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Consent: A process in practise Kate Weston Professional Nursing Advisor Acknowledgements: Cathy Gilmore PNA Karen Rose Legal Adviser www.nzno.org.nz
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Nursing Council
www.nursingcouncil.org.nz
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Competency
RN Domain two – management of care EN Domain two – provision of nursing care These competencies address the issues regarding assessment and documentation www.nzno.org.nz
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Code of Conduct “The Code of Conduct for Nurses, together with the competencies for nursing scopes of practice and other Council guidelines, provide a framework for safe and responsible nursing practice that protects public safety”
Nursing Council July 2012
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PRINCIPLE 1 Respect the dignity and individuality of health consumers.
PRINCIPLE 2 Respect the cultural needs and values of health consumers. www.nzno.org.nz
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PRINCIPLE 3 Work in partnership with health consumers to promote and protect their well-being.
PRINCIPLE 4 Maintain health consumer trust by providing safe and competent care. www.nzno.org.nz
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Standards 3.1 Explain and share information with health consumers that they want and/or need Give health consumers information that is honest and accurate in a way they can understand and invite questions
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Standards 3.5 Where a health consumer is not competent to make an informed choice and give informed consent, you must ensure the care you give is in the best interests of the health consumer and that you have taken reasonable steps to ascertain their views www.nzno.org.nz
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PRINCIPLE 5 Respect health consumers’ privacy and confidentiality.
PRINCIPLE 6 Work respectfully with colleagues to best meet health consumers’ needs. www.nzno.org.nz
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PRINCIPLE 7 Act with integrity to justify health consumers’ trust.
PRINCIPLE 8 Maintain public trust and confidence in the nursing profession. www.nzno.org.nz
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Code of Rights
5 – the right to effective communication
6 – the right to be fully informed
7 – the right to make an informed choice and give informed consent www.nzno.org.nz
Code of Rights
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By law, all providers must comply with the rights set out in the Code of Rights when providing health and disability services I Reuvecamp Buddle Findlay 2011
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Barriers to understanding
Language Age Competence Disability Stress!
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Nurse Accountability / Liability Increasing levels of accountability: HPCA Act 2003 – legislation to protect the public HDC Code of Health & Disability Services Consumers Rights General increase in litigiousness in Society increased expectations , not only in health.
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Nurse Accountability/Liability Nurses and Midwives can be held accountable
Regulatory Authority – Nursing Council/ Midwifery Council Health Practitioners Disciplinary Tribunal
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External review
HDC – breaches of the code of rights ACC – investigation of treatment injury Coroner – sudden/unexpected/violent deaths Can be prosecuted by police under the Crimes Act
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External review
Investigation can be undertaken by ACC if an event is deemed a sentinel event –
an event during care/treatment that has resulted in an unanticipated death or major permanent loss of function not related to the natural course of the consumer’s illness or underlying condition.
If harm has occurred and can be attributed to a specific health practitioner then the ACC must report to the appropriate regulating authority for investigation
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Health and Disability Commission
Complaints by patient’s family regarding treatment to patient Investigation includes statements from health professional Professional/clinical practice screened by impartial expert Findings made based on evidence HDC can advise DoP and regulatory Authority (NC/MC) www.nzno.org.nz
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Nursing Council
Competence Reviews Registration Committee Health Committee Professional Conduct Committee
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Nursing Council Competence Reviews
Required standard of competence is “the standard of competence reasonably to be expected of a health practitioner practising within the Health Practitioner’s scope of practice” Concerns arising due to:
Medication issues Communication and Delegation Documentation Planning www.nzno.org.nz
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Professional Conduct Committee
Deals with complaints and discipline Determines whether conduct in question amounts to Professional Misconduct Makes recommendation to Council Two Stage Test:
Firstly, whether or not there is sufficient evidence to support the allegations If so, whether the allegations reach the threshold of seriousness to frame a charge of professional misconduct. www.nzno.org.nz
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Professional Misconduct s100
Any act or omission that amounts to malpractice or negligence in relation to scope of practice Any act or omission, likely to bring discredit to the profession Convicted of an offence that reflects adversely on fitness to practise Practised while not holding a current practising certificate Performed a health service outside scope of practise Failed to observe conditions included in scope of practice www.nzno.org.nz
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Informed consent occurs when someone who is competent to make a decision has sufficient information about a proposed treatment or procedure to allow them to evaluate the options without pressure and to agree or not agree to that treatment or procedure being carried out. www.nzno.org.nz
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Consent law
Consent law in New Zealand is consumer centred
There is a statutory right for all consumers to make an informed choice and give informed consent
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Informed Consent
Consent is not a single act, but a process involving communication between the consumer and practitioner in which the practitioner openly and honestly provides full information in an environment, and in a manner, in which the consumer can understand it.
