Balancing Respect for Autonomy and Best Interests of Adults Ilona Blee & Jonathan Tsun

Let’s start with the basics…  What is “autonomy”?  “The quality or state of being self- governing”  “Freedom from external control or influence; independence”  What are “best interests”?  In my own words, patient’s best interests is a set of wishes, values, and priorities that a patient would have if they had full mental capacity.

As a doctor, how do you respect patients’ autonomy?  Respect for patients’ values and decisions.  Avoiding deception of patients.  Providing information about choices for patients.  Optimising their capacity to make autonomous decisions.  Avoiding coercion.

Under what conditions can patient autonomy be disregarded? 1. Harm to other (or risk of harm) 2. Social justice  E.g. managing NHS resources responsibly 3. Legal constraints  E.g. the need to use evidence-based therapies only 4. Harm to ourselves (or risk of harm)

When acting in a person’s best interests, what 3 things must you ascertain/consider? 1. The person’s past and present wishes and feelings (in particular any relevant written statements from when person had capacity) 2. The person’s beliefs and values that would likely influence the decision if the person had capacity to do so 3. Any other factors that the person would likely consider if he/she were able to do so

 Before you do anything with/to/on a patient, what must you first obtain from the patient?  Valid consent!  What are the requirements for valid/informed consent? 1. Capacity (competence) 2. Information 3. Voluntariness (free from coercion) This is something that will never stop coming up on exams. Be as familiar with this as you are with your own name.

 What are the requirements for a patient to be deemed as having capacity?  Patient must be able to: 1. Understand the information relevant to the decision 2. Retain the information 3. Use or weigh the information in order to make the decision 4. Communicate the decision back (whether by talking, sign language, or any other means)  What is the legal framework that governs this?  Mental Capacity Act This is something that will never stop coming up on exams. Be as familiar with this as you are with your own name.

Mental Capacity Act – Five Key Principles Think of these principles as things you must always consider when assessing whether or not a patient has capacity. 1. Every adult has the right to make his/her own decisions and must be assumed to have capacity unless proven otherwise 2. An “unwise” decision is not an indication of lacking capacity 3. In a person who lacks capacity, anything done or any decision made on their behalf must be done in the person’s best interests 4. A person must be given all practicable help before they are treated as lacking capacity  (This goes back to the requirements for capacity. E.g. a paralysed patient who is fully conscious but cannot speak or make any large movements – their decision can still communicated via blinking their eyes) 5. Anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms

A 24 year old man presents with a small tumour with early signs of metastasis to various organs. He is otherwise perfectly fit and healthy. If left untreated, the tumour would likely kill him. But if treated early, he would probably recover completely. When talking to him about treatment options, he stops you and tells you he doesn’t want to fight it. He does not believe in altering his life course with medicine and chooses to let the cancer run its course.  Does this patient have capacity? Why/why not?  Yes. From the information given, he does not appear to violate any of the conditions for capacity.  As a doctor, is there any way to “force” treatment upon this patient?  NO!!!!  Adult patients may refuse treatment for reasons which are “rational, irrational, or for no reason”  “…even where the treatment is necessary to preserve life”

And now for some random questions….

What are 3 issues that must be considered for a clinical trial to be regarded as ethical? Describe what each one means/entails. 1. Ethical dilemma  Clinician must provide best treatment option available for each individual patient  Treatments (control vs experimental) must be allocated randomly 2. Clinical equipoise  “Reasonable uncertainty about which treatment (including non-treatment) is better”  Randomisation does not deny any patient the best treatment 3. Informed consent  Must be explained: i. Patient is invited to be in a trial ii. What the alternative treatment options are (and side effects) iii. Treatment will be allocated at random iv. Patient may withdraw at any time  Information must be given:  Verbally and in writing with “cooling off” time for the patient to think about their decision  By a knowledgeable informant

30 year-old male suffered from a right superior gluteal nerve injury in a motorcycle crash. He is examined later and exhibits a waddling gait and a positive Trendelenburg sign. Describe the difference between Trendelenburg sign and Trendelenburg gait. Trendelenburg sign – when you ask the patient to lift the leg on the unaffected side, the patient’s pelvis will drop down toward that side. When you ask the patient to lift the leg on the affected side, the pelvis will remain flat. Trendelenburg gait – when the patient walks, the pelvis of the unaffected side will rise above the affected side, attempting to compensate for the pelvic drop. Loukas, M. (2010). Gray’s anatomy review. Philadelphia: Churchill Livingstone/Elsevier.

30 year-old male suffered from a right superior gluteal nerve injury in a motorcycle crash. He is examined later and exhibits a waddling gait and a positive Trendelenburg sign. Which of the following would most likely be found in this patient? A) Difficulty in standing from a sitting position. B) The left side of the pelvis drops or sags when he attempts to stand with his weight supported by the right lower limb. C) The right side of the pelvis drops or sags when he attempts to stand with his weight supported by the left lower limb. D) Weakened flexion of the right hip. E) Difficulty in sitting from a standing position. X Loukas, M. (2010). Gray’s anatomy review. Philadelphia: Churchill Livingstone/Elsevier.

A 32-year old patient received a badly placed intramuscular injection to the posterior part of his gluteal region. The needle injured a motor nerve in the area. Later, he had great difficulty rising to a standing position from a seated position. Which muscle was most likely affected by the injury? A) Gluteus maximus B) Gluteus minimus C) Hamstrings D) Iliopsoas E) Obturator internus X Loukas, M. (2010). Gray’s anatomy review. Philadelphia: Churchill Livingstone/Elsevier.

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