You are on page 1of 42

Determine

Patient
Decision

Nurul Aida Fathya, dr., SpF

Laboratorium Ilmu Kedokteran


Forensik dan Medikolegal
FK Unjani
A Case of Apotemnophilia
›  Apotemnophilia = desire for amputation
(p. 285)

›  Mr.
A., 65 years old, wants to have a
healthy limb amputated

›  “I
am not happy with my present body, but
long for a peg-leg.”
Two Questions
›  Two questions:

›  Would
it be wrong for a surgeon to perform
the amputation?

›  Would you perform the amputation?


Objectives
›  Define competence and capacity

›  Discuss their ethical and legal significance

›  Consider how they apply in hard cases


Patients In Whom Decision-making
Capacity Comes Into Question
›  depression,
psychosis, dementia, stroke,
severe personality disorders,
developmental delay, comatose patients,
impaired attentional capacity (e.g. acute
pain) or general debility (e.g. metastatic
cancer).
Informed
Consent
Informed Consent
› Respect for Persons

“Informed consent for persons requires that


subjects, to the degree that they are capable,
be given the opportunity to choose what shall or
shall not happen to them. This opportunity is
provided when adequate standards for informed
consent are satisfied”.
Informed Consent

Informed consent is a
process, not just a
signed document.
The Idea of Informed Consent
›  Informed
consent adalah suatu proses yang
menunjukkan komunikasi yang efektif antara
dokter dengan pasien, dan bertemunya
pemikiran tentang apa yang akan dan apa
yang tidak akan dilakukan terhadap pasien.

›  Prinsip Informed Consent


›  Suatu proses
›  Bukan minta pasien menandatangani formulir
The Idea of Informed Consent
›  Informed
consent dilihat dari aspek
hukum bukanlah sebagai perjanjian
antara dua pihak, melainkan lebih ke
arah persetujuan sepihak atas layanan
yang ditawarkan pihak lain.
Definisi

›  Permenkes No 290/Menkes/Per/III/2008


›  Informed
consent = persetujuan tindakan
kedokteran (PTM)

›  Suatu
izin (consent) atau pernyataan setuju
dari pasien yang diberikan dengan bebas
dan rasional,sesudah mendapat informasi
dari dokter dan yang sudah dimengertinya
Syarat PTM
THRESHOLD ELEMENT
1.  Competence

INFORMATION ELEMENTS
1.  Disclosure of information
2.  Understanding of information

CONSENT ELEMENTS
1.  Voluntariness
2.  Authorization
Syarat PTM
Competence:
›  Kapasitas membuat keputusan
›  Lebih ke arah syarat dapat memberikan
consent daripada sekedar elemen
›  Pasal 13 permenkes no 290/menkes/per/III/
2008
›  Dewasa, >21 tahun
›  Sadar
AGE OF CONSENT
›  Diatas 18 tahun
full competence atau sudah menikah
›  12-17 tahun
proxy consent dan assent dari pasien
›  Dibawah 12 tahun
non competence
Syarat PTM
Disclosure:
Adekuat atau tidaknya ditentukan:
›  Tradisi praktek profesional
›  Kebutuhan informasi pada individu pasien
tersebut
›  Kebutuhan informasi bagi reasonable
person

Tak perlu disclosure:


Gawat darurat, tak kompeten, waiver
Syarat PTM
›  Understanding:
›  Dipengaruhi oleh:
›  Illness, irrationality, immaturity
›  Masalah:
›  NONACCEPTANCE : menolak informasi
sebagai suatu kebenaran
›  FALSE BELIEF: keyakinan yang salah atau
irrasional
›  BAHASA atau ISTILAH
Syarat PTM
›  Voluntariness:
›  Bebas dari tiupuan dan paksaan
›  Bebas dari ancaman untuk “dibiarkan”
›  Persuasi masih dibolehkan
Competency
&
Capacity
Definisi
›  Competency is a global assessment and
a legal determination made by a judge in
court. (refers to a LEGAL state)
›  Capacity, on the other hand, is a
functional assessment regarding a
particular decision. Capacity is not static,
and it can be performed by any clinician
familiar with the patient. (refers to a
MEDICAL state)
Capacity vs. Competence
›  Capacity refers to an ability
›  “having capacity”
›  Capacity comes in degrees
›  Capacity is specific to a particular decision
›  Capacity can change over time

›  Competence refers to a property or


characteristic a person possesses
›  “being competent”
›  Competence (relative to a particular decision)
is all or nothing.
Consent or Refuse?
›  schizophrenia
paranoid dengan multiple
delusi dari persecutory, somatic, tipe
grandiose, datang dalam keadaan
rupture ulcus peptic pada cavum
abdominal – suatu kondisi yang
memerlukan operasi life saving
Capacity is specific to a
particular decision
›  pasienyang menderita schizophrenia
mungkin cakap memberikan persetujuan
tindakan medik untuk terapi diabetesnya
tetapi tidak untuk terapi
schizophrenianya.
Competence & Competence
Defined
›  Capacity= the degree to which one is able
to understand the information relevant to a
treatment decision and appreciate the
reasonably foreseeable consequences of a
decision or lack of a decision.

