The Right to Decide
In the May 2008 issue of GeriNotes, William H. Staples PT, DPT, GCS tackles the topic of informed consent and cognitively impaired individuals. Mr. Staples talks about the importance of determining if a patient is capable of giving informed consent. He approaches his topic from the ethics of asking someone-who doesn't have the ability to make decisions-to consent to something. Included in the article is a list of tools that can be used to determine decision making capability.
This made me stop and think. If I were to follow Mr. Staples' recommendations I would first need to determine the patient's ability to give informed consent. If that isn't possible, I would then need to contact the individual with medical decision making power to obtain consent. Mr. Staples makes a good point but doesn't address what therapists face in the real world.
I currently am working at an acute care hospital. The majority of my patients are elderly so I expect some of them to have dementia. As in all facilities there is pressure for PTs to see patients ASAP and continue to follow them. Physicians, a group not known for being patient, want their patients seen now and aren't happy about delays. Mobilization gets patients better faster as well as helps to prevent unnecessary complications. If I take a day or two to obtain consent, I'm going to have some angry physicians to answer to.
I'm not saying we should force a patient to participate against his will. If someone is agreeable to therapy I don't see a problem with taking that as consent. All the facilities I'm familiar with have patients or a representative sign a "consent to treat" form. That covers all treatments ordered by a physician. I can't imagine any therapist forcing someone to do therapy that doesn't want to do so.
Admission to a hospital or nursing facility comes with an unspoken acknowledgement that treatment is needed and puts the reasonability to provide the treatment on the facility. Informed consent becomes more meaningful when considering outpatient and home health settings where the tacit acknowledgement for care that comes with admission doesn't exist. These are patients that require an explanation of what is planned. The assumption that care needs to be provided isn't there. Nor, are the diagnostics as clear.
I'm a therapist. When I work with patients I explain what I am and why am I there. For the most part patients agree to participate with therapy. For those who are unable to indicate a decision, I have a consent to treat form giving me permission. If someone says no, I move on. This is going to grow in significance as the role of the PT changes. Therapists are going to find themselves facing issues they previously never considered. Therapists are also going to have to find the answers.