subject: Obtaining consent from an elderly patient with dementia and a head injury [print this page] Obtaining consent from an elderly patient with dementia and a head injury
In treating the elderly persons, a lot of factors should be put into consideration because unlike in the younger persons, and in this study younger persons mean persons under the age of sixty five, several interconnected mental and physical issues present themselves. It could even be more challenging when it comes to the treatment of the elderly who are demented. One of the requirements in cases requiring surgical operation is the agreement of the patient. In children, the agreement of the parent or the guardian is essential. Very often, doctors find themselves having to appeal to ethics in determining how to handle a particular case. When dealing with the elderly in particular, a lot of issues must be considered, mainly because age often comes with fragility, and predisposition to many diseases, both physical and psychological. The area of interest in this study is the case of an elderly patient who is presented to the Accident and Emergency Unit with head injuries; this elderly person is unfortunately demented. There are so many things that affect the way this person will be treated. Certainly with head injuries, surgery may be inevitable. How can the doctor obtain consent from this demented patient? Obviously someone has to sign for that surgery. So what are the ethical issues around this case?
Dementia and the Possibility of Consent
The significance of being able to agree to undergo certain medical procedures is perhaps not very clear to all. Contrary to what so many think, consenting to a certain procedure is not an instantial thing. It is something that proceeds. Whenever a doctor operates on someone, that person ought to have agreed to undergo that particular operation. Whether one is capable of deciding on a particular medical operation is dependent on the kind of issue at hand. It is not clear what criteria should be used in determining who is capable of making what decision. It is a requirement by law that before any kind of bodily touch takes place, whether in a doctor-patient encounter or whatever form of relationship, an agreement is reached. If this is not done, there is a possibility of one being sued for battery. In law, it does not matter whether a doctor was acting in the best interest of the patient. However this is not to say that the doctor neglects his responsibility and the requirement that care be exercised in whatever he does. How then may a doctor obtain consent from an injured elderly patient with dementia?
This issue sometimes presents serious challenges because it is possible to find a person who is not able to agree to some issues but is still able to agree validly to medical procedures. The question that the doctor should ask himself is whether the patient is capable of understanding what is involved, and whether they are capable of choosing between available alternatives. It is possible therefore to find a patient who has otherwise been declared incompetent but still remains in charge of his/her medical decisions.
In any given society, there are certain standards within which everyone is expected to act. The doctor is expected to act within certain norms that have become agreed to by everyone, and which anyone in their right mind would accept. The doctor knows what is best for the patient and is bound by the Natural Moral Law to do exactly that. The doctor is supposed to determine what is acceptable based on the existing standards, in carrying out whatever procedures on the demented person (Gauthier, 2000). This is often referred to as Hypothetical consent. However, what is morally acceptable in one place could be unacceptable in another. This means that there still is the possibility of the doctor being dragged into relativism. For instance, in some societies, it is acceptable that if the suffering becomes intolerable, and the patient wishes it, then it would be alright to end their life. In many societies however, this is still unacceptable. The doctor is also supposed to seek the opinion of his colleagues in order to ensure that whatever he does is what other doctors would have done if faced with the same situation. If he ignores the patient because that patient is not capable of informed decision, he may still be held accountable for his omissions.
The Legal Possibilities in Demented Patients
A patient could also have, in anticipation of mental incapacitation, appointed someone to act on their behalf in case of mental illness. The doctor should establish if this may have been the case. If it is this person should be contacted as soon as possible in order to consent to the medical procedures that the patient is supposed to undergo. The person who is appointed to act on behalf of the patient is required by law to be fit in order to act in that capacity. This means that he must fit in the legal and medial description of mental soundness. If in any case the person appointed by the patient is also incapacitated at the time when the patient is required to consent, the courts are supposed to determine who is to be charged with this responsibility. The doctor is supposed to check whether in any case the courts may have named a guardian. If a guardian is appointed, he/she is given all the right to information as the patient would have. The doctor is required in all circumstances to consult with the guardian. If this is found to be the case, the guardian must be found. It is important that the guardian be asked to supply the doctor with evidence that they are the ones appointed by the court. The guardian is expected to act with great integrity in matters relating to the patient. In case the patient is awake, the doctor ought to inform him about the procedures involved. However, there still arises the question of whether it would be right for the guardian to decide because he knows the patient, when they probably have no idea regarding the treatment? Even when consent has been obtained, the patient will finally be left on the hands of the surgeon, who will then be acting like the guardian of the patient's life.
