The ethical management of forgetfulness

“Obtaining consent should be an ethical duty first and foremost, one central to respecting the autonomy and dignity of patients”[39]

Informed consent is crucial for patients but it is not truly informed unless they are given full, reliable, evidence based information about the treatment alternatives and the likely benefits, harms, and uncertainties of each of these. Obviously, in the case of cognitive screening there are potential difficulties here in that a patient’s capacity to consent may be impaired.

It is my view that ethically we have a duty to respect individual autonomy, and no screening, even for cognitive impairment, should over-ride this human right. Even in our belief in a procedure’s value, or out of a concern not to worry the patient unduly, we cannot side-step asking for consent.

“The issue for us—the crucial one around older people, in particular—is the culture of care.”[40] Dr Denise Coia

Availability of time in casualty departments for example may be another barrier to seeking consent for testing. “Hurry is the devil,” wrote William Osler. In my biased view rushing consent (or establishing that consent may not be possible) should be avoided in the same way that a medical procedure should not be rushed.  On this, Leon Eisenberg has offered his thoughts:

“… we can change this mindset and view obtaining consent as an ethical duty first and foremost, one that is central to respecting the autonomy and dignity of patients, then we will have taken a major step .… we must take the time to demonstrate to our students how the information the patient needs to have can be presented clearly and more than once, in order that the doctor can support the patient’s right to choose among alternatives.”[41] Leon Eisenberg

When Healthcare Improvement Scotland gave evidence to the Health Committee last winter, Drew Smith (Glasgow) (Lab) opened with the comment below. Respect and dignity can be considered in so many ways, but here I wonder if Drew Smith is expressing, what sometimes seems to me as the prevailing view, that cognitive testing is a necessary requirement for both respect and dignity:

“When HIS was in Glasgow last year and examined Glasgow royal infirmary, its report said that there was a consistent failure to respect the dignity of older people. Two examples of that are the failure to assess for cognitive impairment and dementia, and specific instances of, for example, people being showered in cubicles without screens, which I think Dr Coia would describe as being ‘unforgivable’ or ‘unacceptable’.”44

Here is a different take on this: “It confuses me why signed consent for minor surgical interventions yet often not for things with devastating consequences”[42]

The NICE guideline on Delirium starts with person-centred care[43] “Treatment and care should take into account people’s needs and preferences. People with delirium or at risk of delirium should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If patients do not have the capacity to make decisions, healthcare professionals should follow the relevant national guidance on this”47

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