Obtaining Consent in Pre-Hospital Setting - Essay Example

 INTRODUCTION The mutual trust is the basis of relation between the health care professional and the patients. The patients have the right to decide whether they should undergo a treatment or not. The healthcare professionals should respect the autonomy of the patients. The consent of the patient is very essential for a normal clinical procedure. The person should be informed about a procedure, its methods and complications. This is very essential for avoiding the claim for negligence. The patients were not received much information about the therapeutic risks in the past and it created lots of issues regarding the consent. “By definition informed consent is voluntarily obtained from a competent patient who is aware of the alternatives, risks and benefits.” (Kuehl, A. 2002) The most important factor for legal acceptability of consent is that the patient must be able to understand and remember the information given to him. The patient must have the emotional capacity to understand the information given to him. The patient’s competence depends on various factors like age, educational status and the circumstances for obtaining the consent. So there arise lots of issues on informed consent. “The real enemy of proper informed consent in medicine is not the inability of adult patients to engage in the process. Rather it is insufficient resources to train clinicians to communicate more successfully with their patients and inadequate staff to allow enough available time for this essential communication to occur.” (Doyal, L.2002) LAWS RELATED TO CONSENT The public health law give some points regarding consent it include the following “1. Any person who is eighteen years of age or older, or is the parent of a child or has married, may give effective consent for medical, dental, health and hospital services for himself or herself, and the consent of no other person shall be necessary. 2. Any person who has been married or who has borne a child may give effective consent for medical, dental, health and hospital services for his or her child. 3. Any person who is pregnant may give effective consent for medical, dental, health and hospital services relating to prenatal care. 4. Medical, dental, health and hospital services may be rendered to persons of any age without the consent of a parent or legal guardian when, in the physician's judgment an emergency exists and the person is in immediate need of medical attention and an attempt to secure consent would result in delay of treatment which would increase the risk to the person's life or health. 5. Anyone who acts in good faith based on the representation by a person that he is eligible to consent pursuant to the terms of this section shall be deemed to have received effective consent”. (Wronski, E.G.1999) THE EXCEPTIONS FOR NORMAL CONSENT The exception for normal consent includes people who are in military service, in case of AIDS and other sexually transmitted disease. The Mental Hygiene law permits police officers to direct the removal of a person to a hospital in cases where he is likely to cause serious harm to himself or others. Any individual who is legally minor cannot give a valid informed consent to any sort of treatment and also he or she cannot legally refuse treatment. “Informed consent to participation in research is an important protector of potential subjects' rights and autonomy. Ethical research involving critically ill people is challenging because their medical condition often makes obtaining informed consent impossible. This is especially true in the prehospital setting, where additional barriers to obtaining informed consent exist. A recently published Canadian policy - Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans specifies circumstances under which an exception to the requirement for informed consent may be granted so that vulnerable individuals are not denied the potential benefits of participating in research.” (Thompson, J. 2003) The documentation of consent includes all subjective and objective findings and also objections or refusal by patient. “Patients have a moral and legal right to make decisions regarding their own health. Example – Patient refuses treatment such as oxygen, immobilization, etc, but wants to be transported.” (Los Angeles County, n.d.) The witness statement should be included and also contact medical control for assistance. The emergency medical service agencies work with local law enforcement agencies, hospital administrators, and community youth groups to develop procedures for emergency care. In case of an injury or accident the person is supervised by the law enforced personnel until the relatives are contacted. “The legal basis for consent for research in the incapacitated patient changed on 1st May 2004, when the Medicine for Human Use, Clinical Trials, Regulations 2004 came into force. The new law provides for a legal representative to give consent on behalf of a patient who cannot consent for themselves. A professional legal representative can consent on behalf of an incapacitated patient if no relative or friend is available. For research in emergency care and resuscitation this is obviously a necessity.” (Coats, T. J. & Shakur, H. 2006.) CONSENT IN PREHOSPITAL SETTINGS In case of injuries which do not require hospitalization it is the duty of emergency medical service agencies to decide