The primary focus in determining the legal permissibility of medical end-of-life. Decision should be the issue of patient consent rather than the subjective intention of the doctor or nurse. Explain & Illustrate.
- To give on overview the primary focus in determining the legal permissibility of medical end-of-life. Decision should be the issue of patient consent rather than the subjective intention of doctor.
In line with the broad objective, the specific objectives of the study may be spelled out as follows:
- To show that decision should be the issue of patient consent rather than the subjective intention of the doctor or nurse.
- To provide an overall overview of medical end-of-life.
- To gain ideas about the legal permissibility of medical end-of-life).
- To identify the problems related to the legal permissibility of medical end-of-life.
- To recommend actions that may be necessary to solve the problems.
The report covers about medical end-of-life, patients consent, rights and responsibilities of patients consent, advantage of patients consent.
Within the stipulated time, I have covered some major topic. These are listed below and described in this report:
- The legal permissibility of medical end-of-life.
- About patients consent
- Subjective intention of doctors or nurses
Primary are collected by survey or study for specific purpose. We have collected primary data through the following ways:
- Face to Face conversation with the respective doctor and nurse.
- Practical work exposures on different desks.
- Practical experiences of the officials.
- Collection of relevant information from various departments
Sources of secondary data can be defined as:
In medicine, end-of-life care refers to medical care not only of patients in the final hours or days of their lives, but more broadly, medical care of all those with a terminal illness or terminal condition that has become advanced, progressive and incurable. Regarding cancer care the United States national cancer institute writes:
When a patient’s health care team determines that the cancer can no longer be controlled, medical testing and cancer treatment often stop. But the patient’s care continues. The care focuses on making the patient comfortable. The patient receives medications and treatments to control pain and other symptoms, such as constipation, nausea, and shortness of breath. Some patients remain at home during this time, while others enter a hospital or other facility. Either way, services are available to help patients and their families with the medical, psychological, and spiritual issues surrounding dying. A hospice often provides such services. The time at the end of life is different for each person. Each individual has unique needs for information and support. Patients and their family members often want to know how long a person is expected to live. This is a hard question to answer. Factors such as where the cancer is located and whether the patient has other illnesses can affect what will happen. Although doctors may be able to make an estimate based on what they know about the patient, they might be hesitant to do so. Doctors may be concerned about over- or under-estimating the patient’s life span. They also might be fearful of instilling false hope or destroying a person’s hope. 
Basic objectives of Medical End-of-life:
The ultimate objectives for medical end-of-life are given below:
- Knowledge of core concepts and principles of biological sciences from molecular to systems levels.
- Knowledge of social sciences basic to medicine and skills needed to provide care to culturally, ethnically and ecologically diverse populations irrespective of age or gender.
- Possession of a deep foundation of information about clinical diseases basic to medicine, including not only disease pathogenesis and treatment, but also health maintenance and disease prevention.
- Dedication to life-long learning: the ability to formulate scientific and clinical questions. Possession of the skills to identify resources to answer those questions as well as remaining current in their field of medicine.
Medical END-OF-LIFE: An overview of consent:
A patient’s oral and written agreement to participate in a clinical trial. Consent is based on full disclosure about the treatment, its potential risks and benefits, alternative treatments, and any other information the patient needs to make the decision. Consent is based on the inviolability of one’s person. It means that doctors do not have the right to touch or treat a patient without that patient’s approval because the patient is the one who must live with the consequences and deal with any dis-comfort caused by treatment. A doctor can be held liable for committing a battery if the doctor touches the patient without first obtaining the patient’s consent. Consent must be voluntary, competent, and informed. Voluntary means that, when the patient gives consent, he or she is free from extreme duress and is not intoxicated or under the influence of medication and that the doctor has not coerced the patient into giving consent.
Patient consent is the principle that you have to give express permission before any medical treatment can be carried out on you. Consent is needed, whatever the types of treatment, from a simple blood test to an organ donation.
What constitutes consent?
Consent can only be said to have been given if it is both voluntary and informed. These terms are described below.
- Voluntary: the decision to consent (or not consent) to treatment must be your own, and not the result of coercion by medical staff, friends or family.
- Informed: you must be given full information about what the treatment involves, the benefits and risks, whether there are any other reasonable alternative treatments, and what will happen if treatment does not go ahead.
The only circumstance where treatment can go ahead without your consent is if you do not have the mental capacity to make a decision regarding your treatment, and the healthcare professionals believe that treatment is in your best interests. 
Decision should be the issue of patient consent rather than the subjective intention of doctor or nurse:
- The primary focus in medical end-of-life decisions should be on patient consent, rather than doctor intention because it is not a breach against a patient’s rights if s/he consents to the termination of their life
- Decision should be the issue of patient content rather than the subjective intention of doctor or nurse .Before starting any operation of any patient, doctor takes permission from patients. Because doctors or nurses do not want to take risk if any patient dies.
- The primary focus in medical end-of-life decisions should be on patient consent, rather than doctor intention. Because a doctor who treats without patient consent will be liable under the tort and criminal laws.
