PATIENT AUTONOMY

AAOS ETHICS COMMITTEE

Paul Levin, MD

1

Objectives

• Define patient autonomy

• Define, if any, limits to patient autonomy

• Identify physician alternatives if patient does not accept treatment plan

2

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

3

CaseYou 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 You carefully explain the severity of the injury to the patient and recommend an immediate I&D with intramedullary nailing.

Physicians should not be paternalistic

4

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 care for him that doesn’t require being in an operating room.

5

What are the ethical principles involved?

Do you have any legal concerns?

6

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.

7

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.

8

After the patient explains his fears, you recommend an evaluation by a psychiatrist.

Pixland/Thinkstock

The patient thanks you for your concern, but says “I don’t want to speak with a shrink.”

9

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 life threatening injuriesand died as a result of those injuries. You explain this to the patient and try to persuade him to agree to surgery.

10

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

11

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 institution’s ethics consultant service

12

ReferencesBeauchamp 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. 2005;6(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.

13

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.

14