Nursing Ethics Issues in Patient Autonomy : Nurses take a solemn oath to save lives, but there may be times when their ability to perform that oath is caught in the crosshairs of a patient’s wishes.
Autonomy and respect for individuality are concepts that are deeply embedded in the fabric of Western society, from the U.S. Constitution to religions and moral standards.
However, the lines can sometimes be blurry, and nurses might need to exercise discretion to choose between multiple interpretations of autonomy and informed consent.
Sometimes, it’s as simple as a bilateral decision-making process involving the patient and nurses. However, on certain occasions, there’s really no clear delineation between these boundaries. Other instances call for strict adherence to laws and policies.
Here is a look at the moral and ethical issues surrounding patient autonomy and informed consent.
What is patient autonomy and informed consent?
Patient autonomy describes a patient’s universal right to make decisions about their treatment. However, in practice, that decision often depends on healthcare professionals and how they convey relevant information to the patient. Patients are often willing to trust their nurses’ advice, with widespread beliefs such as “it’s their job”, “they’re the expert”, or ”they know better.”
The principle of informed consent charges nurses to respect a patient’s autonomy and support their decision-making with all the relevant information and advice needed. Nurses are not supposed to impose a treatment plan on patients. Instead, they are obligated to provide them with all the information they need to decide on their own.
Sometimes, patients might regret their treatment decision because they underestimated how costly or painful it might be. However, in this situation, a nurse can take solace in the fact that they did their best to help a patient make the right decisions.
In other instances, a patient may completely lack the capacity to make decisions on their own, such as during health emergencies when the patient is unconscious or during mental health episodes. In such cases, patients are at the mercy of healthcare practitioners. To ensure the best possible outcome here, nurses need to take time to better understand the patient and respect their preferences and personal choices.
Key components of the informed consent process
The process of informed consent can be quite intricate. However, it gets less complicated when you work with a clear understanding of the key components that go into the mix of informed consent.
Assessing the patient’s mental capacity
While it’s important to be transparent and forthcoming with a patient, the first step in the informed consent process is establishing the status of the patient’s mental capacity. Can they handle the information you need to give them, and can they make health-conscious decisions independently?
You can answer all of this by physically examining the patient, asking them questions and considering the types of questions they ask.
Presenting relevant information accurately and understandably
Nurses must tell patients everything they need to know about their health condition. They need to explain their diagnosis in a way they understand, ensuring they fully comprehend the nature of their health problem and the possible causes of their symptoms.
When offering treatment plans, nurses need to go into detail about how the treatment works and any expected side effects or risks. Patients also need to be informed of alternative treatments and the pros and cons of an alternative course of action.
The patient’s right to decline a treatment
Nurses should be prepared for the possibility that a patient will refuse to follow their treatment recommendations. This is particularly common during health emergencies when patients have yet to come to terms with their health situation, or during pregnancy terms or labor when a woman refuses medical interventions that could potentially take them and their fetus out of harm’s way.
Informed consent for patient testing
Informed consent also applies to the testing phase; nurses should not collect specimen samples or subject patients to any form of tests without their express consent.
Just like with treatments, nurses need to explain the nature of a test to patients, informing them of possible risks (such as exposure to x-ray radiation), as well as the risks of not performing the test.
It can be quite challenging to explain the workings of tests to a patient’s understanding, especially complex and highly advanced test procedures, but nurses need to find ways to communicate the necessary information effectively.
Staying in compliance with existing laws
Nurse-patient interactions are guided by laws. It is the responsibility of nurses to learn about these rules and also educate patients about them, especially in cases where compliance could be in jeopardy. For example, testing might be mandatory for certain illnesses in certain places, such as in places with a COVID test mandate, and it is the duty of nurses to inform patients of the mandatory tests as well as the consequences of declining them.
Employing industry best practices
Nurses need to go beyond just policies and regulations when dealing with informed consent, making decisions that are ethically and morally sound. Sometimes, they need to go out of their way to break down complex medical information and feed it to patients in smaller chunks that they can understand and process over time. They’re also morally obliged to tailor the information and treatment recommendations to the preferences and desires of a patient.
Using decision aids
Decision aids are resources ranging from media materials to communication tactics used to help patients make better decisions about their treatment. They can be anything from pamphlets to online videos, educational materials and interactive content.
Decision aids have been empirically proven to improve patients’ outcomes, helping curb indecision or poor decisions. By supporting outcomes that are better aligned with a patient’s values, they can further enhance the prospects of patient satisfaction.
Informed consent document
The last component of informed consent processes is documentation. Everything needs to be well documented, from shared information to the patient’s decisions. The patient’s consent should be well documented and signed by the patient as part of their medical records.
