Fundamentals - Principles, part 2: Informed Consent and the Right to Refuse

by Meris Shuwarger July 12, 2021

In this article, we'll explain two important nursing fundamentals topics: informed consent, and a patient's right to refuse. You'll learn about the provider's vs. the nurse's role in informed consent, and nursing actions to take when a patient wants to leave against medical advice. The Fundamentals of Nursing video series follows along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

Informed consent is an important process that confirms a patient's voluntary decision to undergo a procedure or intervention. During the informed consent process, both the provider and nurse have specific roles to perform.

Check out our Psychiatric Mental Health article on Informed Consent in the mental healthcare setting.

Provider's role

When a patient is giving informed consent, the medical provider's role is to explain the nature, risks, and benefits of the procedure. The provider (NP, PA, MD, etc) must also explain the alternatives to the procedure and the risks and benefits of those alternatives. The provider must also assess the patient's understanding of the information—the patient must understand what has been explained. Most importantly, it is the provider's job to answer all patient questions regarding the procedure.

If a patient has questions about the procedure even after they have already given consent, the provider must be contacted to answer those questions. As a nurse, you can reinforce the provider's teaching, but you would not be the one to answer questions about the procedure for the purposes of informed consent.

Nurse's role

The nurse does not receive informed consent from a patient, the provider does. But, the nurse's role is to sign the patient's consent form as a witness. The nurse must confirm the patient received and understands the procedure, its risks, benefits, and alternatives, and most importantly, ensure the patient was competent and gave consent voluntarily.

The nurse should ensure that this consent was given voluntarily. This means that no one else besides the patient is giving consent—not family members, spouses, children, or medical professionals. The patient has not been coerced or forced into signing the consent. This patient understands, agrees, and wants to have this procedure done.

A nurse's role as a witness for informed consent is just one way that nurses act as advocates for their patients.

Documentation

When a patient is giving informed consent, all elements of informed consent must be documented on a form or in a patient's medical record. So, a signed consent form would be part of a patient's chart.

Who can give informed consent?

For patients to be able to give proper consent, there are some standards that must be met.

Oriented patients

If a patient is not oriented, they cannot be deemed competent to provide consent. A patient being oriented means they are functioning cognitively, and are alert and aware of what's going on.

In the Levels of Consciousness which you will learn in a head-to-toe assessment, a patient is Alert if they are awake, oriented, responding to questions appropriately, and following commands. This and more assessment topics are covered in our Health Assessment Flashcards for nursing students. Orientation is just one of the factors that goes into level of consciousness.

A patient would not be considered oriented to give consent if they are drunk, or high on drugs, on mood-altering medications like strong pain medicines or sedatives, or if they have a cognitive disorder such as dementia. These would impair the patient's ability to give consent.

For more specific teaching on mental health disorders and informed consent, check out our video on Psychiatric Mental Health: Informed Consent & Ethical Principles.

Adult patients

Usually, a patient must be 18 years old or older to give informed consent for a procedure, but there are some exceptions.

Some common exceptions with regards to the patient are if the underage patient is legally emancipated from their parents or guardians (legally granted the status of adult), married, or in the military.

Some other exceptions with regard to the procedure are if the underage patient requires mental health treatment, substance abuse treatment, or sexually-transmitted infection (STI) testing or treatment.

These age-based guidelines vary by state, so it's important to check in your own state.

Language comprehension and/or interpretation

Assuming the procedure explanation and documentation are given in English, a patient who does not speak English cannot consent without a medical interpreter available to translate. A patient must understand what they are consenting to.

It's important to know that a patient's interpretation services for the purposes of informed consent should be from a medical interpreter, not the patient's family members. A medical interpreter ensures the complete understanding of complex medical information to patients who speak a different language.

Who can revoke informed consent?

After a patient has already given informed consent, they still have the right to change their mind and decline treatment.

Refusal of treatment (right to refuse)

Patients who are competent to provide consent have the right to refuse medications or other therapies even if they were involuntarily admitted (except in emergency). This guideline helps protect a patient's autonomy.

Leaving Against Medical Advice (AMA)

A patient is Leaving Against Medical Advice (AMA) when they choose to leave the hospital or facility before the treatment team recommends discharge. Statistically, leaving AMA does place patients at a higher risk for readmission and morbidity/mortality, but it is their choice and right to do so.

Nursing actions for AMA

If a patient is choosing to leave AMA, you must notify the provider. Make sure to discuss the risks associated with leaving AMA with the patient. A patient will need to sign an AMA form, and if they refuse to sign one, you will need to document their refusal to sign.

In order to help protect this patient's health and safety, make sure to remove any indwelling medical devices like Foley catheters or IV catheters before they leave, and apply dressing where needed.

Remember that it is a patient's right to leave AMA, so you don't need to call security and you should NOT restrain them or block their ability to leave. Please note that inappropriate confinement of a patient with restraints, seclusion, or a medication acting as a chemical restraint, is considered false imprisonment and violates a patient's rights.


