Nursing__Consent_to_Share

Patients who are mentally incapacitated are not able to give their informed consent to receiving treatment. This is the case with many elderly folk and provision is made for them under the Mental Health Act (1983). Such a situation occurred at a hospital during one of my practice placements. There was an elderly, female patient in the Elderly and Special Care Ward who was rather confused and consistently refused to take medicine. It was breakfast time and the registered nurse, with her back to the patient, popped a pill into her porridge. She then proceeded to feed the patient. This appeared to me rather irregular, so I politely discussed it with the nurse. She told me it was quite common practice, and it was in the patient’s best interest to take the prescribed medicine. However, in this instance she was acting upon her own initiative. It seemed contrary to the NMC Standards of Conduct (2008) which clearly emphasises the patient’s right to refuse treatment. Medication is part of an overall scheme of treatment and, when agreeing to enter hospital a patient is automatically accepting ‘hospitalisation’ and therefore could be reasonably considered to have agreed to the associated treatment. This would appear to be the general view of many nurses, but doesn’t alter the fact that the final decision lies with the patient who, in this case, said “No”. No person can live in isolation. We all need each other in order to simply survive. When we develop special skills which we place at the disposal of others for remuneration, they are placing their trust in us. We must be able to justify our conduct and are therefore accountable to them for carrying out the duties we have agreed to do. The NMC Code of professional conduct (2004) defines “accountable” as being “responsible for something or to someone” and, for a nurse, there is high priority for that “something” to be her duty of care for that “someone” who is her patient and her patient’s doctor. In the event of a registered nurse acting contrary to direct instructions concerning the care of her patient, she may face censure by her professional body and which could lead to her removal from the register. This would, of course, only happen after a proper investigation. Should the patient suffer any harm as a result of the nurse’s negligence, then the case may go to litigation. Any consequent damages and costs awarded by the court against the nurse could be the responsibility of her employer who holds vicarious liability for negligence of the employee. The NMC Code of Conduct (2008) advises members to carefully consider their position regarding the possible need to arrange personal professional indemnity insurance. It is explained by Griffith, R. and Davies, R (2003) that the law requires, for the administration of medicines, that satisfaction is given on four areas of accountability: To the Public (Consumer Protection Act, 1987) To the Patient (Human Rights Act 1998) To the Employer To the Profession (NMC Code of Conduct 2008) In this particular instance, the issue is one of covert administration of medicine. Whilst this could be considered as a breach of each of the four areas of accountability, it is particularly directed at the NMC Code of Conduct (2008). The NMC Code of Conduct (2008) emphasises the importance of observing the Law. This, of course, embraces the Human Rights Act (1998) which carefully protects the public from invasion of personal health and privacy. The nurse who in this instance covertly administered medicine, was doing what she considered, in her professional judgement, to be best for her patient who she believed to be in a mental condition which prevented her from making her own, rational choice. It might appear reasonable if she claimed to be acting in the best interests of the patient. It is in the matter of definition of what is reasonable that for many years court rulings in negligence cases have looked for direction to the case of “Bolam v Friern Hospital Management Committee (1957). This has been highlighted by Judith Hendrick in Hendrick, J. (2004). It has become known as the ‘Bolam Test’ and, in principle, describes the acceptable standard of nursing care as that which is found to be demonstrated in the professional conduct of her peers. It does, of course, include all health professionals. Although accepted by judges, this approach has frequently been challenged by judicial authorities who have claimed that it seems that professionals decide upon their own standard of care. This was put to the test in the case of ‘Bolitho v Hackney Health Authority’ (1998) and subsequently the courts have more critically considered the matter of reasonable, accepted practice, paying more attention to the logic of expert opinion. It is common knowledge that nursing establishments are frequently hard pressed for time and funding. Therefore, in adopting the ethical ‘utilitarian’ principle as explained in Peate, I. (2006) the nurse is frequently faced with the possible choice of a “short cut” to enable her to give required, beneficial treatment to her patient and providing more time to treat her other patients. Furthermore, she knows that her Code of Conduct requires her to be able to justify her conduct in an emergency as being in the patient’s best interests. However, she will do well to reflect upon whether or not she could have taken some other course of action which could be more beneficial to her patient. For example, in this particular instance the nurse covertly administered a pill to her patient by slipping it into her breakfast porridge. Perhaps, if she had been able to find time to think about it, there would have been several good reasons for making this a rather doubtful course of action. In the first place, there is no guarantee that the pill would not have been left in the uneaten portion of the meal. Similarly, medicine introduced into a drink would not be taken completely if the drink was not fully consumed. Furthermore, there is the matter of the manufacturer’s instructions for the administration of the product. The practice of crushing pills, breaking capsules or mixing medicines in food may well be contrary to the instructions and this could invalidate the prescription, as discussed by Griffith and Davies (2003) through the ‘Medicines Act’ (1968) and the ‘Consumer Protection Act’ (1987). It is possibly in this nurse’s