The right to consent carries with it the right to refuse and the right to withdraw consent.
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Essential elements of informed consent Freed to care Proud to nurse
A competent person Making a voluntary choice About information communicated effectively Which is sufficient to make an informed decision
I Reuvecamp Buddle Findlay 2011
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The Risk Issues in Relation to Consumer Rights Rights
Issues
Treated with respect
Attitude of Staff Privacy Take account of needs, values and beliefs
Freedom from discrimination, coercion, harassment and exploitation
Attitude of Staff Time Informed consent process
Services provided in manner that respects dignity and independence
Attitude/manner of staff Systems Policies Environment Equipment
Service of appropriate standard
Care and skill Staff knowledge and compliance with legal, professional, ethical and other standards Minimise harm, optimise QoL HCT cooperation → quality and continuity
Effective communication
Information - form, language and manner to be understood Environment for open, honest and effective communication: staff attitude, privacy, www.nzno.org.nz interpreter, time
Freed to care The Risk Issues in Relation to Proud to nurse Consumer Rights Rights
Issues
Fully informed
Explanation Options Estimate time service provided Teach & Research Results of tests Results of procedures Information to make choice Honest and accurate answers Written summary
Make informed choice & give informed consent
Competence Advance directive Written consent Refuse/Withdraw Express preference Body parts
Support
Support persons present Safety Others rights
Teaching & Research
Consent
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to care The Risk Issues in Freed Relation to Proud to nurse Consumer Rights Rights
Issues
Make complaint
Where Process Resolution
Other rights
Human rights and freedoms Not deprived of life Not subjected to torture or cruel treatment Not subjected to medical or scientific experimentation May refuse to undergo medical treatment
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Managing / Minimising the Risk Focus
Approaches
Guidelines
Policy, procedure expectations Education about expectations, systems & resources Reinforce professional standards, ethics Processes to deal with consumer staffing preference Process for dealing with refusal/withdrawal of services
Environment
Safe Privacy Equipment → independence, QoL
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Managing / Minimising the Risk Focus
Approaches
Resourcing
Information sheets Expertise Skills mix Education Cultural resources Acc reports Risk Manager - defuse Consumer access to Advocacy Services
Monitoring
Audit Incident follow-up Complaints ACC Claims Teaching & research activities www.nzno.org.nz
Health & Disability Consumers’ Code of Rights – Right 7 Freed to care Proud to nurse
Services can only be provided to a consumer who makes an informed choice and gives informed consent. Every consumer must be presumed competent unless there are reasonable grounds for presuming they are not competent. When a client has diminished competence then they still retain the right to make decisions to the extent of their competence. www.nzno.org.nz
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The Code is Essentially about Good Practice www.nzno.org.nz
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Good Practice is rarely complained about www.nzno.org.nz
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Has the practitioner done all that is practicable with reasonable care and skill
? www.nzno.org.nz
Giving Treatment without Consent Freed to care Proud to nurse
Emergency Treatment Clause 3 Code of Rights
Expectation that only treatment necessary to save life will be provided; everything else should be deferred until consent can be obtained.
