++
KEY POINTS
Treat patients and families with the grace and consideration you would want for your family.
Anesthesiologists are obligated to “own” the advancement and advocacy of all things anesthesiology.
The goal of informed consent is to meet the patient’s needs as the patient defines them. This may include providing reassurance, titrating disclosure, and following the patient’s lead regarding participation in decision-making.
Competent patients have a virtually unlimited right to refuse potentially life-sustaining medical treatment. “Potentially” is used to emphasize the uncertainty that a treatment will be life sustaining.
Patients with limited decision-making capacity should participate in decision-making to the extent their capacity permits.
The risk of liability for honoring properly documented limitation on potentially life-sustaining medical therapy is no more than the risk of not honoring it.
Patients opting for goal-directed perioperative do not resuscitate (DNR) orders usually choose to authorize temporary therapeutic interventions to manage easily reversible events.
Physician Orders for Life-Sustaining Treatment (POLST) are medical orders valid across health care sites that comprehensively document the patient’s preferred end-of-life care.
Clinicians face conflicts of interest in daily practice from production pressure, interactions with industry, and safety and quality care initiatives. Clinicians need to recognize potential conflicts, characterize the potential severity of the conflict, and determine the likelihood and resultant harm of the influence or the appearance of influence.
The discipline of medical ethics provides expertise in recognizing, analyzing, and managing ethical dilemmas.
+++
PATIENT-CLINICIAN RELATIONSHIP
++
The goal of informed consent is to meet the patient’s needs as the patient defines them.1,2 This may include providing reassurance, titrating disclosure, and following the patient’s lead regarding participation in decision-making.3 Most of the time, patients want sufficient information to make substantially autonomous informed decisions. “Substantially” emphasizes that the realistic goal for consent is to sufficiently, as compared to fully, inform the patient.
+++
COMPONENTS OF INFORMED CONSENT
+++
Decision-Making Capacity
++
Patients have decision-making capacity when they are capable of making a specific decision at a specific time. Patients show capacity by understanding proposed treatments, alternatives, and consequences of proceeding or not proceeding and have the ability to express a preference based on rational, internally consistent reasoning. Decision-making capacity is different from competency. The bedside clinician determines decision-making capacity for a specific decision, whereas competency is a legal determination of the global abilities required to provide legal and other authorizations.4 Adults are presumed competent.
++
Clinicians should pay attention to the decision-making capacity of patients with temporary or more permanent limitations in decision-making capacity.5 Patients with more permanent limitations in decision-making capacity should be encouraged to participate in decision-making to the extent of their abilities. Sedated patients with temporarily limited decision-making capacity should be assessed for decision-making capacity with regard to the specific decision. Decisions with riskier consequences require more comprehensive decision-making capacity. In patients with ...