Jeselo O.

Gorme, RN
 Activity:
 Divide yourselves into four groups and discuss
salient provisions in:
1. Republic Act 7876
2. Republic Act 7432
3. Republic Act 9257
4. Republic Act 9994
 The right to self-determination has its basis in
the doctrine of informed consent.
 Informed consent is the process by which
competent individuals are provided with
information that enables them to make
reasonable decision about any treatment or
intervention that is to be performed on them.
 A valid and legally sufficient informed consent
includes a standard of disclosure on:
 Diagnosis
 Nature and purpose of the treatment
 Risks of the treatment
 Probability of success of the treatment
 Available treatment alternatives
 Consequences of not receiving the treatment
“Every human being of adult years and
sound mind has a right to determine
what shall be done with his own body.”

~ Justice Benjamin Cardozo

 The doctrine and standards of informed
consent are intended to apply to the decision-
making capability of one who is competent to
make such decision.
 Competent means one who is able to
understand the proposed treatment or
procedure and thereby make an informed
consent.
 When a person is not competent, the decision
may be made by a surrogate, this is known as
“substituted” judgement.
 A DNR Order is a specific order from a
physician, entered on the physician order
sheet, which instructs health care providers not
to use or order specific methods of therapy,
which are referred to as cardiopulmonary
resuscitation (CPR).
 Each institution should formulate a DNR
policy. The policy should indicate:
 That a facility must have competently trained staff
available 24 hours a day o provide CPR
 Whether CPR will be performed unless there is a
DNR order
 The conditions under which the facility will issue
DNR orders. Considerations include the DNR
provisions under he law of the jurisdiction, required
physician consultations regarding medical condition,
and documented discussions with the client and
family members
 That competency is established, again with proper
documentation or medical consultation.
 The origin of consent for the order: via the client,
while competent; by an advance medical directive
(AMD); or by a substitute or surrogate decision-
maker.
 Provision for renewal of DNR orders at appropriate
intervals with ongoing documentation to note
changes.
 AMDs are documents that permit people to set
forth in writing their wishes and preferences
regarding health care.
 These are used to indicate their decisions if the
time should come when they are unable to
speak for themselves.
 Some also permit people to designate someone
to convey their wishes in the event they are
rendered unable to do so.
 An advance directive is not operative until the
client is no longer capable of decision-making.
 Therefore, the first decision must be whether a
client is capable of making a decision.
 Living wills are intended to provide written
expressions of a client’s wishes regarding the
use of medical treatments in the event of
terminal illness or condition.
 Health Care Agent designations entail
appointing a trusted person to express the
client’s wishes regarding the withholding or
withdrawal of life support.
 Living wills are generally not effective until:
1. The attending physician has the document and the
client has been determined to be incompetent;
2. The physician has determined the client has a
terminal condition or a condition such that any
therapy provided would only prolong dying; and
3. The physician has written the appropriate orders in
the medical record.
 Living wills may be executed by any
competent adult.
 It should also declare that withholding care in
compliance with the document does not
constitute suicide.
 The client’s signature should also be witnessed.
 The witness usually does not have to attest to
the client’s mental competence; however, the
witness should at least indicate that the
principal “appeared” to be of sound mind.
 Pain and comfort measures may not be
withheld.
 A living will may be revoked at any time and
by any means.
 Durable power of attorney is a legal instrument
by which a person can designate someone else
to make healthcare decisions at a time in the
future when he or she may be rendered
competent.
 Springing power is a term used to describe
this type of legal instrument because this only
takes effect in the future on occurrence of a
specific event-in this case, the incompetence of
the patient.
 The person delegating the power of attorney is
called the principal, whereas the person to whom
the power is granted is known as the agent.
 A general power of attorney is different in terms
that it would become invalid on incompetence of
the principal.
 Most AMDs statutes specifically provide immunity
for physicians who follow, in good faith, the
wishes of a client as expressed therein.
 Nurses should note that in most cases this
immunity applies only to the physician.
 Ethics relate to the moral actions, behavior, and
character of an individual.
 The role of the health care professional is to
maintain patient autonomy, maintain or improve
health status, and do no harm.
 The key ethical principles are autonomy,
beneficence, nonmaleficence, justice and veracity.
 Issues of ageism, ethnicity, sexual orientation,
gender, physical or mental disability, and race are
critical areas of difference that may effect the
nurse-patient relationship.
 Many citizens, come physicians, and some
other health care professionals believe that
doctors should be allowed to help severely ill
persons take their own lives.
 Actions such as failure to take steps to prevent
a suicide, deliberate administration of dosage
that will suppress respiration and cause death,
or the heavy doses of pain medications needed
to comfort a terminally ill client may be
intentional or inadvertent acts of assisting
suicide or euthanasia.
 Unlike an act of affirmative euthanasia, where
the nurse’s actions are clear, in situations
where there are competing interests
(therapeutic necessity and likely outcomes), the
nurse must rely on the client’s needs and his or
her own professional judgment.
 What about the person who, although not
terminally ill or in a persistent vegetative state,
is in her 80s and wishes to stop eating or
drinking with the intent of causing her own
death?
 In a 1987 case, In re Application of Brooks, the
court denied the petition of the nursing
administrators to authorize forced feeding.
Although physicians disagreed regarding the
resident’s competence, the court decided she
was competent and thus had a right to
determine what was to be done with her body.
It found that failing to force feed is not abetting
suicide.
 Nursing facility residents, or any clients, may
refuse to participate in experimental research
and they may refuse to be examined, observed,
or treated by students or other staff without
jeopardizing their access to care.
 The goals of research is different from the goals
of care.
 Research seeks to acquire knowledge with no
intended benefit to the subjects, because much of
clinical research is conducted to determine
effective treatments or potential benefits of new
drugs and medical devices.
 The goal of client care, on the other hand, is to
provide benefit only to a specific client.
 Research involving humans should be examined
by an appropriate review board.
 All aspects of the proposed study must be
evaluated to ensure that the research is justified
and is of benefit, and that individual rights of all
persons, including volunteer participants, are not
sacrificed.