Importance of Context

In the article "Informed Refusal: A Patient's Right" published in the September issue of Nursing2022, the author, Kathleen Peterson, overstates the "times when a patient cannot decide to refuse care such as intoxication, the presence of a mental illness, dementia, or when they are at the end of life when a person's cognition may be impaired by the disease process." Peterson does not reference the ANA Code of Ethics for Nurses, with its emphasis on the right to self-determination. However, context is essential to assessing whether or not the right to informed refusal is negated.

Regarding intoxication, mental illness, or dementia, what is the scientific evidence? And regarding end-of-life cognition, what evidence will the physician or advanced practice clinician (APC) use to determine that the individual no longer has the right to refuse?

The tools the author recommends are useful if they are available and if the physicians and APCs know how to use them. However, in community-based primary care, they will not be of much help to physicians and APCs managing patients who may be agitated, intoxicated, or patients with schizophrenia, or with early-stage Alzheimer disease.

Linda Ruholl, RN, PhD

Teutopolis, IL

Author's response

Nursing assessments and judgments are required to determine if a person is not able to make the decision to refuse care in the case of intoxication, mental health crisis, dementia, or end-of-life when a person's cognition may be impaired by the disease process. Unfortunately, these are situations that are not clear-cut with readily available tools for each condition. Family and friends, if available, may assist in the assessment of the cognition level in these cases. In some circumstances, nurses may wish to involve their institution's legal department and ethics committee. Having worked in community-based community care, I understand that healthcare team members in the community do not have the teams of providers to confer, legal departments, or ethics committees. This is when nursing assessments, evaluations, and judgments are critical.

The ANA Code of Ethics for Nurses1 should have been referenced in this article-thank you for the opportunity to add this. Provision 1.4 states:

"Respect for human dignity requires the recognition of specific patient rights, in particular the right to self-determination. Patients have the moral and legal right to determine what will be done with and to their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed decision; and to be assisted with weighing the benefits, burdens, and available options in their treatment, including the choice of no treatment. They also have the right to accept, refuse, or terminate treatment without deceit, undue influence, duress, coercion, or prejudice, and to be given necessary support throughout the decision-making and treatment process."

Thank you,

Kathleen Peterson, PhD, RN, PPCNP-BC, CNE

Brockport, N.Y.

REFERENCE