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The practitioner who is undertaking to do the procedure should be the one who obtains consent
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Your role:
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Check understanding Does the patient know the potential side effects and what to do if any occur? Be honest if you cannot answer their question refer to the health professional who can provide further information - do not be pressured by time constraints Document your discussions
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Watchpoint Written
consent does not necessarily mean informed consent has been gained www.nzno.org.nz
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Children’s Consent
The HDC Code of Rights has a presumption that all consumers, including children are competent to make an informed consent UNLESS there are reasonable grounds for believing otherwise – Right 7 (2)
The code therefore operates that there is no age of consent, it is determined by the functional level of competency or understanding
The code is subject to all other laws – right 7(1) and clause 8
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Right for Child to refuse
The Code and the Bill of Rights provides that everyone has the right to refuse treatment – so the starting presumption is YES.
The child has the right to an informed decision generally if appropriately informed and supported a child will not refuse
Usually when the issue comes before the Courts the treatment is usually allowed on the basis that the child is not competent or it is in their best interests www.nzno.org.nz
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Right for Child to Refuse
How to determine competence – a 3 stage test has been set in English courts; a child is competent to consent if they:
Can comprehend and retain necessary information about the procedure / treatment
Are able to understand what is being asked
Able to weigh the information, balancing risks and needs and so arrive at a choice
Equally important is an ability to communicate a choice www.nzno.org.nz
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Examples
MeNZ B ™ and HPV campaigns Sexual health issues for young people under age 16
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PPPR Act
The Protection of Personal and Property Rights Act 1988 (3PR Act) is described as an Act to provide for the protection and promotion of the personal and property rights of persons who are not fully able to manage their own affairs or able to communicate their wishes. www.nzno.org.nz
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PPPR Act
The act can apply to a wide range of people, including people: - Who are mentally ill - With an intellectual disability - Who have severe head injuries - Who are elderly and have become mentally incapacitated www.nzno.org.nz
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Enduring Power of Attorney
There are two types of EPOA – one for personal care and one for money and property. Independent legal advice should be sought before creating an EPOA. The EPOA should be someone trusted who has the “donors” best interests at heart. www.nzno.org.nz
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Being someone’s next of kin does not give you any specific rights when that person is alive Need to have EPoA or have been appointed a Welfare Guardian www.nzno.org.nz
EPOA
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Welfare Guardians or individuals who have been granted an Enduring Power of Attorney (EPOA) for personal care and welfare matters under the Protection of Personal and Property Rights Act 1988 are excluded from being able to refuse
life-saving measures for the person in their care. For example, they cannot sign a “Do not resuscitate” order on behalf of the patient. However, their knowledge of the patient’s prior preferences could still be very influential in a resuscitation decision.
ASMS publication 2011
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Advanced directives
Patients have the right to use an Advance Directive, which is defined in the Code of Health and Disability Services Consumers' Rights as "a written or oral directive - a) By which a consumer makes a choice about a possible future health care procedure; and b) That is intended to be effective only when he or she is not competent". www.nzno.org.nz
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Advance decisions regarding CPR By a consumer – Advance Directive - Individual autonomy
By Doctor – Do Not Resuscitate Order - in the course of treatment planning Should ideally be after discussion with patient and family
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Emergency situations
In an emergency, treatment can be given without obtaining consent
Must be necessary to preserve life, health and well being and be in the best interests of a person
However...
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...The treatment
Must not be contrary to the known wishes of a competent person Must not be inconsistent with a valid Advance Directive given by a person Must be no more than what a reasonable person would expect to receive in all the circumstances I Reuvecamp Buddle Findlay 2011
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DNR
Resuscitation Orders are known by various names (such as “Do Not Resuscitate” – DNR – directives). They are prepared in advance to assist health professionals who must make urgent decisions about an unconscious patient with cardio-respiratory collapse.
