Autonomy has always been the humans basic need in order to make firm identity and to be acountable on ones own self.Individual autonomy is an idea that is generally understood as the capacity to live life according to reasons and motives that are taken as one’s own and not the product of manipulative or distorting external forces.According to Almeida (2010),”autonomy is define as power of self over oneself, thefreedom. It is the individual’s sovereign over himself ,his body and mind”
Being confined to health care setup, autonomy plays a vital role in medical decisions. According to human rights and legislation by WHO (2005), patient is autonomous of refusing or selecting any mode of treatment and maximum freedom is provided to him.But it has been more challenging when needed to be followed in mental health care where patient’s rights must be secured while maintaining his dignity but at the same time improving his health as well,which remains an ethical dilemma.In socio-cultural context autonomy is considered as ethically and legally controversial issue. In western society, taking a client-centered approach, patient’s dignity and autonomy are given more importance as compared to Eastern society, where physicians and nurses are considered authoritative and given right to do what is better for patient.( Firoozabadi & Bahredar, 2009)
The reason for the selection of this topic is that as a nursing student, I found that autonomy is one of the most important ethical issue in mental health care setup. As Psychiatric patients usually have altered perception of reality which makes it difficult for the care provider to explain them the plan of care but at the same time protecting their rights as well, which make it an ethical dilemma for nurses but a great matter of concern as well. This paper will elucidate upon the importance of autonomy the significance of advance directives in mental health care mainly dealing with autonomy crisis.
A 28 years old woman was admitted at karwan-e-hayat with the diagnosis of schizophrenia. She was admitted with the complains of suspiciousness and aggression. She was suspicious with the staff and was refusing medicines due to paranoid delusion.The staff had given her medicines forcefully.As a result she gets aggressive and need to be restrained usually at the time of medicines.According to staff they had to deal these types of patients forcefully in order to improve their health.Although giving medications may improve her mental health but on the other hand forcing her generates the feeling of being dependent and compromised self-identity. Moreover, studies have shown that taking patient’s all of the autonomy have negative psychological outcomes on patients.while the patient with autonomy acquire positive attitude and high self esteem and as they are optimistic about future and feel empowered so they recover earlier than those with no autonomy(sakellari,2008)
According to WHO(2003),450 million people worldwide suffer of a mental or behavioral disorder.Is this significant population should be put in category of no autonomy just because they are mentally ill?.As they have been tagged as psychiatric patient and they don’t have decision making capacity hence there psychiatrist will take all decisions.If this is called as beneficence so we are just observing one side of the coin. A mentally ill patient usually has low self-esteem due to the stigmatization by the society and even their own family.Furthermore when the health care setup in the name of beneficence take over their autonomy, it shatters their dignity and self-respect and when patient gets aggressive and not participative due to being less autonomous ,soon we document the symptoms.
Even a normal person also gets angry when treated forcefully.Here the point of view is that giving all the autonomy to health care professional just because patient is mentally ill is not the only solution.A mutual decision should be taken to satisfy patient and not to harm him as well. As in the above case scenario patient was not ready for taking medication and following treatment but at the same time medications were important for him but giving him forcefully seems a psychiatric patient with no autonomy.
Psychiatric advance directive has found to be one of the more promising innovations in recent years to give patients a greater voice in their psychiatric treatment.It involves patient and his family in making decisions, fosters better collaboration between care providers and patient. Individual feels that he has some control over his life, and has input into the course of treatment, thus does not feel helpless,or dependant on others. According to (Elbogen et al., 2007) “Psychiatric advance directives are legal tools allowing mentally ill individuals to document prospective treatment choices in the event of becoming incompetent in the future”.However it was first practiced by scotland in 2003 when included in scotland’s “Mental Health Act 2003”.
Advance directive help patient to make decisions about his treatment. It is the way of encouraging patient and care provider to negotiate on mutually agreeable care plan.As a result patient remains autonomous and treatment process is also not hindered(Appelbaum,2004).It will not change the course of treatment but will explain it in ethical way as in the above mentioned case patient’s medicines are improving patient’s health but except of forcing the patient and violating the autonomy if advance directive would have been followed prior to it,It may have helped nurse in handling the patient and patient might not be aggressive.
According to Srebnik & Fond(2007), psychiatric advance directives are divided into two major classes.Instructional directive contains instructions in the form of living will by the patient in advance that tell care providers that how to handle a patient in any mental health crisis. whereas proxy directive allows an individual to designate someone else either family member or closed one,to make medical decisions on patient’s behalf. Proxy directives are most commonly used in mental health where another person who is mentally competent and on which patient trusts most, take the decisions on patients behalf.As in the above senerio instead of forcefully giving medications to the patient by staff a close one or a family member whom which patient trust the most have took the decision so patient might would not be suspicious and aggressive.
According to shared decision making model (Adams et al.,2007) patient should have equal participation in making decision for care plan along with the health care provider as it promotes patients autonomy and motivates patient participating actively in treatment and reducing anxiety of patient. Advance directives has proven to be an efficient way for including patient in his own treatment plan as before directives particularly psychiatric patients were not the part of decision making . But like other patients psychiatric patient can equally get involve in their treatment
In Pakistan advance directives in psychiatric setup has not been practiced yet and nor it has been included or supported by mental health Act though it has been practiced in critical care since many years. Furthermore very less population is aware of it due to which autonomy crises have not been significantly reduced. But due to the emerging role of advance directive in mental health, it is needed to be included in mental health Act but also making it compulsory.Secondly staff and the health care professional should be taught using the advance directives and legal and ethical formalities fulfilled at the time of signing the legal document. Lastly patients and their families should be given awareness about it because most of the time legal Acts are available but due to lack of knowledge, not used.
In conclusion autonomy has always been a leading ethical issue in mental health care where beneficence overrides it but use of advance directives provides patient autonomy for making treatment decisions and helps care provider giving care being in an ethical context.Advance directives not only act as solution for ethical issues but also contribute in increasing patient’s self esteeem,self respect and feeling of empowerment.It is needed to be the part of mental health care setup and patients should be aware of using it as it gives a mutual path of not voilating autonomy and improving health as well.
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