#All smiles behind her mask, duly informed of the benefit / risk ratio of the SARS-CoV-2 vaccination and consenting, #Mauricette, 78 years old, willingly takes part in the media photo shoot organized in her long-term care unit in #Sevran, this #Sunday, #December 27, 2020.
#But what about all the other vulnerable patients, suffering from cognitive disorders, residents in long-term care (LTC, “long stays”) or in a residential establishment for dependent elderly people (#Ehpad )? “Prioritized” within the framework of this very recent vaccination campaign, because of their old age or their multiple pathologies, how to collect and trace their consent? #Could we decide for them?
#Consent in medicine
The revelation of the atrocities committed during the #Holocaust, which led to the killing of nearly 6 million #Jews in #Europe by #Nazi #Germany, resulted in the writing in 1947 of the #Nuremberg #Code.
#This text sets out the rules for consent to biomedical research by people incapable of judgment. #This principle, fundamental in medical ethics, is reaffirmed in the law of #March 4, 2002, which advocates autonomy, including in care procedures, rather than paternalism, which until then was marked by the doctor-patient relationship. #It is about involving patients in decisions that affect them. #Concretely, any practitioner must inform the patient to obtain his consent to the care he offers, in accordance with article 35 of the #Code of medical ethics. #It is required to give understandable information, “#Fair, clear and appropriate”. A good practice rule is to base this communication on an oral interview, with the support of a document given to the patient.
The oral exchange is important because the patient can ask questions, have certain points repeated or clarified. #It is also thanks to him that the caregiver can ask the patient to rephrase, in his own words, what he has learned from the exchange, and thus ensure his level of understanding. #In any case, informed consent cannot therefore be reduced to affixing a signature on a form (such a document has moreover only relative legal value in #French law).
#What does “consent” mean?
#According to #Littré, to consent means to adhere to, to accept something as possible, achievable, to authorize, to allow, to conform to. #It is also to give in, to condescend to, to deign. #To surrender to a feeling, to a will, to an obligation.
#We note that several meanings emerge from this word, declining chiaroscuro which range from acquiescence to constraint. #In my medical practice, with my very old patients suffering from #Alzheimer’s disease, I retain this definition from #Latin: allow, of cum, together and feel, feel, think. #To consent is to “feel together”.
#Doses of the #Pfizer-BioNTech vaccine against #Covid-19, at #René-Muret hospital in #Sevran. | #Thomas #Samson / AFP / #Pool
#When illness breaks the symmetry of consent
#Consent is the expression of two wills where the first suggests, proposes and states and the other adheres, accepts or refuses. #Consent implies an agreement, a mutual commitment, after the rights and duties have been stated, like a marriage or divorce. #In his #Technical and critical vocabulary of philosophy, the philosopher #André #Lalande notes that “#To consent is an act of will by which one decides or even expressly declares that one is not opposed to a determined action the initiative of which is taken by another”.
The act of consenting supposes a double competence: that of understanding and that of being able to determine oneself freely and to make choices. #This implies, at the same time, the possibility of refusal, termination, termination of the contract at any time. #For consent to be fair and informed, the proposing party and the consenting party must have the same bases for analyzing the situation.
#We can clearly see that, in the case of #Alzheimer’s disease, this “symmetrical” contract is not appropriate: the two parties are not in equal understanding, in the capacity to reach an agreement. #Not asking the other for his opinion because of his cognitive alterations, or insisting, arguing, pressing an individual to the point of overriding a refusal, until obtaining this famous consent, reduces him to the quality of an object. #However, the sick, until the end of their lives, remain people to whom we must address as such, despite their impaired capacities.
#What to do about #Alzheimer’s disease?
#To consent, you must understand what we are offering you: in this specific case, the long-awaited vaccination against the SARS-CoV-2 coronavirus responsible for #Covid-19. The patient must therefore be informed, but repeatedly and within a specific timeframe: the information must be delivered in thehere and the now, under penalty of being quickly forgotten. The deliberation time is therefore reduced.
#We have to make sure that the person concerned understands the situation, that he has the possibility to refuse, that he understands the benefits and the risks, explained in layman’s terms, and that he understands what are the alternative solutions, if necessary. there is. #We too, doctors, must be informed of the recommendations in force concerning vaccination, such as those issued by the #High #Authority for #Health (HAS), in order to be able to respond if fears are expressed.
#Consent or assent?
#In practice, we have found that consent, understood as the expression of complete autonomy in care or entry into an institution, is one of the most difficult ethical problems to resolve. #It is arguably inappropriate in the context of #Alzheimer’s disease. Therefore, in patients who suffer from it, it is better to seek assent.
#Even if the etymologies of the words “consent” and “assent” are similar, these terms are not similar. #Consent is an agreement between two parties, after having received and understood the information concerning this “contract”, and with the possibility of a refusal. #Rather, assent consists of a posteriori consent, which is more flexible and can be given despite incomplete understanding, in a climate of mutual trust and without showing any sign of opposition. The recommendation of the #Erema (#National #Space for #Ethical #Reflection on #Alzheimer’s #Disease) is moreover to seek, “A deep assent, an agreement of participation founded on an incomplete understanding, by signs indicating a confidence”.
#When #Alzheimer’s disease progresses and no longer allows for consideration of the patient’s opinions and fundamental options, we turn to “substituted consent”. #It is a question of seeking the wishes expressed in the advance directives, the opinion of the person of trust, of the family, or the decision of the legal representative according to the law of #March 23, 2019 on the reform of protected adults (guardian to the person or family empowerment).
#Seeking at all costs the free and informed consent of patients with #Alzheimer’s disease when vaccinated against SARS-CoV-2 also means considering them as human beings capable of autonomy, choice and discernment, despite their over-vulnerability. #You have to know how to interpret a refusal, a hand or an arm that withdraws at the last moment, accept that a “no” expressed in response to a given person, at a precise moment, later turns into a “yes” with someone. ‘another. #It will always be the will of the patient that must take precedence.
The doctor must seek and trace this consent (or this refusal), and above all be guided by ethical vigilance which will lead to avoiding some pitfalls: consent in place of these patients, do not ask the question of consent, be satisfied with a parody of consent on a form. #If consenting does indeed mean “feeling together”, then let’s spare ourselves the time to indulge in it.
#This article is republished from The #Conversation under a #Creative #Commons license. #Read the original article.
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