Healthcare and decision-making in dementia
The following information is taken from Law N° 1 (I) 2005 Safeguarding and Protection of the Patients’ Rights Law, which came into force on 7 April 2005 and can be downloaded at: http://www.bioethics.gov.cy/Law/cnbc/cnbc.nsf/All/6960B7A5AA76C4A3C22571C9002B99F0/$file/Patients%20Rights%20Law-English%20translation.pdf
Consent to medical treatment
Article 11 (1) states, “A prerequisite for the provision of health care is the patient’s consent given after complete medical information, which is provided by the health care services provider to the patient, in due time, and in a manner that is comprehensible to the patient, so that the latter may understand the information provided and make a free and independent choice.”
If the patient has chosen someone else to receive information on his/her behalf (please see relevant section), this person has the right to decide on his/her behalf. Such consent can be given in writing or orally, provided that it is put in writing as soon as possible.
In article 21 (4) of this Law, it is stated that in the case of patients who do not have the capacity to exercise their rights (which includes consent), such rights shall be exercised by a legal respresentative or a person whom the patient has appointed to that effect. If a representative is not available, reasonable measures must be taken in order to ensure the effective exercise of the patient’s rights.
A person who has been appointed by law to consent on behalf of a patient must involve the latter in the decision making process to the extent that his/her capacity and circumstances allow this.
Consent in case of emergency
In situations where medical care is urgently needed and the patient is in no position to express his/her will due to his/her mental or physical state, consent can be presumed, unless it is obvious from previously expressed wishes that he/she would have refused (article 13, §1).
If someone has or should have been appointed by law to consent on behalf of a patient (due to the patient’s mental or physical state) and such consent cannot be obtained in time, the consent of the patient for urgent medical care can be presumed, unless it is obvious that, in the circumstances, the patient would have refused (article 13, §2). In such cases, the patient shall be involved in the decision-making process to the extent that his capacity and circumstances allow this.
If health care is urgently needed and proper consent cannot be obtained, article 13, §5 authorizes healthcare services providers to provide such care provided that it is deemed to be in the patient’s best interests or beneficial to his/her health. Previously expressed wishes should in such cases be taken into consideration.
Refusal of consent (by proxy decision maker)
If the person appointed to consent on behalf of the patient refuses to give such consent and the health care provider believes that the treatment is in the patient’s best interests, he/she can, time permitting, refer to a court or other body prescribed by law. In the case of a medical emergency, the health care provider must act in the patient’s best interests (article 13, §4).
The right to refuse treatment
There does not seem to be any explicit reference to the refusal of consent in Law N° 1 (I) 2005 although the possibility of refusing treatment can be detected in a few articles For example, article 11 (§1) states that consent is a prerequisite for the provision of healthcare so presumably healthcare cannot be provided if such consent is not given (i.e. if it is refused). Similarly, the obligation on the part of doctors to inform patients about the likelihood of success and the possible risks of various forms of treatment but also of non-treatment suggests the possibility of refusing consent (article 12, d). Finally, article 13 (1) makes a reference to the refusal of consent in previously expressed wishes.
Consent to non-conventional treatment
For innovative treatment, the patient (or his/her representative) must be appropriately informed. Written consent must be obtained (article 11, §3).
Consent to participate in clinical teaching
The patient’s consent must be obtained if he/she participates in clinical teaching (article 11, §5).
Consent to the donation of organs and/or human tissue
Consent must be obtained from the patient to use any substances from his/her body. Such consent may be presumed if the substances are to be used for the purposes of diagnosis, treatment or care for which consent has already been obtained (article 11, §4).
Consent to research
According to the provisions of article 14, §1, people may take part in scientific research and experimental treatment if the following conditions are met:
- there is no alternative solution of comparable effectiveness;
- the risks which may be incurred by that patient are not disproportionate to the potential benefits of the research;
- the research project has been approved by the competent body after independent examination of its scientific merit, including assessment of the importance of the aim of the research and multi-disciplinary review of its ethical acceptability;
- the patient has been informed of his/her rights prescribed by this law;
The following additional conditions (article 14, §2) apply just to people who are unable to consent:
- the results of the research have the potential to produce real and direct benefit to his/her health;
- research of comparable efficiency cannot be carried out on individuals capable of giving consent;
- the necessary authorization provided for in article 13 (covering healthcare without the consent of the patient) has been given specifically and in writing, and
- the person concerned does not object.
Consent to clinical trials
It is not clear whether the above conditions also apply to participation in clinical trials.
Information is missing about advance directives. However, there are two references in article 13 to previously expressed wishes:
13, §1 Where the patient is in no position, due to his mental or physical state, to express his/her will and the provision of medical care is urgently needed, the consent of the patient may be presumed, unless it is obvious, from previously expressed wishes that he/she would have refused.
13, §5 In any case where proper consent is impossible to be obtained
a) any health care imposed as urgent may only be provided if the health care services provider deems it to be of benefit to the patient’s health or in the patient’s best interests;
b) any previously expressed wishes of the patient concerning health care shall be taken into consideration.
Whenever healthcare is provided without the prior consent of the patient, any previously expressed wishes concerning healthcare must be taken into consideration. However, there are no guidelines as to how previously expressed wishes should be recorded, the extent to which they are binding or just advisory and whether they must be made in writing.
