Defining Autonomy
Ethics is a vital component of providing quality patient centered care. One of the most prominent ethical principles is autonomy. This concept is defined as “the right of patients to make decisions about their medical care without experiencing undue influence from their health care providers.”1
It is an idea that everyone should have self-governance over their healthcare. How does this apply to the prehospital care setting in which sometimes the lines are blurred between a patient’s wishes and what the standard of care is? An in-depth analysis can help caregivers to understand how autonomy applies in the prehospital care setting.
Capacity
To determine if a patient is able to make decisions about their care, they must first be deemed to have capacity. Capacity is the “ability to engage in authentic autonomous decision-making.”2 This concept implies the patient is of sound cognitive function to make decisions about their care. At the basic level, capacity is determined by the ability of an individual to answer person, place, time and event questions with accuracy at the time care is being rendered.
It should however be noted that some individuals may not be able to answer these questions dependent on specificity. For example, some patients may be unaware of the exact day of the week or date in terms of individual day in a month but rather are aware of exact month or year.
When there is an influence such as toxic effects of drugs or a neurological event patients may deviate from their baseline cognitive function this is when the provider needs to use judgement to determine what level of capacity a patient may still possess.
In some areas, there are legal courses of action to ensure a patient receives care in the event of an overdose regardless of capacity clearances.
Implied and Informed Consent
When a patient does not pass a capacity assessment their care may fall under implied consent. Just as when it can be inferred that an unresponsive patient would wish to receive interventions these patients fall into the same category.
Legal protections are offered to providers in most cases who provide care under implied consent scenarios. There is a notion that anyone of sane mind and decision-making capacity would wish for lifesaving care to be given when they are incapacitated.
To further elaborate upon this when a patient who does clear capacity agrees to receive care tests and interventions there may appear to be implied consent for these items, but this is not necessarily true. Informed consent is when a patient is educated prior to tests and procedures about associated benefits and risks.3
Then and only then is a patient truly capable of giving consent to their care. It is not uncommon for providers to forego explaining the risks of a treatment but rather explain risks of not receiving a treatment.
Advanced Directives
One of the many forms of autonomous decision making a patient may have prior to becoming incapacitated are legal documents known as advanced directives. These include DNRs, living wills. On paper these are great for patients and providers as they allow patients to have their wishes expressed when they themselves are not able to voice their wishes in the immediate moment.
A living will provides an outline of what care should be provided at the end of life. This may include only comfort measures, refusal of intubation or other treatment. In EMS terms this is a protocol for care of that specific patient. A DNR or do not resuscitate is very straight forward as its name implies no effort for resuscitation should be provided. This should not be confused with not treating a patient as the DNR is only enacted in the event of cardiac arrest.
Danger to Thyself or Others
Those who are suicidal or homicidal may be deemed to not have the ability to decide what care they receive within some limitations. A patient who is experiencing a behavioral health emergency can be mandated to receive transport and care at a facility and EMS professionals are legally obligated to transport these patients.
However, if a patient is not experiencing a medical or traumatic emergency, they still retain their right to refuse intervention and assessment such as vital signs. Without a court order or legal directive interventions only should be provided under instances in which there is an immediate risk to life such as with ingestion of a toxin.
Pediatric Patients
Our smallest patients or at least in some cases. Patients who are under the age of 18 possess capacity in many instances but still cannot make the final judgement about their care. There are a few special circumstances which fall outside of this rule.
Emancipated minors are a group typically found in their late teens who have full medical autonomy, as a result their parents are no longer responsible for their wellbeing. Another special consideration within the realm of pediatric autonomy is reproductive health. When a patient is seeking care for concerns such as pregnancy, sexually transmitted infection, or sexual assault they do not require parental consent for care to be rendered.
If the pediatric patient does not fall into these categories consent from a parent or guardian should be obtained. If a guardian is not present phone calls should be made, if possible, to contact someone who is able to provide consent for care. In some rare cases there may be an inability to contact someone to consent to a pediatrics’ care, in an emergency lifesaving treatment would fall under implied consent as a parent or guardian would likely consent to intervention to save the child’s life.
Family and Friends
There are two main legal documents discussed when someone close to the patient is allowed to make decisions of care for a patient who may pass a capacity assessment these being a Medical power of attorney (POA) and a guardianship.
“But this paper says I get to decide for my dad.” The power of attorney is an often-misunderstood document by families. Those caregivers who are listed as the POA tend to believe that their loved one is no longer in charge of their care, this simply is not the case. A power of attorney appoints an individual to act as a proxy to carry out a patient’s best interest in the event they are unable to do so.
It does not allow for forced care on an individual who has capacity to make decisions. A guardianship, however, does allow for the bypass of the patient to a health proxy for decisions of care. This provides an individual with someone who has the best interests of the patient in mind to make decisions on their behalf. More often than not these are provided for patients who have a mental deficit or are incapacitated.
Conclusion
Understanding when a patient is able to make decisions about their care is an ethical obligation of the prehospital provider. The vast majority of patients have the right to autonomous decision making in the medical setting with only a few caveats to this rule.
Maintaining an understanding of local, state, and federal law in conjunction with bioethical principles can guide the provider in determining what care if any is rendered for patients declining care.
- References
- Ubel, P. A., Scherr, K. A., & Fagerlin, A. (2018). Autonomy: What’s Shared Decision Making Have to Do With It?. The American journal of bioethics : AJOB, 18(2), W11–W12. https://doi.org/10.1080/15265161.2017.1409844
- Calcedo-Barba, A., Fructuoso, A., Martinez-Raga, J., Paz, S., Sánchez de Carmona, M., & Vicens, E. (2020). A meta-review of literature reviews assessing the capacity of patients with severe mental disorders to make decisions about their healthcare. BMC psychiatry, 20(1), 339. https://doi.org/10.1186/s12888-020-02756-0
- Aveyard H. (2002). Implied consent prior to nursing care procedures. Journal of advanced nursing, 39(2), 201–207. https://doi.org/10.1046/j.1365-2648.2002.02260.x
