PATIENT AUTONOMY

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PATIENT AUTONOMY

• AAOS ETHICS COMMITTEE
• Paul Levin, MD

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Objectives

• Define patient autonomy
• Define, if any, limits to patient autonomy
• Identify physician alternatives if patient does
  not accept treatment plan

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Patient Autonomy

• Accepted standard of care in the United States
• Self rule or independence
• Ethically and legally sound principle
• Physicians should offer reasonable options and
  work with patients to make reasonable decisions

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Case

• You are covering the ED
• Saturday evening when
• a 33 year-old motorcycle
• rider is brought in by
• EMS with a type IIIA
• open tib/fib fracture.
• Ryan McVay/Digital
  Vision/Thinkstock.com
• You carefully explain the severity
• of the injury to the patient and recommend an
  immediate ID with intramedullary nailing.
• Physicians should not be paternalistic

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• The patient states that he trusts you and knows
  that he should have the operation. Despite his
  confidence in you, he declines operative
  intervention.
• He explains to you his best friend died
  in the operating
• room after a motorcycle accident, and
  he is afraid that he will also die in the
  OR. He requests that you think of a
  different way to Pixland/Thinkstock.com
  care for him that doesnt require being in an
  operating room.

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• What are the ethical principles involved?
• Do you have any legal concerns?

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Ethical Principles

• Individuals with decision- making capacity are
  allowed to make unwise or seemingly foolish
  decisions.
• Beneficence demands that you help the patient.
• Non-maleficence requires that you not harm the
  patient.

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Legal Responsibilities

• You are on-call to the ED and are required to
  care for the patient.
• You need to ensure that the patient has
  decision-making capacity.

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• After the patient explains his fears, you
  recommend
• an evaluation by a
• psychiatrist.
• 
  Pixland/Thinkstock.com
• The patient thanks you for your concern, but says
  I dont want to speak with a shrink.

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• You sit down with the patient and discuss his
  injury, the dangers of not having surgery, and
  the urgency to prevent an infection.
  You ask about his friend, and it is
  evident that his friend had sustained
• Pixland/Thinkstock.com life threatening
  injuries
• and died as a result of those injuries. You
  explain this to the patient and try to persuade
  him to agree to surgery.

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Strategies to Assist Patient

• Sit down and spend time to assist patient in
  his/her understanding
• Persuasion is appropriate coercion and threats
  are immoral and illegal
• Suggest a second orthopaedic opinion
• Suggest we include family/friends in discussion

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Recommendations

• Develop appropriate communication skills to
  assist all of your patients
• Seek assistance from your colleagues when
  patients are declining appropriate management
• Consider a consultation with your institutions
  ethics consultant service

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References

• Beauchamp T and Childress J Principles of
  Biomedical Ethics, ed 6. New York, NY, Oxford
  University Press, 2009.
• Lo B Resolving Ethical Dilemmas, A Guide for
  Clinicians, ed 4. Philadelphia, PA, Lippincott
  Williams Wilkins, 2009.
• Pellegrino E and Thomasma D The Virtues in
  Medical Practice. New York, NY, Oxford
  University Press, 1993.
• Ganzini L, Volicer L, Nelson W, Fox E, Derse A
  Ten myths about decision-making capacity. J AM
  Med Dir Assoc. 20056(3 Suppl)s100-4.
• Tongue J and Otsuka N Patient-Centered Care
  Communication Skills and Cultural Competence.
  American Academy of Orthopaedic Surgeons,
  Orthopaedic Knowledge Update 10, 2011.

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• American Academy of Orthopaedic Surgeons
  Patient-Physician Communication, Information
  Statement 1017. Adopted 2000, revised 2011.
• http//www.aaos.org/about/papers/advistmt/1017.asp
  
• Council on Ethical and Judicial Affairs Code of
  Medical Ethics, Opinion10.02. Chicago, IL,
  American Medical Association, ed 2010-2011.