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This ethical dilemma has three parties, but primarily two. One party is the patient, Mr. Jack Burns. The second party is a nurse practitioner, Ms. Cecelia Langer. The third party are the healthcare professionals that will be conducting the renal scan. The patient is an individual with a very poor health literacy and clearly has stated that he dislikes hospitals. Like many, Burns expressed that he is “allergic” to hospitals. This attitude alone already puts him a closed off position wherein he is not likely to accept nor comprehend the course of care.
Langer realizes that Burns is a difficult patient and spends more time with him explaining the findings of his symptoms and the course of action they will be taking to further investigate his symptoms. As previously stated, Burns is closed off to the environment. Upon introducing the materials for the scan, Burns explodes and states that he did not expect to be injected with chemicals. It is my speculation that he was not listening when Langer explained the procedure to him when she presented him with the consent.
Perhaps Burns was fully attentive but because he is of low health literacy, did not fully understand the parameters that would surround the scan. Burns earns his living as a truck driver.
Thus, we can conclude that there is very little intelligent that goes with this position. Notwithstanding, he is not in an industry remotely like medicine to understand much of it. A dilemma arises when Burns informs the scan team that he was not aware that there would be chemicals involved and blames Langer for not fully informing him how the procedure would take place.
There are two possibilities: Burns was either inattentive when Langer read the consent to him or is of inadequate literacy. First and foremost, the patient seems confused when it comes to consent forms and healthcare procedures. It is quite common for individuals with low health literacy to not fully comprehend what is going on. “Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions”. (Health Literacy – Fact Sheet: Health Literacy Basics) In most facilities, before healthcare professionals have seen a patient on the first visit, a health literacy screen has been conducted to obtain the level and document it in the patient’s chart for staff members to be mindful of. This usually consists of three health questions or more.
The first question should be “How confident are you filling out medical forms without help?” This is crucial in assessing how well a patient can read and comprehend what is being asked of them. The patient should be instructed to answer in the following manner: 1-Extremely 2-Quite a bit 3-Somewhat 4-A little 5-Not at all. The second question is “How often do you struggle with learning about your health condition because of the inability to understand the written information provided to you?” The patient should be instructed to answer in the following manner: Responses are: 1-Never 2-Occasionally 3-Sometimes 4-Often 5-Always. Surprisingly enough, many providers explain to their patients their condition and how they will be treating it and the patient never understood. Understanding what is going on with your body and how the medication given will affect it is very important for optimal results. The last question should be “How often do you have assistance in reading material provided by your provider” A score in any of these questions of 3 or greater indicated adequate health literacy. Thus, from the patient’s reaction in the renal unit in preparation for the CT scan we can conclude he is of inadequate literacy.
Langer has done her part in explaining both consent forms to Burns during the initial encounter and later when she was requested by the patient. Let’s suppose that Burns is a competent individual with adequate health literacy. If this is the case we can conclude that Langer nor the Renal Unit carried out their duties to consent Burns properly. In order for any medical treatment to be performed whether it is a procedure or simply seeing the patient, an executed informed consent form must be obtained prior to the initiation. “An informed consent document spells out how health professionals intend to use specific diagnostic or treatment interventions for the purpose of improving a patient’s condition. If designed appropriately, the document enables the person to become well informed before entering the decision-making process” (Purtilo, 2016). I personally believe that consent was not sought prior to the procedure. If it were, Burns would not have reacted in the manner in which he did. Nevertheless, it is a protocol to inform the patient in the CT department of the procedure as well. Thus, Burns would have had the procedure explained to him from two different healthcare professionals. Two ethical standards arise here: lack of informed consent and communication. A two-step process by Langer and healthcare professionals in the Renal Unit did not occur wherein both parties should not have proceeded with the scan without reassuring the patient had full understanding of the process. Upon hire, both parties must have received training on how to obtain informed consent.
I believe the first parameter in consenting was not evident to either. In order the gain consent, the provider should:
Common Law, 45 C.F.R. Part 46 (subtype A) governs informed consent at the national level. Each state has laws pertaining to informed consent that is required by healthcare providers to seek from their patients prior to initiating any process involving their care. All laws apply to both physician and nurses as sometimes nurses carry out the duty of consenting a patient for the respective physician as we have seen in this case. In order for the consent to occur, it must be evident that the information provided is understood by the patient. 45 C.F.R. Part 46 (subtype A) covers all the parameters of consenting a patient whether it is for research or medical care. Notwithstanding, 45 C.F.R. Part 46 (subtype A) touches base on consenting minors, mentally disabled, prisoners, and patients who competency for consent is questionable. This law protects both the physician and the patient as lack of informed consent has been the root of many lawsuits brought to the Court.
When a healthcare provider failed to seek informed consent for a procedure it is essentially, unauthorized. Any unauthorized procedure performed for non-emergency cases can result in criminal charges such as battery. Burns would have the right to bring legal against the Renal Unit if this is the case. He was not well informed on how the procedure would take place which caused him to react the way that he did. This is why assessing a patient’s literacy is crucial in the informed consent process. By assessing Burns literacy, Langer would have been the frontrunner in realizing that this patient needed extra time and materials for consent. Medical terminology can be difficult to understand. Moreover, if Burns was not understanding the material that was being read to him, then Langer should proceed with addressing the key points on the form with visual material. In any event, Langer put the Renal Unit at risk. Nevertheless, the Renal Unit also had a duty to confirm the procedure had already been discussed with Burns and, in the event, it was not, repeating the process until it is understood and agreed by all parties.
The first step in reaching an ethical solution to this case is to gather relevant information. (Purtilo, 2016) Interview Burns and ensure what was communicated to him and what the patient was told he was signing. In speaking with Langer, we should be able to gather information from her on what she did to ensure Burns understood the procedure and was rightfully informed. It would also be useful to ask Langer what she used to explain the procedure if whether it was just the document he signed. The Renal Unit should also be interviewed on whether there was confirmation from Langer that Burns was consented and whether they themselves confirmed on their end that he fully understood the procedure. The second step is to identify the ethical problem, which I believe be lack of informed consent leading to an unauthorized procedure. (Purtilo, 2016) Step three deals with using ethic theories or approaches to analyze the problem. (Purtilo, 2016)
As previously stated, we must assess Burns literacy to then draw the conclusion whether there indeed was informed consent. If the patient did not fully comprehend what was being communicated to him, then consent does not exist. Step four is to find alternatives. Step five is to complete the action. (Purtilo, 2016) We discussed that in order to measure informed consent we must first assess the patient’s literacy level by asking a series of questions and formulating a score. Thereafter, come to a conclusion based on their literacy score whether consent exists. If his score is 3 or greater, inform consent exists. Should the score fall below 3, then we can assume there is a lack of informed consent and deem the procedure unauthorized. Finally, Step six is to evaluate the process and outcome. (Purtilo, 2016) This last step is crucial in dictating that this situation never arises again.
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