Gray areas of informed consent
We mentioned earlier that nurses may need to take responsibility for decisions about a patient’s treatment when a patient lacks the mental capacity or surrogates to make those decisions for them. This can cause a moral dilemma for nurses, and it’s something they need to prepare for with mental fortitude and a strong sense of moral judgment.
Here are some key considerations for these gray zones:
The decisions of a nurse can mean the difference between life and death for patients in emergencies. Nurses need to navigate the fine line between presumed consent and make life-saving decisions for the patient in a timely manner.
There are often many intervening steps that must be taken before nurses can assume responsibility for a patient’s decisions, such as reaching out to the patient’s relatives or surrogates and referring to standard procedures for such emergencies.
In some cases, patients give out medical directives in advance, and these must be respected in emergencies.
Sometimes, nurses may have the prerogative to withhold medical information from a patient to prevent the risk of causing physiological or psychological harm. For example, they may choose not to inform a woman in a medically unstable condition that she has just suffered a miscarriage.
For ages, therapeutic privilege has been a contentious issue in the medical industry, and it can be abused and used in questionable practices. It’s considered ethically inappropriate due to the potential of it being used to manipulate medical outcomes for reasons other than the patient’s well-being.
However, it is sometimes in a nurse’s purview to moderate the amount of information fed to a patient at a time according to the patient’s ability to assimilate information, their preferred mode of learning and other personal considerations.
Consent under duress
In some cases, patients may come under some form of pressure to make certain medical decisions, and it is a nurse’s place to advise against it, especially if there are risks of health complications.
For example, if you suspect that a patient is opting to terminate a pregnancy out of pressure from her partner, it is morally justifiable to intervene in their relationship and try to talk her out of it in a one-on-one, heart-to-heart conversation.
Tips for navigating issues with patient autonomy
As a nurse, you’ll run across issues concerning patient autonomy on all fronts, from interviews to admissions, diagnosis, treatment and post-treatment care.
Informed consent is an integral part of the patient experience. It goes beyond just signing forms, and its delicate nature calls for a meticulous approach.
Most of the discussions concerning informed consent will take place between the patient and the physician, and nurses are usually just intermediaries relaying information between both sides. However, nurses are still responsible to some degree for compliance with morally and ethically sound best practices.
Here are tips to help nurses live up to their responsibilities:
Discuss autonomy from the outset
Use patient autonomy discussions to set the tone for the rest of your nurse-patient relationship. Let the patient know you acknowledge their full autonomy and make sure they’re aware of the facts related to their diagnosis, treatment options and the possible outcome of each course of action.
Repeat this process every step of the way, as long as there are new decisions to be made. You should also ensure that patients can assimilate and retain this information and make conscious decisions based on it.
Become the patient’s advocate
Autonomy means you have to respect a patient’s wishes, even if it might lead to their death. However, it’s still necessary to try your best to ensure the best outcome for them. That means advocating for them and helping facilitate processes that can bring about a safer outcome.
The process of informed consent goes beyond just signing a document and is heavily influenced by the quality of the nurse-patient relationship.
Programs like the CCNE accredited advanced nursing program from Walsh University trains students on evidence-based strategies for advocating on a patient’s behalf. It comes with an extensive clinical placement that exposes students to patient autonomy issues in a real-life setting under close supervision, helping them cultivate their critical thinking skills and sense of ethics and morality.
Keep an eye out for innovative practices
From time to time, new theories on how best to handle informed consent are being developed and tested. It has been suggested with clinical evidence that nurses should accommodate a patient’s wishes based on how the benefits weigh against the harm. For example, they can take a softer stance on a seemingly risky decision by the patient as long as there are sufficient reasons to conclude that it could lead to greater patient satisfaction and a better outcome.
Some innovative theories still have a long way to go before they are introduced into standard practice, but nurses need to keep abreast of every major development in the space.
Stay updated on regulations and policies
Informed consent is one of the most contentious issues in healthcare and one that captures the attention of policymakers across all levels. Nurses always need to be on the lookout for evolving informed consent laws, whether they are local, state, or federal regulations.
Laws in certain locations permit physicians to withhold specific information from patients during initial counseling, including substance addicts or abortion patients.
Regardless of the laws, nurses always have the ethical and moral obligation to openly discuss health and personal matters with the patient as long as it is likely to lead them to well-thought-out decisions.
Autonomy and informed consent are integral parts of nurse-patient relationships, affecting every stage of your interactions with patients. While most of the discussions on informed consent are between patients and their physicians, nurses still play a critical role in ensuring compliance with standard practice and helping patients make well-informed decisions.
Informed consent goes beyond just signing a written consent letter, influencing the therapeutic impact of a nurse-patient relationship.
In many cases, it can be a scary prospect to seek a patient’s consent for a treatment that is seemingly excruciating. However, it is the responsibility of the nurse to soothe nerves, allow calm heads to prevail, and help patients see the reasons a specific course of action might be best for them.