Respecting patient autonomy: understanding the impact on NHS hospital in-patients of legislation and guidance relating to patient capacity and consent

摘要

Objectives: To determine the extent and nature of the decisions individuals are asked to make as in-patientsnand whether doctors, nurses, other health care practitioners, and housekeepers engaged in routine (non-nemergency) medical assessments, investigations and treatments, or acts of personal care observe the ReferencenGuide to Consent for Examination or Treatment, the principles of the Mental Capacity Act (England and Wales)n2005, and the guidance from the Dignity in Care Campaign.nMethods: Hospital staff working on a general medical ward and a ward for older people in a large teachingnhospital in England were observed for over 50 hours carrying out acts of medical and personal care. Thenobservations were recorded using a semi-structured record sheet, complemented by unstructured field notesnObservations were subsequently categorized, coded and counted.nResults: A total of 206 acts were observed, 127 (62%) of which were acts of medical care and 79 (38%) were actsnof personal care. Patients approached for acts of personal care were generally presented with choices and optionsn(78%). In contrast, when approached for acts of medical care, they were rarely presented with a choice (6%);ninstead, health care practitioners either requested permission to perform a procedure (29%) or informednpatients that they were about to perform a procedure (50%). Irrespective of the way in which health carenpractitioners approached patients about acts of medical care, in the overwhelming majority of instancesnpatients complied (80%, 99 cases), either by giving permission for the act to be performed, or by complyingnand/or cooperating with the health care practitioner. In only a minority of cases did patients either refuse ornresist a proposed procedure (9%).nConclusions: Patients were asked to make many varied decisions and the approaches taken by hospital staffndiffered depending on the nature of the decision and/or act in question. In contrast to personal carendecisions, when health care practitioners approached patients in order to undertake routine acts of medicancare, they generally did so in a manner that did not acknowledge that the patient had a right to exercise anchoice. This is contrary to current law, policy and guidance. It seems to be rooted in the practical demands ofnrunning a hospital ward and uncertainties as to the purpose of securing patient consent before undertaking