ABSTRACT
Background: The relationship between patients and health professionals emphasizes deliberation and joint decision making, that derives in the informed consent. Aim: To evaluate decision making of patients in health care and to identify the notion of capacity for decision making, according to lawyers and physicians. Material and methods: A semi-structured interview about procedures to assess decision making capacity was applied to 27 selected physicians and lawyers, considering their experience in this area. A qualitative analysis of answers was performed. Results: Several differences were observed between physicians and lawyers, probably originated in their respective disciplines as well as the context of their professional practice. For physicians the notion of capacity is associated to comprehension of the information, it is not absolute, and it must consider the intellectual maturity of the teenager and the autonomy of the elderly. This evaluation is frequently performed in the clinical interview and standardized protocols do not exist. For lawyers, capacity is established by age and is associated to rights and obligations, as determined by law. When it is assessed by experts, including physicians, it becomes evidence. These professionals assume that experts will use standardized assessment instruments. Capacity has significance in the legal system. Conclusions: Since there are substantial consequences when a person is deemed incompetent, it is necessary to distinguish between health capacity and legal capacity, and to ¡ink the informed consent with the fundamental rights of citizens, such as taking decisions about our own health.
Subject(s)
Adolescent , Adult , Aged , Child , Humans , Middle Aged , Decision Making , Informed Consent , Lawyers , Mental Competency , Physicians , Professional Practice , Age Factors , Chile , Comprehension , Human Rights , Interviews as Topic , Qualitative Research , Social ResponsibilityABSTRACT
The decision making capacity of patients will acquire special relevance with the introduction of informed consent in clinical practice and the new normative that will appear in the future when the bills about health services are approved in the Congress. This paper reviews the concept of decision making capacity in the context of health care and its legal background in Chile. The main problems that arise from the comprehension, use and assessment of decision making capacity, are analyzed. The assessment of this capacity is, in most cases, subjective since there are no criteria, protocols or standards to be used. In courts of justice, the exercise capacity assessment is requested to experts. These specilized physicians will evaluate the mental health of the subject and its implications in the capacity to make decisions. In practice, it is difficult to integrate the concept of capacity from the law or health care perspective. It is concluded that the elaboration of criteria, standards and procedures to evaluate the decision capacity of patients, is mandatory.
Subject(s)
Humans , Delivery of Health Care , Mental Competency , Informed Consent , Patient Participation , Decision Making , Chile , Mental Competency/legislation & jurisprudence , Informed Consent/legislation & jurisprudence , Expert Testimony , Ethics, MedicalABSTRACT
La limitación del esfuerzo terapéutico es una de las decisiones más complejas que se ha de tomar en la atención de los enfermos. Caso clínico: Laura, es una niña prematura de 25 semanas que durante su hospitalización en cuidado intensivo neonatal recibe todo el apoyo diagnóstico y terapéutico al alcance, sin embargo muere a los 17 días. Se reflexiona desde el punto de vista bioético respecto de la necesidad de hacer un análisis de proporcionalidad de tratamiento a tiempo el que deriva, en este caso, en la decisión de limitación del esfuerzo terapéutico. Se reconoce la complejidad de las decisiones que se debe tomar. Se enfatiza el rol de los padres en las decisiones de sustitución. Conclusión: Ante la duda razonable la conducta éticamente correcta es actuar en favor de la vida, pero la duración de los tratamientos de prueba deben ser por un tiempo razonable para no caer, como en el caso de Laura en el Encarnizamiento Terapéutico.
Subject(s)
Humans , Infant, Newborn , Ethics, Medical , Infant, Premature , Intensive Care, Neonatal , Physician's Role , Decision Making/ethics , Bioethical Issues , Professional-Family Relations/ethics , Withholding TreatmentABSTRACT
Background: Personnel working in neonatal intensive care units frequently face difficult ethical problems related to the initation, maintenance or withdrawal of life support therapies. Aim: To assess the importance of ethical issues in the clinical decision making of health care providers in neonatal intensive care units. Material and methods: A questionnaire based on five clinical vignettes that assessed judgments about quality of life, impact of parent's opinions and decision making in emergency situations and with different degrees, of certainty, was designed. Eleven neonatologists and 20 nurses and midwives specialized in neonatology anonymously answered this questionnaire. Results: There was a great inter individual variability in therapeutic approaches in cases with a bad vital and neurological prognosis. In cases of medical emergencies with uncentain diagnoses, bad vital prognosis but neurological indemnity, most professionals coincided in delivering all possible therapeutic options. Parent's opinions had a great impact in medical decisions, except when there was neurological indemnity. Conclusions: The specific responsibilities of the different agents in medical decision making must be delimited. Parents do not have absolute rights over their offspring and physicians must reject useless therapies