Consent to nursing care
In Quebec, like elsewhere in Canada, nursing consent is an inseparable notion from the debates surrounding healthcare. Consent is an ethical and legal principle. As a nurse, you have a duty to clearly explain to your patient their health status, the existing treatment options, as well as the associated benefits and risks. They can give or withhold their consent for the recommended care protocol.
Let's explore this essential principle together!
Free and Informed Consent
Nursing consent must be free, which means that the patient must not be subjected to any pressure to make their decision. It is their personal choice and it must be respected.
It must also be informed, which means that the patient or legal representative is fully informed of the risks, benefits, alternatives, and consequences of a medical intervention or treatment. They are therefore able to make an informed decision in full knowledge of the facts.
This implies providing the patient with factual and understandable information about their medical condition. Informed consent is a fundamental principle in nursing. It guarantees respect for the patient's autonomy and dignity, while promoting a thoughtful and joint decision between the patient and the healthcare professional.
Capacity to Consent
Understanding the Patient: A 4-Step Evaluation
The patient must be able to understand the information provided to make an informed decision. For this, the nurse must proceed with a 4-step evaluation:
The initial assessment of understanding, where the nurse explains the nature of the decision to be made in simple terms and verifies if everything is clear for the patient.
The assessment of reasoning capacity involves a discussion of the available options. The nurse estimates the patient's ability to weigh the pros and cons of the different options.
The ability to communicate is also assessed by verifying if the patient can clearly express their preferences and if their decisions are consistent with their values and goals.
Finally, the assessment of emotional stability and mental state is also crucial. It involves observing the patient's overall mental condition and the presence of any emotional distress or external pressure.
To ensure a rigorous evaluation, it is recommended to use standardized tools such as the Mini-Mental State Examination (MMSE), to document all stages of the evaluation in detail, and to consult other healthcare professionals in case of doubt.
The involvement of loved ones, while respecting the confidentiality of certain patient information related to medical confidentiality, and the knowledge of local laws on nursing consent are also essential. By following these steps and best practices, the nurse can systematically and ethically assess the patient's capacity to consent, ensuring that each decision is made in accordance with the law and the patient's rights.
If a Patient Refuses Care
If, after the evaluation, the patient is deemed capable of consenting but refuses care, the nurse must comply and respect the patient's choice.
In the Far North, one of our nurses shared an experience of refusal of care: "A patient needed medical treatment to treat an infected wound, but for several days she refused the proposed treatment plan. She and her family had consulted the community healer who recommended the application of poultices based on natural medicine instead.
It was a delicate situation, because we have to respect the wishes of the patients (in this specific case, she was capable of consenting) while following our code of ethics, which dictates that we must offer the best available treatment option.
The doctor and the head nurse discussed with the patient several times to ensure she understood her condition and the characteristics of the proposed treatment, without diminishing the importance of natural medicine. Everything was done with respect and non-judgment. The doctor, who speaks the community's language, was able to discuss with the patient and her family in their native language to answer their questions.
Ultimately, we reconciled modern and traditional medicine to respect her wishes while offering her the best possible care."
If a Patient is Not Capable of Consenting
In Quebec, when the patient is unable to give informed consent due to mental incapacity or other reasons, the nurse must first assess this incapacity in collaboration with other healthcare professionals and inform the responsible physician.
According to the OIIQ, if the patient is incapable of giving informed consent, a substitute consent must be sought. This may include a representative designated by the patient in a power of attorney or mandate in case of incapacity, or a guardian or curator appointed by the court. If none of these options are available, consent must be obtained from the next of kin, following a legal hierarchy: spouse, parents, children, etc.
It is also essential to maintain transparent and ongoing communication with the patient's family, explaining the situation and the decisions made. Finally, the nurse must regularly re-evaluate the patient's capacity to consent and adjust procedures accordingly, while ensuring that all actions taken are well documented and in compliance with provincial regulations and ethical standards.
Implied Consent
In certain emergency situations where it is not possible to obtain formal consent, implied consent may be presumed to safeguard life or prevent serious harm.
This generally occurs in medical emergency circumstances where the patient is in critical condition, if there is an inability to clearly communicate, or if their legal representative is not available.
Legally, in such situations, healthcare professionals may presume that the patient would have consented to necessary emergency medical treatment to save their life. Implied consent is based on the ethical principle of beneficence, which implies doing what is deemed to be in the paramount interest of the patient in urgent circumstances.
However, it is crucial to note that implied consent is limited to emergency situations where the delay in obtaining formal consent would endanger the patient's life or health. The nurse must carefully document the reasons for their decision, including the patient's incapacity to give explicit consent and the urgent nature of the life-threatening situation.
Care Order
If an adult refuses care, but appears to be making incoherent statements or is confused, for example, or if they do not seem able to do so in a free and informed manner, the nurse may resort to the Tribunal, which can issue a care order.
Before going to court, a doctor must evaluate the patient and write a report justifying the necessary treatment. At least five days before the hearing, the healthcare facility must send the patient, via a bailiff, a copy of the application, the medical report, and a document explaining their rights, including the right to a lawyer. If the report risks worsening the patient's health, it can be sent to another person designated by the court. If the patient is a minor, the facility must inform the parents or guardian.
If the patient is an adult and represented, the facility must inform the spouse, a close relative if the patient has no representative, or the Public Curator if no representative is available.
In court, the patient must be represented by a lawyer; if this is not the case and they are deemed incapable, an ex officio lawyer will be appointed. The nurse and their healthcare facility must prove that:
The patient cannot consent to care
They refuse care
This care is necessary and beneficial
The patient does not understand the nature of their illness, the treatment, and the associated risks.
Witnesses, such as other nurses or loved ones, may testify. The patient has the right to speak and call witnesses in their favor. The court then decides whether to authorize the care, specifying its nature and duration. The patient can appeal the decision within 5 days.
Nurses' Ethical Duties and Obligations
Obtaining free and informed nursing consent is one of the duties of nursing staff announced by the Ordre des infirmières et infirmiers du Québec. These ethical and professional rules are ethical and professional rules that nurses must follow in the practice of their profession. These include:
Assessing the physical and mental condition unless there is a refusal of evaluation
Reporting any potential incapacity to consent to the patient's care team
Creating a care plan adapted to the patient's wishes
Validating the categorical refusal in the case where a refusal is expressed by attempting to administer the care several times to ascertain its categorical nature
Establishing a relationship of trust, whether therapeutic or not, in order to provide care
Testifying in good faith at all stages of their work
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