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LAW AND MEDICAL PRACTICE FOR AMC MCQ

THE APPROPRIATE PERSON TO CONSENT OR REFUSE TREATMENT FOR OLDER CHILDREN

MCQs
1. A 15-year-old girl who has lived on the streets for some time is taking OCPs for the last 3 years. She comes to you complaining of vaginal bleeding. She has a 17-year-old boyfriend. You need to get consent in order to do vaginal examination. Who will you need to get the consent from: a. Her parents. b. Contact a guardianship. c. Get consent from her. d. Her boyfriend. e. Her oldest brother.
Recall: 21st November 2010

THE APPROPRIATE PERSON TO CONSENT OR REFUSE TREATMENT FOR OLDER CHILDREN After the age of 18 years children are legally entitled to make their own decisions. However, as children grow up, they gradually acquire the right to make their own decisions about at least some procedures. Children are becoming physically mature earlier than in the past and have increasing financial independence.
Skene L. Law and Medical Practice. 3rd Edition. Chapter 4. Page 126

MCQs
2. A 14-year-old girl comes to the ED with a diagnosis of acute appendicitis. Taking the medical history she says that has run away from home 2 days ago. Who is the most suitable person to make the consent for her surgery? a. The patient. b. The patients parents. c. The patients boyfriend. d. A guardian appointed by the guardianship court. e. The patients best friend.
Recall: 28th November 2009

SIMPLE PROCEDURES
The age at which a child is sufficiently mature to consent independently to treatment depends not only on the age but also on the type of procedure in question. A relatively young child, for example, even a child of only seven or eight years, could consent to simple procedures (non-invasive).

Skene L. Law and Medical Practice. 3rd Edition. Chapter 4. Page 127

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MORE SERIOUS PROCEDURES

GILLICK COMPETENCE: Mature minor test If the procedure is more serious the child must be older before being able to consent. For most of these procedures in question the age is older than 16 years. If younger, before acting on the consent of a child a doctor must be satisfied that the child has sufficient understanding and intelligence to understand fully what is proposed.
Skene L. Law and Medical Practice. 3rd Edition. Chapter 4. Page 128

MCQs
3. A 72-year-old patient with diagnosis of Alzheimers dementia is brought to the ED by his wife and 25-yearold son. He had a fall and a subsequent fracture of femur for which needs an urgent surgery. Who is the more suitable person in order to get consent for surgery? a. The guardianship court. b. His son. c. His wife. d. His best friend. e. The patient.
Recall: 21st November 2009

MORE SERIOUS PROCEDURES

A child who is socially independent of the parents, living alone and self-supporting, is more likely to be legally competent to consent. The more serious or invasive the procedure, the more carefully the doctor should assess the childs level of understanding.

MCQs
4. A 72-year-old man with diagnosis of Alzheimers dementia has just been diagnosed of a terminal illness. His wife wishes her husband to have palliative care but his 25-year-old son demands full treatment. What is the most appropriate thing to do in this situation? a. Follow wifes wishes. b. Follow sons wishes. c. Check competence of the patient. d. Contact guardianship court. e. Have a family meeting.
Recall: 21st November 2009

Skene L. Law and Medical Practice. 3rd Edition. Chapter 4. Page 128

TREATMENT OF CHILDREN WITHOUT CONSENT

As with adult patients, it is sometimes lawful for a doctor to treat a child without the consent of a parent or guardian, the child or anyone else. If an emergency arises and there is an imminent risk of death or serious injury to a child, doctors may do whatever is necessary to avert that risk without seeking consent from anyone.
Skene L. Law and Medical Practice. 3rd Edition. Chapter 4. Page 143 Recall: July 2010

MCQs
5. A 60-year-old woman was brought in by her husband to the ED saying that she has not eaten for weeks because she believes she does not have bowels. After stabilizing the patient the husband tells you that they do not live together. During psychiatric assessment it is proposed ECT but the patient refuses to it. What is the most appropriate thing to do? a. Do ECT under legal order act. b. Obtain consent from husband. c. Obtain consent from the patient. d. Obtain consent from his nearest relative. e. Contact the mental health tribunal.

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ASSESSMENT OF PATIENTS
Tests for competence require the patient to be capable of understanding the nature and effect of the proposed procedure and capable of indicating consent or refusal. The definition of a person who is incapable of giving consent has been given as: incapable of understanding the general nature and effect of the proposed procedure of treatment or of communicating consent or refusal.
Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 154

CONSENT FOR ADULT PATIENTS WHO ARE NOT MENTALLY COMPETENT TO CONSENT

CONSENT FOR ADULT PATIENTS WHO ARE NOT MENTALLY COMPETENT TO CONSENT
Although relatives have commonly been consulted and involved in decision making in some circumstances, there is no common law authority to support this practice, and relatives have no legal authority at common law to consent to treatment. Relatives and carers have legal authority to consent only where the common law principle has been changed by legislation.
Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 153

WHO HAS AUTHORITY TO CONSENT FOR AN INCOMPETENT PATIENT?