favour that she knew the pill to be part of the patient’s prescribed treatment in her care plan and it would be correct, bearing in mind the patient’s inability to make her own rational choice, to adopt a suitable device to administer it. Nevertheless, if the patient suffered any consequential harm, the nurse might well be called to account and to answer whether or not she had considered the foregoing matters in making her choice of action. The nurse is always, as a member of a team, entitled to expect advice from the next person in line and in order of authority. Usually this could be the ward sister and the case doctor. If the practice of covert administration of medicine continued unchecked it is inevitable that, sooner or later, it will be discovered by the patient, who may see what was happening or be told by another patient. This would breed distrust in the nurse/patient relationship. It poses the possibility that this state of mistrust would pervade the whole ward – even throughout the establishment! It may appear to be rather an exaggeration and a “prophesy of doom”. Nevertheless, the possibility is there and, in fact, is part of the general principle that rumours need very little to get going and have a tendency, as they spread, to embellish the original act. However, in spite of weighty argument against covert administration of medicine, a nurse will no doubt claim she worked to the important rule that she should always act in the best interests of her patient. Here, she would be well advised to remember that the welfare of her patient depends not only upon personal care but also upon collective care. The welfare of patients generally will also make a strong contribution to the welfare of each individual patient. This is the ‘Utilitarian’ principle of ethics which, as described in Peate (2006) seeks to maximise the value of effort. Thus, in such a dilemma, the nurse in question would recognise the vital important of the general nature of nurse/patient trusting relationship and its importance in generating and supporting the trust in her personal relationship with her patient. The term “risk management” is commonly used in most professions, not least the medical profession. It is self evident that each of us, as individuals, face risks every day. Broadly speaking, a risk is the possibility of the appearance of an adverse situation. Many such possibilities are known to us and, by consideration and experience, we are able to estimate the level of possibility and to make provision for it. This still leaves many other, unforeseen possibilities, for which we also try to make provision. This is what an engineer calls a “safety factor” (sometimes reported as the “ignorance factor”!). Regarding medicine; the manufacturer, after careful study and analysis, invariably considers their use, including administration. As explained in Griffith and Davies (2003) he will minimise risk by providing appropriate instructions for use of a medicine which may prevent any mixing with other substances. Should the nurse who is administering the medicine depart from the manufacturer’s instructions, then although no harm may appear to be done, she will nevertheless be infringing the “risk factor”. Any consequential damage will be to her account. The important matter of patient consent to treatment cannot be over emphasised. The Law clearly requires that there shall be no invasion of a person’s body or privacy without their full, uncoerced consent. That consent must represent the undeniable will of the patient concerning proposed treatment. The NMC Code of Conduct (2008) devotes a whole section to this vital issue and commands that in the case of mentally incapacitated patients their will shall be enshrined at the centre of decisions made on their behalf. Consent given by a person of sound mind should be informed consent. However, this applies also to mentally incapacitated patients as far as they are able to comply. Some such patients have a “fluctuating capacity” as described on pages 225 and 228 in Hendrick (2004). The nurse of such a patient should consider this possibility before making any decision on her patient’s behalf. Furthermore, there are some patients whose attitude towards receiving medication will vary during the day. An astute nurse will recognise this and discuss with her superior the possibility of rearranging the time schedule for medication. There are also those patients who, whilst they were in an earlier sound state of mind, did at that time make their wishes known, just as they would make their Wills. Such expressed choices would be currently valid. It is interesting to note that there is a body of expert opinion who favour the covert administration of medicine in appropriate cases. This is mentioned in Tannsjö (1999). This particular instance concerns a registered nurse treating an elderly, mentally confused patient. It posed a dilemma such as can be expected daily. The method she adopted in dealing with it could have easily become routine and open the door to further deviation from the rules which are designed for the welfare of the public and for care personnel. A registered nurse is a person held in trust by her patients and employer. She is deemed, and expected to be, properly equipped to perform the duties assigned to her and is depended upon to vindicate that trust in all of her professional conduct. She is therefore, through her registration, accountable to all who trust her because of it. The administration of medicine by a registered nurse during the course of treatment must be carried out efficiently and in strict compliance with instructions from the patient’s prescribing doctor. The covert administration of medicine to a patient who is unable to give informed consent is not considered to be a recommended procedure unless authorised by the prescribing doctor. See the Viewpoint in the Lancet by Treeloar et al (2001). The careful observance of the rules, especially as crystallised in the NMC Code of Conduct should, for a registered nurse, be an expression of her compassionate concern for the welfare of her patient. Any decision, particularly when she is faced with a dilemma, should be made against the clear understanding of her accountability, and in the best interests of all concerned she should seriously consider the wisdom of seeking the early advice and instruction from her nearest available superior.