What is the model of physician focus care to patient centred care?
The triangle: Nurse & Physician (bottom of triangle points)
Patient is the centre of the triangle
Institution is the top point of the triangle
What is the meaning of “Autonomy”?
Auto = Self
Nomos = Rule
It means “I’m the boss of me”
Why is autonomy important?
- It shifts away from physician centred medicine (paternalism)
with its emphasize to limit paternalism with patient centred care - Legal reasons: respect the patient autonomy by asking for consent
- Respect for persons (deontological perspective): assume the patient is autonomous, which is the reason we respect the persons
What is paternalism ?
It means the physician is empowered to make decisions on behalf of the patient even if the patient is capable of making decisions for themselves
Presumption of Autonomy
Always assume I’m dealing with an autonomous patient unless proven otherwise
Mental illness causes patients to be autonomous and sometimes not autonomous, we need to be paternalistic sometimes
EX. when the patient is unconscious
3 Standards to identify an autonomous patient:
- They are at liberty (freedom)
- They are capable of effective deliberation
- They are capable of authenticity
They are at liberty (freedom)
Majority of the patients are NOT at liberty, especially with the MHA
They are capable of effective deliberation
- The patient can think about what’s happening
- Patients are free to make decisions you disagree with
- Patient decisions should reflect their own goals and desires, not what your goals are for them
- Because of the illness, patient’s lack effective deliberation
They are capable of authenticity
- Think of the decisions based on goals and desires
- The TR is necessary to allow the patient to be their authentic self and share their thoughts and goals truthfully and authentically
- Medication alters patient authenticity
Limited paternalism applies when:
- When it is an emergency and it is in the patient’s best interest
- When the patient is unconscious
- When a patient is high
- When a patient is a child (parents make decisions - ascent)
What is the age for a child to make health decisions ?
There is no age restriction in BC for a child to make health decisions
What happens when a patient does not meet autonomous criteria?
- Documentation
- Advanced Directives
- Psychiatric Advanced Directives
- Legal Proxy Decision Maker
What happens when none of the documentation is available?
- Speak with a social worker
- Speak with the ethics committee
- Speak with the case worker
- Speak with patient’s family* LAST because stress can influence the families input to the patient care
Documentation includes DNR:
DNR = Do not resuscitate, which refers to CPR
The survival rate is 12-20%
Advanced Directive (AD)
- It is a living will
- It is a set of instructions for the patient’s care that has no limitations on what it can say
- It is not always recognized by HC
Psychiatric Advanced Directive
- It is a set of instructions for patient’s care in case of psychiatric illness
- COMFORT PLAN: it allows the patient to be authentic, what makes them worse and what makes them better
The comfort plan; - Is more usable
- It is less legal
- The patient population is able to answer these questions
Legal Proxy Decision Maker
- Also known as a medical power of attorney
- It is a designated person that knows the decisions the patient wants regarding their care
- The power of attorney needs to be connected to the patient
Problems with patient autonomy include -
- The impact of the illness
- Conflict over treatment plans
- Poor health literacy
- Patient “noncompliance”
The impact of illness:
- You’re not the most “you” when sick with an illness
- Vulnerability leads to dependency
Conflict over treatment plans:
- There may be disagreement with the nurse, patient, patient’s family, and physician
- Use negotiation and compromise to solve disagreements
Poor health literacy:
- Jargon affects patient understanding of instructions
- There needs to be accessible language
- Patient needs clarification on their options*
Patient “noncompliance”
- This is a warning the patient is difficult
- This word is judgmental and changes the treatment and the way we have a TR with this patient
- Change it to say: “patient has chosen not to adhere to their treatment plan” because this identifies the patient made a choice and it shows the patient found reasons not to adhere to their plan because…. (their personal reasons)
*Understand when patient tells you what’s wrong
Voluntary Informed Choice = “Informed Consent”
- The patient needs to volunteer
- Consent means to agree, CHOICE means you decide yes or no
- HCP needs to provide enough information to have the patient decide yes or no, not just enough information to agree*
- The information given is enough to expect the patient to make the decision, but not enough information to scare them from making the right decision
What is the reasonable person?
The patient is given information at a grade 8 level of reading who is an ordinary person
We do not meet the reasonable person standard because we have additional knowledge that the average person does not have*