1. Advance directive by patient.
The first source of guidance for doctors on the treatment to be offered to an incompetent patient is the patients own advance directive given BEFORE he or she became incompetent. This may state whether the patient wishes to have particular treatment or to refuse it.

Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 157

CATEGORIES OF INCOMPETENT PATIENTS

Incompetent from birth due to a congenital condition that impairs their mental capacity. Others become incompetent later in life, due to mental illness.

WHO HAS AUTHORITY TO CONSENT FOR AN INCOMPETENT PATIENT?

2. Surrogate decision maker appointed by the patient (Health attorney, medical agent or enduring guardian).
If a patient is incompetent and has no previously consented to treatment or refuse it, a person appointed in advance by the patient may have authority to decide on the patients behalf. Most Australian jurisdictions now have legislation enabling patients who are over the age of 18, while competent, to appoint someone else to make medical decisions for them if they later become incompetent.
Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 158

Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 153-54

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WHO HAS AUTHORITY TO CONSENT FOR AN INCOMPETENT PATIENT?

3. Guardian appointed by a board, tribunal or court.
If a patient is not competent (and, in jurisdictions that have legislation allowing people to make advance directive or to appoint their own substitute decision maker, has not done so), it may be necessary for a substitute decision maker to be appointed by a guardianship body.

WHO HAS AUTHORITY TO CONSENT FOR AN INCOMPETENT PATIENT?

4. The bottom line: Relatives and carers.
If there is no person who has been formally appointed as a surrogate decision maker, either by the patient or by a guardianship body, a relative or carer may be able to consent. This Acts set our a hierarchy of people to decide the person responsible including relatives and carers, for consenting to treatment (different depending state).
Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 164

Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 161

WHEN A GUARDIANSHIP BODY CAN APPOINT GUARDIAN

A guardianship body will not intervene by appointing a guardian unless that is NECESSARY. IF THE PERSONS RELATIVES ARE CARING FOR THE PERSON SATISFACTORILY, IT IS GENERALLY CONSIDERED THAT THERE IS NO NEED FOR A GUARDIAN. If, however, there is a dispute between family members about the persons care, a formally appointed guardian may be needed to make or review decision about the person.
Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 161-62

WHO HAS AUTHORITY TO CONSENT FOR AN INCOMPETENT PATIENT?

Victoria: 1. A person appointed by the patient under the Medical Treatment Act. 2. A person appointed by the Victorian Civil and Administrative Tribunal to male decisions in relation to the proposed treatment. 3. A person appointed under a guardianship order with power to make such decisions. 4. An enduring guardian appointed by the patient while competent. 5. A person appointed by the patient with power to make such decisions. 6. The patients spouse of domestic partner. 7. The patients primary carer. 8. The patients nearest relative.

Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 166

WHEN A GUARDIANSHIP BODY CAN APPOINT GUARDIAN

The pragmatic reasons for not appointing guardians in every case where a person is mentally impaired are evident. If it is necessary to apply for a guardian to be appointed in every case where an incompetent patient has something done to his or her body, the costs and administrative procedures will be enormous.
Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 162

WHO HAS AUTHORITY TO CONSENT FOR AN INCOMPETENT PATIENT?

A doctor may undertake urgent treatment for an incompetent patient to save patients life, prevent serious damage to the patients health; or prevent the patient suffering or continuing to suffer significant pain or distress

Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 167

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MCQs
6. A 75-year-old man with diagnosis of Alzheimers dementia is admitted to the ICU for a diagnosis of MI. The possibility of intervention is discussed with his wife. How does his guardian or wife base the decision for consent? a. Risk and benefit of current decision. b. Based on the patients previous wishes and interests. c. Based on her own wishes. d. Based on the doctor wishes. e. Based on her family wishes.
Recall: 21st November 2009

Although parents who have the authority to consent are also entitled to refuse treatment that a doctor recommends, this is subject to statutory provisions and court intervention. IMMUNISATION: In Australia, immunisation of children is not compulsory, but they may be required not to attend school if there is an outbreak of disease.

Skene L. Law and Medical Practice. 3rd Edition. Chapter 4. Page 125

The decision maker must consult the represented person and take account of his or her wishes as far as possible and also of the family. The decision maker must be satisfied that the proposed procedure is in the persons best interests. The guardianship legislation directs that treatment should be the least restrictive possible, in the patients vest interests and should take account of the patients wishes.
Skene L. Law and Medical Practice. 3rd Edition. Chapter 5. Page 162-63

MCQs
7. A mother presents to your clinic with her 12-month-old baby and wants to talk about immunisation. After discussing about risks and benefits she decides not to have her child immunized. WOF is correct regarding immunisation? a. In Australia immunisation of children is compulsory therefore there is need to proceed with the program. b. In Australia immunisation of children is NOT compulsory therefore we respect her wishes. c. The doctor is compelled to seek court authorisation for the immunisation to be undertaken. d. The doctor can tell the mother to calm down and come back next week. e. None of the above is correct.

Recall: May 2009