical managers of each of the randomly selected hospitals included in the study. Finally, written informed consent was obtained from each participant after full information disclosure prior to participation in the study.

Demographic characteristics of participating doctors are as shown in Table 1. There was a broad representation of all clinical specialties with participating doctors from all major clinical specialties Table 1. After a critical review of captured data a total of 19 participants were excluded due to ineligibility. Therefore a total of individuals were finally included in the study, comprising doctors, professional nurses and patients.

Here I report the results of doctor's responses to the questionnaires on the quality of informed consent. The cohort of participating doctors was then regrouped into 8 major clinical disciplines or specialities for further analysis Figure 1. The majority of doctors spent about 5 to 10 minutes providing information to patients prior to treatment decision Figure 2.

When asked whether the amount of time was sufficient, Those who thought the time spent was inadequate gave various reasons including language barriers and uneducated patients requiring more time for explanations. Others complained of time constraints, administrative responsibilities and large patient numbers being factors militating against spending more time explaining procedures in order to obtain valid informed consent from patients Table 3. While others explained that the time spent depends on the procedure. Some stated that the time spent was "definitely inadequate" with comments like "in an ideal world, patients [should be] counselled for at least 30 minutes with enough time for questions and clarifications".

When asked about what types of information was generally disclosed to patients prior to obtaining consent. The majority of doctors provided information on ' diagnosis ' About Only When doctors were asked whether they thought the amount of information provided to patients was sufficient for valid informed consent, When asked whether the current consent form used to obtain informed consent from patients is adequate, When asked to explain why the current universal consent forms used in public hospitals was inadequate, many doctors complained that the current form does not give opportunity to detail specific complications because different clinical conditions may require different mandatory disclosures.

Some suggested that the consent forms should contain tick-boxes for more detailed information disclosure. Others complained that the current form does not take into account "privacy, language and cultural values". Others complained that the form contains "no binding space that consent was given or alternatives discussed" or that it was "not specific to minors; when guardian details must be recorded". Others concluded that the current form has not "not kept up with current progress in medico-legal teaching". When asked what types of risks were disclosed to patients?

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Chi-squared tests were used to test for statistical significance on the types and nature of information disclosed to patients across different clinical specialties. All other categories of information disclosed were not statistically significant across different clinical specialties Table 2. When asked how patients normally provide consent for clinical procedures. About 6. Doctors who answered 'it depends' gave various reasons for obtaining consent using different formats.

Most stated that it depends on the type of procedure. Others said it depends if it is an 'emergency' or if the patient is unconscious or a minor. Some doctors said it depends if written consent is required by law. To examine the extent of patients understanding of informed disclosed by doctors, we asked questions about the language and methods used to obtain informed consent from patients. When communicating with patients, To enhance or facilitate understanding of information disclosed to patients, When doctors were asked if they think patients understood the information given to them; When asked whether they generally presumed that patients had the capacity to consent to treatment, When asked whether they routinely assessed a patient's capacity to give consent to treatment, When asked to rank methods used in assessing patients' capacity when confronted with difficult cases, When asked to specify what method they routinely used in assessing patients capacity when dealing with difficult cases, majority of doctors said they used a mini- mental status exam MMSE , followed by level of consciousness or orientation in time place and person, and the Glasgow coma scale GCS in difficult cases.

When doctors were asked whether they obtained consent in emergency cases, Doctors who answered 'it depends' gave various reasons for not obtaining consent in emergency cases, including level of consciousness or mental status of the patient, availability of parent or guardian to serve as surrogate.

Medical Ethics for Student Doctors

Others said if the patient was in a stable condition and able to comprehend, then they would obtain consent. Others said if patient is incapacitated, then proxy consent is obtained from the consultant or medical superintendent of the hospital. Others indicated that it depends on the procedure and whether it was a life threatening situation. To further explore whether doctors allowed their patients to exercise choice or act on their own free will during clinical encounters, doctors were asked about their understanding and use of implied and presumed consent in practice.

More doctors said they used implied consent in an emergency rather than in the than in the hospital wards or clinics Table 5.


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The issues surrounding voluntariness and consent to treatment will be evaluated further from the point of view of patients, when patients' data are analysed. Doctors were asked to rank a series of potential challenges experienced while obtaining informed consent in practice, on a seven point scale of , with 1 being most difficult and 7 as least difficult Table 3.


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The major challenges identified by doctors in this setting included 'language difficulties' , ranked highest by The least important constraints identified were 'cultural barriers' , by Cultural barriers identified by doctors included religious beliefs such as Jehovah's witnesses or cultural abhorrence of organ transplantation, amputations and blood transfusions.

The need to obtain approval from husbands or family members prior to giving consent, preference for traditional healers, cultural taboos, and 'disempowered caregivers' according to one respondent. A test of statistical significance using the Kruskal-Wallis test for independent variables, showed that the 'lack of administrative support e.

To test for general know of informed consent laws and regulations in South Africa, doctors were asked some specific questions. When asked to select the current age of consent to routine treatment in South Africa, only This question was answered wrongly by many doctors with Further, when asked to select the correct age when women can consent to termination of pregnancy TOP in accordance with South African law, only Majority gave the wrong answer with Chi-squared tests were used to test for statistical significance in terms of general knowledge of informed consent laws and regulations across all specialities.

There was no statistical significance detected in terms of age of consent, age for women to request for TOP, or standards of information disclosure.

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When asked whose responsibility it was to assure that adequate information was provided before informed consent, only When asked whether the current standards for information disclosure were based on a 'reasonable doctor' or 'prudent patient standard'. Most doctors, When asked whose duty it was to obtain consent from patients in practice, To compare informed consent practices across occupational ranks of doctors and nurses, as well as between clinical specialties.

I developed an aggregate score using a modified version of the method described by Sugarman and others [ 51 ]. While the previous authors used a series of seven questions derived from a brief informed consent evaluation protocol BICEP during research studies [ 51 ]. Here I have selected a series of questions from the questionnaire which relate to information disclosure, voluntariness, assessment of capacity and understanding or comprehension Table 6.

A total of twelve questions from the questionnaire were adjudged to satisfy these criteria. Each of the selected questions was given a rank score of one 1 and the aggregate score is the sum of the scores 12 Table 6. In this case anaesthetists and radiologists had the lowest ICAS scores with a median score of 7 and 8, respectively, while the highest scores were obtained by OBGYN, Internal medicine and GP doctors with a median score of Finally when the ICAS scores of doctors was compared with that of professional nurses. Scores by professional nurses was lower than that of doctors with a median score of 8, while the median score for doctors was Most studies evaluating the quality of informed consent especially in developing countries have focused on informed consent practices in clinical research.

These include previous studies from Nigeria [ 52 ], Uganda [ 53 ], South Africa [ 54 ] and Mali [ 55 ].