- Doctors do not have the right to touch or treat a patient without that patient’s approval because the patient is the one who must live with the consequences and deal with any discomfort caused by treatment. A doctor can be held liable for committing a battery if the doctor touches the patient without first obtaining the patient’s consent.
- If patient is due to undergo a major medical intervention, such as an operation, patient consent should be sought well in advance, so that patient has plenty of time to study any information relating to the procedure. Patient should also have the opportunity to ask as many questions as patients want.
- There may be some circumstances when, during an operation, it becomes obvious that you would benefit from an additional procedure that was not in the scope of your original consent. For example, you may be undergoing abdominal surgery and the surgeon notices that your appendix is infected, dangerously close to bursting, and needs to be removed.
- If it is felt that it would be too dangerous to delay the additional procedure in order to wake you up to obtain your consent, the additional procedure can go ahead providing that it is in your best interest.
- However, additional procedures cannot go ahead just because it would be convenient for the medical staff. There has to be a clear medical reason why it would be unsafe to wait and obtain your further consent.
How is consent given?
Consent should be obtained from the healthcare professional who is directly responsible for your current treatment. This could be a nurse who is arranging a blood test, a GP who is prescribing new medication for you, or a surgeon who is planning your operation.
Consent can be given:
- Non-verbally – for example, you may raise your hand to indicate that you are happy for a nurse to take a blood sample
- In writing – by signing a consent form
A signed consent form by itself does not constitute consent; it simply serves as evidence of consent. If your consent is not voluntarily, informed, or you do not have the sufficient mental capacity to give consent, the consent form will not be valid.
Under the terms of the 2005 Mental Capacity Act, all adults are presumed to have sufficient capacity to decide on their own medical treatment unless there is significant evidence to suggest otherwise.
The evidence has to show that:
- a person’s mind, or brain, is impaired or disturbed, and
- The impairment or disturbance means that the person is unable to make a decision at the current time.
Examples of impairments or disturbances in the mind or brain include:
- mental health conditions, such as schizophrenia or bi-polar disorder (manic depression),
- serious learning disabilities,
- long-term effects of brain damage,
- physical or mental conditions that cause confusion, drowsiness, or a loss of consciousness,
- delirium, and
- intoxication caused by drug or alcohol abuse.
Someone is thought to be unable to make a decision if they cannot:
- understand information about the decision,
- remember that information,
- use that information as part of their decision-making process, or
- Communicate their decision by talking, using sign language, or by any other means.
- If someone makes a decision about treatment that most people would consider to be irrational, it does not constitute a lack of capacity if the person making the decision understands the reality of their situation.
- For example, a person who refuses to have a blood transfusion because it is against their religious beliefs would not be thought to lack capacity because they understand the reality of their situation, and the consequences of their actions.
- However, somebody with anorexia, who is severely malnourished, yet rejects treatment because they refuse to accept that there is anything wrong with them, would be considered to be incapable because they do not understand the reality of their situation.
If you have sufficient capacity and make a voluntary and informed decision to refuse a particular treatment, your decision must be respected. This is still the case if your decision would result in your death, or the death of your unborn child. You are still entitled to any other appropriate medical treatment and care that is felt would be in your best interest. However, if you request a course of a treatment that health care professionals believe would not be in your best interest, they have no obligation to provide it.
Children and Teenagers:
Teenagers who are 16 and 17 years of age are entitled to consent to their own treatment, and this consent cannot be overruled by their parents.
Children who are under 16 years of age can also consent to their own treatment if it thought that they have sufficient intelligence, competence, and understanding to fully appreciate what is involved in their treatment.
No one except the courts can override the consent of a child who is under 16 years of age. However, a person who has parental responsibility for a child, or teenager aged 16 or 17, can override that consent if the child refuses treatment.
The mother of a child, and the child’s father (if he is married to the mother) automatically have parental responsibility. If the parents are not married, the father will have parental responsibility if he acted with the mother to have his name recorded in the registration of the child’s birth, and the child’s birth was registered after 1st December 2003.
An unmarried father can also obtain parental responsibility by later marrying the mother, by making a parental responsibility agreement with her, or by getting a court order.
Parental responsibility can also be granted to other people by the courts, such as a legally appointed guardian. As with other adults, people with parental responsibility can only provide, or refuse, consent if they are thought to be capable.
If a parent refuses to give consent to particular treatment, this decision can be overruled by the courts if treatment is thought to be in the best interests of the child.
In an emergency, where treatment is vital, and waiting to obtain parental consent would place the child at risk, treatment can proceed without consent.
If you believe that you have received treatment for which you did not provide consent, you can make an official complaint. You can either use the NHS complaints procedure, or you can contact the General Medical Council (GMC).
The GMC only investigates complaints that relate to doctors, rather than other health care professionals, such as nurses.
If your complaint is upheld, the GMC can issue a formal warning to the doctor involved. In the most serious of cases, the doctor’s license to practice medicine can be withdrawn.