Full Transcript

Hi, I'm Meris and in today's video, we're going to talking about informed consent and the patient's right to refuse.

I'll be following along with our Fundamentals of Nursing flashcards which are available on LevelUpRN.com. So if you have them you can follow along with me. I will be starting on card number four. So let's get started.

Alright, card number four. We're talking about informed consent. And in this card we talk about the provider's role and the nurse's role and how we document things.

The provider is the person who is performing the procedure. This could be an NP, a PA, an MD, anyone who is the person performing the procedure. And the role of the provider is to explain to the patient the risks and benefits of the procedure, the alternatives to the procedure, and the risks and benefits of those alternatives.

So this key to informed consent because this is how a patient is informed before they give their consent for a treatment or a procedure. They need to understand everything that goes into that. And that's the provider's job. And if you see here, we do have in bold red on this card the fact that the provider's job is also to answer all the patient's questions.

So that means that if your patient has questions, even after signing informed consent, it is the provider's job to answer them. So you would not do that as the nurse.

What would you do as the nurse, though? So the nurse's job is to sign the form as a witness. So the nurse does not get the informed consent. The nurse is responsible for saying, yes, this patient was given the risks, benefits, and alternatives by the provider, they had all of their questions answered, and that the patient is competent to provide consent.

Meaning that they are cognitively intact. So they are not, for instance, drunk or high on drugs, that the patient does not have a cognitive disorder such as dementia. All of those things would impair their ability to give their consent.

And then the nurse should also ensure that this consent was given voluntarily. That essentially means no one, not family members, spouses, children, or even medical professionals, no one is coercing this patient or forcing them into signing this consent. That this patient understands, agrees, and wants to have this procedure done.

And then you're going to document this in the medical record, along with the signed consent form is going to be uploaded to the patient's chart. So that is informed consent.

Okay, so moving onto the next card about informed consent. This is key points, and I'm going to tell you, when we take the time to pull out key points on a topic, that usually means it is pretty heavily tested. It usually means you're going to see it come up, right? So I would really pay attention to this card in your [flashcard] deck because it outlines a lot of information you need to know about informed consent.

So like I said before, the fact that the patient is oriented is crucial. Your patient may not be able to provide consent if they are on mood-altering medications such as strong pain medicines or sedatives, and then things as well like delirium, dementia, use of alcohol or drugs.

All of those things would make a patient not competent to provide consent. The other thing is that the patient needs to be 18 years or older, right? They need to be a legal adult, except when they don't.

And this is going to be very important for you to know what your state laws are, but in many states, a patient who is under the age of 18 can provide consent in some rare instances such as if they are married, if they are in the military, if they are legally emancipated, meaning that they are legally granted the status of being an adult, and then there are some other times, such as if the patient needs mental health treatment, substance abuse treatment or STI (sexually transmitted infection) testing or treatment. Those things would be covered for them to consent to themselves.

Other than that though, they should be 18 years or older.

Again, and listen, I've told you twice. It's really important. If your patient has questions, who do we contact? The provider. The nurse can always reinforce teaching, but the nurse may not answer questions about the procedure for informed consent.

Another thing that I cannot stress to you how important this is, if the patient does not speak English, they cannot provide consent unless they are provided interpretation services.

And usually this is with a medical interpreter, not the patient's family members. We need to have someone who is a medical interpreter, who this is their job and we can confirm that they are an objective third party.

The other thing that—guys, this is so crucial to know for fundamentals, for mental health, for everything—is that even after informed consent has been obtained, the patient still has the right to refuse. So if your patient signed informed consent for a surgery and then said, "Actually, you know what? I've changed my mind I don't want it, that is their right.

Go back and look at our video about ethical principles and tell me in the comments which ethical principle are we upholding when we support a patient's right to decline treatment even after signing their informed consent?

Lastly, we're going to talk more about a patient's right to refuse treatment. This is so, so, so important and we need to understand everything that goes into refusing treatment. So like we said, if you are competent to provide informed consent, then you are competent to refuse treatment.

So all of those same conditions apply when it comes to being competent to give refusal for treatment.

The other thing is that patients do have the right to leave against medical advice, and this means that they have been explained the risks of leaving and that this is against the advice of a medical provider.

And usually there is a form for them to sign and all of that sort of good stuff to document, "hey, we told them and they left anyway." They still have the right to leave, so you're not going to block their ability to leave. You're not going to call security if they try and leave AMA. Even if they can't sign that form or won't sign that form, you're still going to let them leave.

And then the other thing is when it comes to leaving against medical advice, you need to make sure to remove any sort of indwelling devices like Foley catheters or IV catheters before the patient leaves. That's very important for their health and safety.

Okay, that is it for informed consent and a patient's right to refuse. I hope that review was helpful. In my next video, I'm going to be talking about advanced directives and HIPAA, so I hope you will follow me over there and check out that information. Thanks for joining me. Please don't forget to like, comment, and subscribe so you can see videos just like this on all kinds of nursing content. Happy studying!


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