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Difficulty: Very hardInformed Consent

A 79-year-old client with a documented history of mild cognitive impairment is scheduled for the elective placement of a permanent pacemaker. The client's legally appointed healthcare proxy signed the informed consent document the previous evening. While the registered nurse (RN) is preparing the client for transport to the catheterization laboratory, the client becomes tearful, grasps the RN's hand, and states, "Please don't let them put that metal box in my chest. My child is forcing me to do this so I live longer, but I am ready to pass on naturally." The client is currently oriented to person, place, and the immediate situation. What is the priority nursing action?

  1. Withhold any preoperative medications, pause the transport process, and immediately notify the primary healthcare provider of the client's explicit refusal.Answer
  2. B
    Attribute the client's tearfulness to the expected progression of their cognitive impairment and proceed with the scheduled transport, as the legal proxy has already consented.
  3. C
    Ask the client, "Why did you wait until right before the surgery to tell us that you disagree with your child's decision?"
  4. D
    Instruct the unlicensed assistive personnel (UAP) to sit with the client and explain the life-saving benefits of the pacemaker to calm them while the RN prepares the surgical chart.

Answer

The correct action is to withhold any preoperative medications, pause the transport process, and immediately notify the primary healthcare provider of the client's explicit refusal.
The correct answer acknowledges the fundamental principle that informed consent is an ongoing process, not a one-time signature. Even if a legally appointed healthcare proxy has consented, if the client demonstrates situational orientation and actively refuses an elective procedure, the procedure must be halted. The nurse's primary role is to act as the client's advocate by ensuring their immediate autonomy is respected and notifying the primary healthcare provider, who is responsible for conducting a formal reassessment of the client's decision-making capacity before proceeding.

Step-by-Step Solution

1
Assess the client's current clinical and cognitive status in relation to their expressed statements.
The client is oriented to person, place, and situation, and is clearly expressing a desire to refuse the elective procedure despite the proxy's prior consent.
Determining the client's immediate level of orientation helps establish if they possess situational capacity to revoke consent.
2
Identify the legal and ethical hierarchy of consent.
Even when a healthcare proxy is established, a client who demonstrates situational capacity and actively refuses an elective procedure cannot be forced to undergo it.
The ethical principle of autonomy requires the nurse to advocate for the client's current, expressed wishes over the proxy's decision, pending a formal medical reassessment of capacity.
3
Implement the safest intervention to protect the client's rights.
The RN halts all preoperative procedures (including sedation) and contacts the healthcare provider.
Only the primary healthcare provider can formally re-evaluate the client's decision-making capacity and determine the legal next steps regarding the revoked consent.

Key Concept

Client Advocacy and Revocation of Informed Consent
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Topics

Informed Consent

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