Resuscitation orders: an overview of issues in New Zealand The Specialist: Issue 89 -December 2011
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HDC case 07HDC 11318
Mr A was admitted to the private hospital for gastric bypass surgery. However, abnormal liver function blood tests (increasing the risks of surgery) were not noticed until immediately prior to surgery, by which time Mr A had been anaesthetised. Dr E decided to operate without advising Mr A of the increased risks, which Dr E subsequently estimated increased the risk of death fivefold. www.nzno.org.nz
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HDC case 07HDC 11318 “the test is not what other reasonable surgeons would do, but rather what a reasonable patient, in the particular patients’ circumstances, would expect to be told”
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Documentation
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Lets set the scene..
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Changing environment
The aging population Patients with multiple co-morbidities Issues associated with poverty Rural isolation Presenting late to hospital, discharged quickly Higher acuity than in the past Increase in unregulated health workers
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Changing consumer attitude
Negative impact from media coverage More aware of their rights and more inclined to assert these Computer literate – may have “researched” their own or family member’s condition English increasingly a second language
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Documentation No matter how skilled a nurse you are, poor nursing documentation will undermine your credibility. If you are ever involved in an investigation, everything that you have or have not stated in your notes, that you have or have not done, will be scrutinized and judged.
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Group Excercise:
Who routinely sees your notes?
Who might see them if there is an incident?
Who might see them if there is a serious or sentinel event?
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Freed to care Proud to nurse Documentation is important because:
Ensures the patient is getting the appropriate care It protects you if your care of the patient is challenged Most investigations of a nurses’ care is usually 1-2 years after the actual event. The only way to prove that you gave adequate care to a patient is documentation
of EVERYTHING you do for them. www.nzno.org.nz
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Documentation No matter how skilled a nurse you are, poor nursing documentation will undermine your credibility. If you are ever involved in an investigation, everything that you have or have not stated in your notes, that you have or have not done, will be scrutinized and judged.
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It might not be about you... It might be about the team!
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All documentation
Timely Accurate Objective Complete Signed/dated Have a unique patient identifier on each page
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Common errors
Care plan currency Critical data in the progress notes is lost Response to treatment is not noted Professional judgement, nursing action is not apparent
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EARLY WARNING SCORES!
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SBARR: The basics
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Situation: The problem
1.
What is going on with the patient?
Background: Brief, related, to the point
2.
What is the clinical background or context?
Assessment: What you found/think
3.
What do I think the problem is?
Recommendation: What you want
4.
What would I do to correct it?
Response: acknowledgement of information given
5.
What is the receivers response?
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SOAP(IE)
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Subjective – what is the patient telling you Objective – what are the observations you have made - eg about the wound, recordings
Assessment – Planning Intervention Evaluation
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Communication
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Effective and timely communication within the wider team is CRUCIAL Minimize use of abbreviations so that the is a clear, shared understanding – we all have our own discipline specific language !
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Communicate
Communicate
Communicate
Communicate
Communicate
Communicate www.nzno.org.nz
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If you are involved in an investigation
Report accurately – objectively Seek professional support promptly indemnity insurance is so important – you can rely on legal and professional support
NZNO members 0800 28 38 48
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Any Questions?
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Useful links
www.nursingcouncil.org.nz
www.nzno.org.nz
www.moh.govt.nz
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Useful links
http://www.communitylaw.org.nz/com munity-law-manual/chapter-17protection-of-personal-and-propertyrights/power-of-attorney/#c5278
http://www.nzma.org.nz/patientsguide/advance-directive www.nzno.org.nz
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Useful links
http://www.hdc.org.nz/publications/res ources-to-order/leaflets-and-postersfor-download/advance-directives-inmental-health-care-and-treatment(leaflet)
http://www.hdc.org.nz/ www.nzno.org.nz
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http://www.hdc.org.nz/education/prese ntations/informed-consent-in-the-codeof-health-and-disability-servicesconsumers'-rights
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