At my first block of forth year I was at a general placement. For the first three weeks I spent my time in the surgical wards and for the last three weeks I spent my time in the medical wards. The surgical wards offered for conversation with patients and great interaction. The medical wards were the complete opposite. Many of the patients in the medical wards had suffered a stroke or had some sort of TBI resulting in their inability to speak, follow commands or acknowledge my presence. The lack of interaction was so unpleasant and I genuinely didn’t enjoy the time spent in those wards.
Besides my personal dislikes, I wasn’t able to gain verbal or written consent from most of my patients. When I queried my concern about not gaining consent, I was told that patients who are not viewed as capable of autonomy are placed into the hands of their doctor. The referral letter from their doctor is basically approved as consent to treat the patient. According to Appelbaum (2007), practitioners are required by law and medical ethics to gain informed consent from patients before treatment. Thus when patients lack the ability to provide informed consent, a substitute decision maker needs to be identified. With this being said, it is essential to distinguish between patients who are incapable of providing informed consent and protecting these patients. As well as acknowledging when patients do have the cognition for autonomy. The case of patients, who lack the ability to provide informed consent, should be taken to a court for further decision making. But this process would be a lengthily one and would cause a halt in the medical system and consequently, in the patients treatment. Thus, allowing practitioners to make decisions for the patient to be treated on behalf of the patient is seen as suitable.
According to the National Patients Right Charter (2007), every patient has the right to informed consent as well as the right to refusal of treatment. Thus, my concern still lies in the fact that the doctor and the patients family are not the patient. This concern came into play with a gentleman who had suffered a stroke. He deteriorated over a period of a week. When I first saw him with one of the comserves, we did not gain consent from him as he could not speak. In this session he was able to actively participate in treatment with guidance and facilitation. Perhaps if we had tried and placed more importance on gaining consent, we would’ve been able to. In the next session and the ones thereafter the patient could not interact or assist in treatment. Thus the treatment became passive. It was then nearly impossible to gain consent from the patient. The patient became very chesty and he was retaining secretions. Unable to clear, there was a need for him to be suctioned. He was reluctant and kept pulling away. He’s unaffected hand was restraint so that he could not pull at the suctioning tube. He would pull his head away and the only way I was able to get the suctioning tube down, was to hold his face in place. This felt wrong and I was reluctant to suction the patient. Looking for reasons such as an exceptionally dry throat or the fact that he was suctioned by the nurses to not have to perform the treatment myself.
I feel that my reluctance was unprofessional but I did not feel that forcing the patient to be suctioned was ethical. As important as it is to weigh out the pros and cons and how the need for suctioning and clearing secretions is more important than the discomfort of suctioning (said by the comserve on placement). It is as important, I feel, to have the patients consent especially if they are awake and not sedated or intubated. If the patient cannot give consent, is it considered ethical to force the patient into being suctioned because it will be beneficial for them, even life-saving? My patient was awake and alert. He was unable to communicate verbally or through writing. He was further unable to understand forms of communication through squeezing hands. There was no way for me to identify if he was okay or if he understood why I was sticking this pipe down his throat. I still have no idea if he understood my explanation or if he felt better by my reassurance. I understand that sometimes we as health care practitioners have to be hard and stick to our guns about what is needed for our patients treatment. But what about the patient? What about what he wanted? What about his rights?
Appelbaum, P. (2007). Assessment of Patients’ Competence to Consent to Treatment. New England Journal Of Medicine, 357(18), 1834-1840.