on the custody of the person. There are certain protocols for treatment in prehospital settings. In case of minors the emergency medical service agency is responsible for the custody of the person until the adult guardian arrives. “The absolute right to refuse medical treatment, even if the reasons are irrational, is confined to competent adults. Children under 16 years can give legal consent to treatment in the absence of consent from those with parental responsibility. Children under 18 years do not, however, have an absolute right to consent, or refuse to consent, to treatment. The views of children assume increasing importance with age and maturity. Accident and emergency medical and nursing staff may face difficult decisions when children, or those with parental responsibility, refuse to consent to medical treatment.( Williams, L et al. 1997) Always act in the best interest of the person in emergency. “Patients in emergency situations with impaired consciousness are unable to give informed consent to participate in clinical trials. In this situation, some ethics committees ask that consent is obtained from a relative or a legal representative. Others however, waive the need for informed consent and allow the doctor in charge to take responsibility for entering such patients.” (Roberts, I. 2004) The study conducted in Sydney regarding the pain management by the paramedic working in the ambulance reveals some important issues. The paramedics were asked to seek the consent of the patients for management of pain. The paramedics ask the patient to rate the severity of the pain. They use a simple device to record the pain. It is a scale with one end marked as no pain and opposite end of the scale is marked with worst pain ever. “Performing emergency medical research in situations where patients are unable to give their own informed consent has long been a thorny issue. For example, a common problem is whether or not a patient in the middle of having an acute myocardial infarction can really weigh up the information in a few minutes and give properly informed consent for a trial of a thrombolytic.” (Coats, T. J. & Shakur, H. 2005) Giving the patient adequate analgesia is important challenge in pain management in prehospital environment. The formal assessment of the nature and severity of the pain is the main problem in prehospital settings. The problem is with quantifying and qualifying pain. Other factor affecting the management of pain are the individual belief, values and attitudes of the people relating to the use of analgesics. The paramedics should make an attempt to objectively assess the severity and quality of patient’s pain. Sometime in prehospital settings the unrecognized and under treated pain may be present. So there is need for effective analgesia, which can be achieved by following formal protocols and clinical practice guidelines. Prehospital research settings pose some challenges regarding obtaining informed consent. The older method of reading and signing the enrolment document of consent of research is a tough job today and usually the concerned physician will not be present at the time of enrolment. Usually consent is obtained through a proxy over radio or telephone after a brief oral description of the research. Prospective consent is a type obtained form patients who regularly visit the emergency medical service system like for asthma, haemophilia etc. ACHIEVING EVIDENCE BASED PRACTICE Almost every professional code hold the idea that it is of utmost importance to obtain the informed consent of the patients before treatment or care and also the procedure are to be made clear to the patients so that they could make an autonomous decision. The practitioners should provide the adequate information in an understanding manner to the patients. Essential time should be provided to do necessary discussion with others and take decision for giving consent. Informed consent can be given in various ways including verbally by cooperating. In a similar manner they can also withdraw their consent. With the development of concept of evidence based practice, the way in which informed consent is obtained is influenced by evidence based choice. “Muir Gray suggests that when appraising the best available evidence to provide patients with evidence based information the practitioner should calculate The probability that the patient will benefit The magnitude of any benefit The probability that the patient will suffer adverse effects of treatment The magnitude of any adverse effects” ( Hamer, S et al .2005) Patient information booklet should be made available in the form of patient leaflets in written information in order to include the strength of evidence in obtaining consent. Some physicians are of opinion that it is difficult to provide evidence based information to patients. But by giving evidence the views and decisions of patients get altered. The physician should have and obligation to incorporate evidence based information into their practice. Over the past few years the prehospital emergency medical care has undergone dramatic changes and new technology has been introduced. But still there are lots of ethical dilemmas in the prehospital care. The fundament ethical principles for prehospital care 1. principle of justice 2. principle of beneficence 3. respect for patient autonomy The law of each state varies considerably regarding the