›  Competence = being able to understand


information relevant to a treatment decision
and to appreciate the reasonably
foreseeable consequences of a decision or
lack of a decision.
Capacity components
›  Communication. The patient needs to be
able to express a treatment choice, and this
decision needs to be stable enough for the
treatment to be implemented.

›  Understanding.
The patient needs to recall
conversations about treatment, to make the
link between causal relationships, and to
process probabilities for outcomes. Problems
with memory, attention span, and intelligence
can affect one’s understanding.
Capacity components
›  Appreciation. The patient should be able to identify the
illness, treatment options, and likely outcomes as things that
will affect him or her directly. A lack of appreciation usually
stems from a denial based on intelligence (lack of a
capability to understand) or emotion, or a delusion that the
patient is not affected by this situation the same way and
will have a different outcome.

›  Rationalization or reasoning. The patient needs to be able


to weigh the risks and benefits of the treatment options
presented to come to a conclusion in keeping with their
goals and best interests, as defined by their personal set of
values. This often is affected in psychosis, depression,
anxiety, phobias, delirium, and dementia.3
Components of Capacity
Assessments
Tools
›  TheMini-Mental Status Examination
(MMSE) is a bedside test of a patient’s
cognitive function, with scores ranging
from 0 to 30.4 Although it wasn’t
developed for assessing decision-making
capacity, it has been compared with
expert evaluation for assessment of
capacity; the test performs reasonably
well
Tools
›  The MacArthur Competence Assessment Tools
for Treatment (MacCAT-T) is regarded as the
gold standard for capacity assessment aids. It
utilizes hospital chart review followed by a
semi-structured interview to address clinical
issues relevant to the patient being assessed;
it takes 15 to 20 minutes to complete
›  The test provides scores in each of the four
domains (choice, understanding,
appreciation, and reasoning) of capacity. It
has been validated in patients with dementia,
schizophrenia, and depression.
Tools
›  The Capacity to Consent to Treatment
Instrument (CCTI)
›  The Hopemont Capacity Assessment
Interview (HCAI)
Tools Comparison
Why does capacity matter?

›  Two kinds of reason

›  Moral
›  Legal
Moral Reason #1: The
Importance of Consent
›  Capable patients are, by definition, able
to give informed consent to treatment

›  The
importance of informed consent is
supported both by

›  The principle of autonomy – respect for persons


requires respecting their informed decisions

›  The principles of beneficence/non-maleficence –


generally, an informed patients is a good judge of
what broad sort of treatment is in his/her best interest
Moral Reason #2: Beneficence
Toward Incapable Patients
›  An assessment of capacity helps us figure out
what matters morally

›  In the case of an incapable patient, we no longer


have recourse to the principle of autonomy.

›  The principles of beneficence/non-maleficence


require that incapable people be protected from
making decisions that are harmful or that they
would not make if capable
Legal reasons
›  In
law, capable patients entitled to make
their own informed decisions

›  If patient incapable, physician must obtain


consent from designated substitute decision-
maker
›  Advance Health Care Directives Act (NL)

›  Presumption of capacity for adults

›  For minors, check provincial legislation on mature


minors (NB), child welfare act, etc.
Legal reasons
›  Sahnyasebuah perjanjian dalam KUHPer
pasal 1320:
›  Kesepakatan mereka yang mengikatkan
diri (KUHPerd. 28, 1312 dst.);
›  Kecakapan untuk membuat suatu
perikatan (KUHPerd. 1329 dst.);
›  Suatu pokok persoalan tertentu (KUHPerd.
1332 dst.);
›  Suatu sebab yang tidak terlarang
(KUHPerd. 1335 dst.).”
Legal reasons
›  KUHPer
Pasal 1330: Yang tak cakap untuk
membuat persetujuan adalah:
›  anak yang belum dewasa;
›  orang yang ditaruh di bawah
pengampuan;
›  dan pada umumnya semua orang yang
oleh undang-undang dilarang untuk
membuat persetujuan tertentu.
Who will
give the
consent?
Permenkes No 290 (2008)
› Persetujuan
oleh pasien atau
keluarga dekat atas dasar
penjelasan mengenai
tindakan medik untuk
tindakan kedokteran atau
kedokteran gigi terhadap
pasien tersebut
Proxy Consent
›  Adalah consent yang diberikan oleh orang yang
bukan si pasien itu sendiri, dengan syarat:
›  bahwa pasien tidak mampu memberikan consent
secara pribadi,
›  consent tersebut harus mendekati apa yang
sekiranya akan diberikan oleh pasien (bukan baik
buat orang banyak).
›  Umumnya urutan orang yang dapat memberikan
proxy consent adalah suami/istri, anak, orang tua,
saudara kandung, dst.
›  Proxy consent hanya boleh dilakukan dengan
pertimbangan yang matang dan ketat.
Advance Directive
›  a
legal document (as a living will) signed
by a competent person to provide
guidance for medical and health-care
decisions (as the termination of life
support or organ donation) in the event
the person becomes incompetent to
make such decisions

You might also like