Access to information/diagnosis
Articles 10, 12, 13, 15 and 18 of Law N° 1 (I) 2005 Safeguarding and Protection of the Patients’ Rights deals with access to information.
The right to be informed
Article 10 (§§1-6) states that every person has the right to be informed about patients’ rights and to have sufficient information about health services, as well as ways to make better use of them. Patients are also entitled to complete medical information. Any information given to the patient or his/her selected representative (please see below) must be in a comprehensive form with as little as possible technical terminology. Medical information is defined in article 12 as:
- the diagnosis of the patient’s medical condition and, if possible, its prognosis;
- a description of the purpose, anticipated benefit and likelihood of success of the proposed treatment;
- the risks entailed in the proposed treatment, including side-effects, pain and discomfort;
- the likelihood of success and the risks of various forms of treatment or non-treatment.
Access medical files
Article 18 of Law N°1 (I) 2005 Safeguarding and Protection of the Patients’ Rights covers access to medical records. It states that patients and their legal representatives have the right to access and if necessary rectify, erase or block records on the grounds that the information is inaccurate or missing. They are also entitled to receive a copy or extract of such information unless this information is likely to cause serious harm to the patient’s health or, in the case of genetic data, to certain relatives, or would unavoidably lead to the disclosure of information about other people. These rights may be directly or indirectly exercised through a patient’s legal representative.
Certain provisions of the Processing of Personal Data (Protection of Individuals) Laws of 2001 and 2003, as well as of the Processing of Personal Data (Licenses and Fees) Regulations of 2002 may also be relevant.
The right to designate another person to be informed on one’s behalf
People have the right to appoint someone else to receive information on their behalf (article 10, §5). If such a person is appointed, he/she also has the right to decide on behalf of the patient.
The doctor’s right to withhold information
Article 10, §3 states that certain information may exceptionally be withheld from the patient on the grounds that it might cause serious harm to his/her mental or pyhsical health. However, such information must be provided to the spouse, father, mother and descendants (whichever is reasonable in the circumstances) (article 11, §1).
The patient’s right to refuse information
The patient can refuse to receive information but such refusal is only valid if it is in writing. This right can be deduced from article 10, §4 which states, ”The patient is not considered to have disclaimed the right to information, unless he/she has so requested in writing.” According to article 10, §5, the patient also has the right to choose another person to be informed on his/her behalf.
Confidentiality/disclosure of information to other people
Article 15 of Law N° 1(I) 2005 Safeguarding and Protection of the Patients’ Rights covers confidentiality. Paragraph 1 contains the following provisions:
- Subject to the provisions of subsection (2), all information about the patient’s medical condition, diagnosis, prognosis and treatment, as well as any other personal data shall be kept confidential even after the death of the patient and shall not be disclosed to any person or authority.
- The competent health care services provider or any person working in a medical institution shall not disclose any information regarding a patient which comes to his knowledge in the course of his duties or his/her work.
- The administration of a medical institution or the competent health care services provider shall make the necessary arrangements to ensure that persons working under their direction shall not disclose such information.
The provisions of subsection 2 (mentioned above) permit the disclosure of medical information to other people in certain circumstances e.g. if the patient has given written consent to do so or if non-disclosure is likely to lead to serious harm to other people or society as a whole. Consent to disclose information can also be presumed where such disclosure is necessary for the treatment of the patient.
In cases where information about a patient is disclosed, the patient’s identity must be protected and the people receiving the information are keep such information confidential.
The right to privacy is covered in article 15 of the Constitution of Cyprus which states, “Every person has the right to respect for his private and family life”.
End-of-life care and issues
Law N° 1 (I) 2005 Safeguarding and Protection of the Patients’ Rights contains a section on dignified treatment. Article 5, §4 of this act states that patients have the right to health care and respect of their dignity all through the final stage of their lives, within the limits of the law and legitimate procedures.
Additional rights covered in this section of the law (but not necessarily limited to end-of-life care) include the following:
- the right to be treated with dignity during health care provision, which shall be rendered with appropriate respect for the person’s cultural values;
- the right to enjoy the support of one’s family, relatives and friends and continuous spiritual support, including religious as well as psychological support and guidance, if needed (…/…);
- the right to be relieved from pain and suffering, in accordance with the available scientific knowledge and the Medical Professional Ethics Regulations of the Board of the Pancyprian Medical Association, in force for the time being, within the limits of the law and legitimate procedures.
Article 218 of the Criminal Code (amendment) Law 46/1982 prohibits assisted suicide (Council of Europe, 2003).
Although there is no legislation on euthanasia, doctors who carry out euthanasia may face disciplinary proceedings according to codes of medical deontology (Council of Europe, 2003).
According to the European Association for Palliative Care (2006), there are no initiatives in Cyprus seeking the legalisation of euthanasia or assisted suicide.
European Association for Palliative Care (2006), Report on palliative care in Cyprus, http://www.eapcnet.org/download/forPolicy/Cyprus.pdf
Steering committee on bioethics (2003), Results of questionnaire, Council of Europe: http://www.coe.int/T/E/Legal_Affairs/Legal_co-operation/Bioethics/Activities/Euthanasia/Answers%2520Euthanasia%2520Questionnaire%2520E%252015Jan03.asp#TopOfPage
Last Updated: mercredi 27 avril 2011