Does Chuck have the capacity to give consent or refusal of consent?
Who should decide if Chuck was deemed to lack capacity?
- Chuck Bass (patient)
- Jenny (Registered Nurse)
- Healthcare team
- Zoya and Julien (twins of the patient)
- Serena (a close friend and neighbour of the patient)
2.1 Ethical principles (Beauchamp & Childress, 2019)
Autonomy– the right to have one’s wishes respected
Chuck is conscious and desires not to receive medical attention, although it is for his benefit. In collaboration with the care team, RN Jenny has to provide information about his health status, possible treatment, and the consequences of failure to get treatment to Chuck in a language that he understands and in a manner that makes it possible for him to understand considering his culture.
Beneficence– the best interests of the patient
Jenny and the care team discharging Chuck is likely to do more harm to himself and those close to him, especially his twin children Zoya and Julien and Serena, his closes friend. Since Chuck can gain optimal health and lead a healthy life through medication intervention, the care team should do everything necessary to receive the care.
Non-maleficence – to do the least amount of harm possible
Jenny and the team discharging Chuck is likely to do more harm to himself and those close to him, especially his Zoya and Julien, and Serena. Since Chuck can gain optimal health and lead a healthy life through medication intervention, the team should do everything necessary to receive the care.
Justice – the threefold duty of distributive justice, rights-based justice, and legal justice
Jenny and the team are responsible for providing quality care to Chuck irrespective of the nature of his medical care or demographic characteristics. She also has to ensure that the law is followed concerning the patient’s decision-making capacity. This will also ensure that lawful consent for treatment is gained.
2.2 ICN Code of Ethics for Nurses (revised, 2012)
E.1.1: ‘The nurse’s primary professional responsibility is to people requiring nursing care’.
Irrespective of the interest of other partners involved in the case, Jenny should prioritise the patient’s health with the team, thus doing what is best for him.
E.1.2: ‘… the nurse promotes an environment … the human rights, values, customs and spiritual beliefs … are respected’.
While Chuck’s ability to make medical decisions is significantly impaired, it will be respectful of his dignity to appoint a guardian or an attorney to evaluate the possible options and make the right decision in his best interests.
E.1.3: ‘The nurse ensures … accurate, sufficient and timely information in a culturally appropriate manner …’.
The team under Jenny’s leadership is responsible for informing the patient on the severity of his health condition and the possible outcome of the care provided. This will be instrumental in helping Chuck what is at stake and the best treatment and how lack of treatment will affect his health and wellbeing and that of those close to him. Besides, the team should explain all that is needed and be involved in the care plan in a language that he understands.
E.1.5: ‘The nurse … initiating and supporting…those of vulnerable populations.’.
Considering that Chuck is vulnerable as he cannot make the right decision based on the severity of his dementia, Jenny should support decision-making process that prioritize his care needs.
E.1.7: ‘The nurse demonstrates professional…’.
Jenny can show respectfulness to Chuck by basing their decision on his needs. She can demonstrate responsiveness, understanding, dependability, and integrity by designing and implementing a patient-centred care plan and taking responsibility for making decisions.
E.2.1: ‘The nurse carries personal responsibility and…’.
Jenny is responsible and accountable for ensuring that Chuck gets the best care to save his life and improve his health status.
E.2.6: ‘The nurse strives to foster and maintain…’.
Jenny and the team can retain practice culture by working within the law and nursing practices, maintaining open communication, and applying nursing ethics to improve patient safety and experience.
E.4.2: ‘The nurse … safeguard individuals … endangered by … any other person’.
Jenny should make the right decision to safeguard Zoya, Julien, and Serena from Chuck. Chuck has dementia that clouds his judgment and makes him see and feel things that are not real. If he is discharged without proper care, he is not the only danger to himself but also to his daughters and neighbours. Therefore, the final decision should be based on protecting him from himself and protecting those close to him.
According to the GAA s 11, an adult is presumed to have the capacity for a matter, and the PAA s 63 provides a detailed scheme to foster the exercise of power for financial matters and personal matters by or for an individual who needs or may need, another individual to exercise power. Thus, Chuck will be presumed to have capacity to make decisions unless shown to be incapable (McDonald & Then, 2019). He should understand the information provided to them, retain and weigh up the information provided to make the decision (Brightwater Care Group (Inc) v Rossiter). In Chuck’s case, he presents unable to make a comprehensive decision. Although he is conscious and the care team explains that medical intervention is imperative, he insists on going home to his penthouse apartment. Additionally, the severity of his dementia makes it impossible to understand the severity of his health condition. He has also been talking of friends who died a long time ago as alive and present, underlining the deterioration of his mental awareness and the capacity to make informed decisions. As per GAA s 146, a declaration of capacity of Chuck can be made in cases of doubt/disagreement by the Queensland Civil and Administrative Tribunal (QCAT).