Most of the elderly persons today are placed under the care of someone, a close relative or a nurse. Many are in care centers for the elderly. The persons responsible for the patient often carry very significant information regarding the patient, demented or otherwise, and this information should be carefully obtained (Katz and Hendrie, 1995). The same case applies when the patient is under the care of members of the family. The elderly person is at a very high risk because, most biological functions have already slowed down and most likely than not, majority of the elderly will be under some sort of medication (Agich, 1993). This means that when an elderly patient is taken to the hospital for whatever reason, the doctor must be more careful in whatever he does with this patient. The doctor should look for as many details as possible. Details like the period of the mental condition and the cause, if known, should be established. It is important not to leave anything unchecked. No assumptions should be made, like for instance ruling out possible suicide attempt simply because an elderly person is involved. In obtaining consent, the doctor is not just interested in consent, but valid consent. Obtaining as many details as possible would help the doctor to establish the possibility of the patient consenting but also provide the doctor with a starting point. The law requires that if someone agrees on behalf it be similar to the one that person would have agreed to if he/she was in their normal selves. The close relative would certainly know more about the elderly person. However, what happens when the patient, like in this case, is both demented and injured?
The Complicated Path
If the doctor decides to get details from the patient first, the patient will probably die, considering the fact that this patient is elderly, which means they are naturally frail, and probably have a list of other ailments that plague them apart from the head injury. The injury may not allow the doctor to take any time, because this is an emergency. Accepting all the procedures that will be carried out is not a very simple thing. It means that one is fully aware of what they are assenting to, meaning all the details of the procedure and the risks that would be assumed. Sometimes these medical procedures have lifelong consequences. It also means that the patient has been adequately informed about the full extent of the procedures. Clearly a demented person is not able to agree on the basis of knowledge. If the patient was just presented to a hospital without company, the norm is that the doctor tries to save the life of that patient first (Thienhaus, Rowe, and Woellert, 1998). The patient is likely to be unconscious and thus it would even be impossible to determine the mental condition of that patient. The doctor must assess, based on his knowledge and past experiences, what the exact nature of the injury is and decide on what would be the best course of action (Bell and Hall, 1977). In this case the doctor would just act in accordance with the Hippocratic Oath. He just ought to act with the best interest of the patient. In itself, the ability to decide what ought to be done to you is extremely critical. Many people see it as being very closely tied to the right of the human beings, and rightly so. In all of this, eventually, the manner in which the doctor reasons, the value he has regarding life, and his experiential standing are extremely important in the management of the demented person. As already mentioned earlier in this study, it is possible to find someone who is considered as falling short of mental capacity, but still being in a position to determine what is good for them medically. There are cases in the psychiatric wards where a patient is being rehabilitated for mental conditions, but the same patient is the one in control of his health decisions. This then means that the doctor who is presented with a patient with dementia will have to establish this possibility. As already earlier indicated, the most acceptable standards must be applied. However, unless guaranteed that the patient will be reprieved of suffering after the operation, the level of pain that may ensue from the surgery, not to mention the possibility of death, would be severe. The doctor may not be able to determine with certainty the outcome of the surgery because the patient is elderly, and as already mentioned, this includes the possibility of the patient taking several drugs at the same time. These may also interfere with the recovery process after the operation. Either way, the chances are that the patient will have complications resulting from the operation due to the slowing down of the biological clock. It is obvious that age matters in medical procedures, and it greatly influences the decision that the doctor is likely to make (Colenda, Greenwald, and Crossett, 1997). The doctor while trying to obtain consent must let the patient know of this reality, but at the same time try by all means at his/her disposal to not only increase the chance of life for the patient, but also the quality of that life. This is because the risk of death may be higher than in younger person, and this includes suffering. The duration that persons with dementia are likely to live is very difficult to determine. Sometimes during treatment, it becomes imperative that more advanced techniques be applied. This may present a great difficulty for the doctor, especially if the patient cannot say what their wishes were. Today with the increase in the levels of knowledge regarding consent, it has become very difficult to make decisions.
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