transport of dangerous patients. So the ethical theory should be universally applicable in prehospital emergency condition. The law always do not reflect the ethical behaviour. The emergency medical service should not take into consideration the income, social position or class of people. The emergency medical care service should priorities the cases. The people with serious illness are given priority and patients with minimal illness are transported later. But this allocation must not penalize a particular group unfairly. In circumstances which require intubations and cardiopulmonary resuscitation the emergency medical system in prehospital should develop a reliable mechanism. These must be recognizable and legally acceptable. “Once the consent process is underway, it is best conducted in a quiet location and under conditions that allow time for the subject or legally authorized representative to consider the pros and cons and review the materials. Some research, though, such as research in emergency and critical-care situations, makes that difficult, given the abrupt onset of illness/injury and the short period of time available in which care/interventions could be useful.” (Neff, M. J. 2008) The verbal requests given by the relatives cannot be accepted as a valid consent except in conditions where the relatives have the power of attorney for health care decisions. A study conducted on the feasibility of neuroprotective agents administration by prehospital personnel found that 81.3 % of stroke patients were able to give informed consent or they had some relatives who could give consent. “Informed consent is another very important consideration when discussing the feasible administration of drugs that are new, not widely used, and unfamiliar to the public and many practitioners. Often, family members will not arrive at the Emergency Department before many interventions are started or need to be started to improve patient outcome. These problems are decreased when family members are on scene with the patient and Emergency Medical Services can obtain consent.” (Crocco, T et al. 2003) CONCLUSION At the time of crisis it is not possible to have discussions so all the directives should be standardized. The patient may express preference and voice demand for intervention. This includes refusal of care or elements of care, transport without intervention etc. “Patient autonomy, beneficence, and justice are the fundamental ethical principles of an emergency medical service. Ethical conflicts are present in the daily practice of prehospital care. Emergency medical services must remain fair and equitable, equally available to those it is designed to serve, regardless of the patient's social or economic status". (NAEMSP, 1993) So there should be protocols and policies to deal with these circumstances. REFERENCES Coats, T. J. & Shakur, H. 2006. Consent in emergency research. Emergency Medicine Journal. BMJ. 23. p. 489-490. [Online] Available at: http://emj.bmj.com/cgi/content/extract/23/6/489 [accessed 19 Apr 2009] Coats, T. J. & Shakur, H. 2005. Consent in emergency research: new regulations. Emergency Medicine Journal. BMJ. 22. p. 683-685. [Online]Available at: http://emj.bmj.com/cgi/content/extract/22/10/683? [Accessed 21 Apr 2009] Crocco, T et al. 2003. Feasibility of Neuroprotective agent administration by Prehospital personnel in an urban setting. Stroke. 34. p. 1918-1922. [Online] Available at: http://stroke.ahajournals.org/cgi/content/full/34/8/1918 [Accessed 19 Apr 2009] Doyal, L.2002. Good clinical practice and informed consent are inseparable. Heart. PubMed Central [Online] 87(2), p. 103-105. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1766979 [Accessed 20 Apr 2009] Hamer, S et al 2005. Achieving evidence based practice: a Hand book for practioners 2nd Ed. China: Elsevier Health Sciences. Kuehl, A. 2002. Prehosptal system and medical oversight 3rd edition USA: Kendall/Hunt Los Angeles County, n.d. Prehospital code of Ethics. Ethics for EMS personnel Available at: http://www.emscourses.net/Forms%20and%20documents/New%20items/Ethics.pdf. [Accessed 21 Apr 2009] National Association of EMS Physicians, 1993. Ethical challenges in Emergency medical services. Available at: http://www.naemsp.org/documents/EthicalChallengesinEmergencyMedicalServices.pdf. [Accessed 22 Apr 2009] Neff, M. J. 2008. Informed consent: What is it? Who can give it? How do we improve it? Respir Care. 53 (10) p. 1337-1341. Available at: http://www.rtjournalonline.com/10.08.1337.pdf. [Accessed 22 Apr 2009] Roberts, I. 2004. Research in emergency situations: with or without relatives consent. Emergency medical journal. BMJ. 21. p. 703. [Online] Available at: http://emj.bmj.com/cgi/content/abstract/ [accessed 21 Apr 2009] Thompson, J. 2003. Ethical challenges of informed consent in prehospital research. CJEM. PubMed, 5 (2) p. 108-14. [Online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/17475101 [Accessed 19 Apr 2009] Williams, L et al. 1997. Consent to treatment by minors attending accident and emergency departments: guidelines. Journal of Accident and Emergency Medicine. BMJ 14. 286-289. Available at: http://emj.bmj.com/cgi/content/abstract/14/5/286? [Accessed 21 Apr 2009] Wronski, E.G.1999. Patient care and consent for minors. Bureau of EMS policy statement. New York. Available at: http://www.health.state.ny.us/nysdoh/ems/policy/99-09.htm [accessed 20 Apr 2009] Read More