According to GAA s 66, if an adult has an impaired capacity for health matters, the matter may only be dealt with if he had made an advance health directive. Otherwise, the matter may only be dealt with by the appointed guardian or guardians. However, suppose the tribunal has not appointed a guardian, and the patient does not have a document appointing an attorney. In that case, the matter may only be dealt with by the statutory attorney. Considering that Chuck does not have a prior health directive, or a document appointing a guardian, or the tribunal has not selected a guardian. The statutory attorney will only deal with the matter.
According to PAA s 63, a statutory attorney is an individual who is a spouse of an adult if the relationship between the adult and the spouse is close, and who may also be an individual over 18 years and who cares for the adult and should not be a paid care provider. This means the twins and the neighbour could be the substitute decision-makers depending on who provides the most care and other conditions.
3.1 NMBA code of conduct for nurses (2018)
P2.1.b – ‘provide leadership to ensure the delivery of safe and quality care …’.
Jenny should guarantee safe and quality care and understand their professional responsibility to protect Chuck.
P2.1.c – ‘document and report concerns …’.
Jenny should document and report concerns if they believe the practice environment compromises Chuck’s health and safety.
P.2.2.a. – ‘take a person-centred approach … supporting the person in a manner consistent with that person’s values and preferences’.
Jenny should support Chuck based on his preferences and values, and provide care based on his health needs, preferences, and values. This would, in turn, improve his experience, safety, and satisfaction with the care delivered.
P2.2.b. – ‘advocate on behalf of the person …’.
Jenny should intervene on Chuck’s behalf when the need arises and acknowledge when substitute decision-makers are necessary. Chuck’s desires should be respected and the family understands the reasoning behind taking a particular course of action, especially appointing a guardian.
P2.3.c&d – ‘act according to the person’s capacity for decision-making and consent …’.
Jenny and the team should work based on Chuck’s decision-making capacity and consent. Their behaviour and decision should reflect Chuck’s ability to understand the proposed care’s nature. Before beginning the care process and providing treatment, an informed consent should be obtained from Chuck or an appointed guardian.
P3.6.b – ‘… the person has the right to refuse treatment …’.
Jenny and the healthcare team must identify and evaluate if the continuation of treatment is in Chuck’s best interest, especially where he did not leave a directive or there is no guardian to help make the right decision. Jenny and the team need to evaluate if treating the patient is in his best interest and the overall effect of the care.
P3.6.e. – ‘… ensure support is provided to people, and their families …’.
Jenny should support the appointment of a guardian, although the decision might not be popular among all the parties. They should discuss the advantages and disadvantages of this decision to make them understand why it is important.
3.2 Options for Action
- Get QCAT or the Supreme Court to appoint a guardian to make an informed medical decision.
- Talk to the family and Serena about the importance of having a guardian decide on behalf of the patient, given their dilemma.
- Seek a counsellor, social support, and cultural support if the need arises.
- Discuss the situation with all parties involved to help the patient make
- an informed decision.
- Follow the decision and instructions of the appointed guardian.
- Advocate for Chuck to ensure that the family and Serena understand the reasoning behind following the guardian’s decision.
- Arrange for any counselling needed or social work for all the parties involved.
- Document the decision and all processes and procedures involved.
6. Assess Outcomes
- Evaluate decisions.
- Seek support if needed.
Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics, 8th edn, Oxford: Oxford University Press.
Brightwater Care Group (Inc) v Rossiter (2009) 40 WAR 84
GAA (Guardianship and Administration Act) 2000 (QLD)
ICN (International Council of Nurses). (2012), ICN Code of Ethics, Switzerland, accessed 19 August 2021, retrieved from https://www.icn.ch/sites/default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf
McDonald, F. J., & Then, S.-N. (2019). Ethics, law and health care: a guide for nurses and midwives, 2nd edn, London: Red Globe Press.
NMBA (Nursing and Midwifery Board of Australia). (2018). Code of Conduct for Nurses, Nursing and Midwifery Board of Australia, Melbourne, accessed 19 August 2021, retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards.aspx
PAA (Powers of Attorney Act) 1998 (QLD)