The GMC cannot provide you with compensation for any liability, or injury, relating to your complaint.
The NHS complaints procedure can be used to complain about any NHS staff member who is involved in your treatment. You must make sure that you make your complaint within six months of the event you are complaining about. In some cases, compensation may be available.
People, who have conditions that are covered by the Mental Health Act (1983), such as schizophrenia or bi-polar disorder, may not be competent to give consent. However, this should not be taken for granted and needs to be assessed at the time that consent is required.
Mental Health Condition:
The patient’s preferences should be investigated, and their agreement to treatment should be sought, whenever they are able to make a rational decision. These wishes should be respected if, later on, the patient is not able to give proper consent.
If the patient lacks capacity and has not previously expressed their wishes, their mental health condition may be treated without consent, as may any related conditions – for example, those resulting from self-harm. Unrelated physical conditions cannot be treated without consent.
An advanced directive prohibiting certain kinds of treatment can be overruled if you are being held under the Mental Health Act, even if you wrote the advanced directive when you were capable. For example, you may have stipulated that you do not wish to be treated with antipsychotic. However, if your medical staff feel that the use of antipsychotic is required to prevent possible danger to yourself, or to others, their use will be allowed.
Intervening when the patient lacks capacity:
If an adult lacks capacity, any physical interventions must be in the ‘best interest’ of the patient. Firstly, it must be determined whether the person has previously expressed any opinions regarding certain procedures, perhaps on the grounds of religious or moral beliefs. This wish must be respected. It is only when the patient may die if an intervention is not made, that this can be carried out without consent.
However, if the patient had already expressed a clear opinion on this matter, the doctor cannot override this, whatever the consequences, unless the person is being held under the Mental Health Act.
If it is safe to wait until the patient can provide their permission, this must be done. In such circumstances, doctors are advised to refer to a senior colleague for advice. Any doubts can be referred to the High Court for a decision. 
There are some circumstances where a decision should always be referred to a court, if the person cannot, or will not, give their permission. These situations include:
- Sterilization for contraceptive purposes,
- Donation of regenerative tissue, such as bone marrow,
- Withdrawal of nutrition and hydration from a patient in a persistent vegetative state, and
- Where there is serious concern about the patient’s capacity, or best interests.
3. www.cks.nhs.UK/patient information/ consent to treatment
Breach of patient confidentiality refers to incident where patient’s confidential information, learned by the doctor within the physician-patient relationship, is divulged to a third party without the former’s consent or court order.
Breaching can be oral, written, or done via telephone or fax, or electronically by using email or health information network. Importantly, the medium of disclosure is not important but special security requirements may apply to the electronic transfer of information.
¨ The piece-meal approach to fixing systemic problems, e.g., MMA, results in serious unintended (but foreseeable) consequences for patients.
¨ Growing expectations for unreasonably positive outcomes due to hyper-optimism and marketing.
¨ Potential for an adversarial breakdown of relations between hospitals and doctors; with money exiting the system, physician purchases of CT and PET scanners, and radiation therapy equipment directly competes with hospitals.
¨ Ignoring rapidly rising drug costs for all, the inevitable increase in those who cannot afford care and the widening gap between those who can and cannot afford to pay for therapy.
¨ Continuously falling compensation may cause early retirements or curtailment of practices, leaving fewer, overly burdened practices; the public and Congress don’t understand that at this rate we will end up with too few resources and providers to give care they expect.
¨ Patients must give their consent for their personal data to be recorded on the NJR.
¨ Consent must be voluntary, competent, and informed. Voluntary means that, when the patient gives consent, he or she is free from extreme duress and is not intoxicated or under the influence of medication and that the doctor has not coerced the patient into giving consent. 
4. ama_patient confidentiality/www.ama_amn.org/ama/—/patient
In medicine, end-of-life care refers to medical care not only of patients in the final hours or days of their lives, but more broadly, medical care of all those with a terminal or terminal condition that has become advanced, progressive and incurable. Decision should be the issue of patient consent rather than the subjective intention of doctor or nurse. Because it is not a breach against a patient’s rights if he/she consents to the termination of their life. Consent must be valid .If the patient does not understand its meaning or if a patient has been misled, then consent will be invalid. So doctor should take care of this matter that decision should be the issue of patient consent.
¨ N Johnstone M.J, Bio-ethics, a nursing perspective, First Edition, Harcourt Brace Jovanovich Group, Sydney, 1989
¨ Jonsen A.R, Siegler M and Winslade W.J,
¨ Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical
¨ Medicine, Third Edition, McGraw-Hill Inc., 1992
¨ Kennedy I. And Grubb A, Medical Law: Text and Materials, First Edition, Butterworths, London, 1989
¨ Waller L and Williams C.R, (Brett, Waller
¨ and Williams), Criminal Law: Texts and Cases, Eighth Edition.
¨ Butterworths, Melbourne, 1997
¨ Young P.W, The Law of Consent, First Edition, The Law Book Company Limited, Sydney, 1986