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Bulgaria

Healthcare and decision-making in dementia

Consent

Consent to medical treatment

Article 87 of the Law of Health of 1 January 2005 (last amended 02.09.2009) states that medical activities may only be implemented after expressed informed consent has been given by the patient. Article 88 specifies the kind of information that the doctor should provide to the patient, which includes details of the diagnosis and the nature of the disease, details of the nature and goals of the treatment, possible alternatives, expected outcomes, potential risks, the likelihood of a favourable outcome and the risks involved in opting for an alternative treatment or in refusing treatment (Goffin et al., 2007).

Consent to treatment in the case of incapacity

In the case of incapacity, a few options for consent exist:

 

  1. If the patient is “under limited interdict” (under partial legal incapacity) with regard to medical activities, his/her consent as well as that of his/her guardian is required (article 87 of the Law of Health).
  2. If the patient is “judicially incapable” (under full legal incapacity) informed consent must be provided by the guardian (except in cases determined by law).
  3. For patients will mental disorders and established inability to express informed consent, such consent shall be expressed by persons mentioned in article 162 of the same law.

 

Article 162, paragraph 3 of the Law of Health states:

“When lack of ability of the person is accepted, the court shall decree compulsory treatment and appoint a person from the relatives of the ill person, who is to express informed consent for the treatment. Upon conflict of interests or lack of relatives, the court shall appoint representative of the municipal health service or a person, defined by the mayor of the municipality at the headquarters of the medical establishment, who is to express informed consent about the treatment of the person. ”

In certain cases, this information and the informed consent must be given in writing. Such cases include surgical intervention, total anaesthesia, and invasive and other diagnostic and therapeutic methods leading to an increased risk to the life and health of the patient or to a temporary change in his/her consciousness.

Medical care can only be carried out without the necessary consent in specific cases determined by law (art. 91).

Consent in case of emergency

The medical activities mentioned earlier which necessitate written informed consent can be carried out without written informed consent only if the patient’s life is immediately threatened and:

1. his/her physical or mental status does not allow the expression of informed consent;

2. it is impossible to obtain informed consent from the guardian or the trustee or by the person mentioned in art. 162, para 3;

For people with mental disorders and established inability to express informed consent, such medical activities can only be carried out with the permission of the commission for medical ethics and after obtaining the consent of lawful representatives or of the chief of the medical establishment (if there is no commission for medical ethics).

The right to refuse treatment

At any time, the patient, his/her guardian or trustee or his/her appointed representative can refuse proposed medical care or the continuation of medical activities. Such refusals must be signed and recorded in the patient’s medical file. If those concerned are unable or refuse to sign, the treating doctor and a witness must sign in their place (art. 90).

If treatment is refused and this threatens the life of the patient, the chief of the medical establishment can decide to initiate life saving treatment.

The right to withdraw consent

As stated above, the patient, his/her guardian or trustee or his/her appointed representative can refuse the continuation of medical activities (i.e. withdraw consent that has already been given). The patient may also withdraw the refusal of treatment at any time. Medical care against the wishes of the patient may be given only in cases determined by law.

Consent to the donation of organs and/or human tissue

According to article 24 (1) of the Law on Transplantation of Organs, Tissues and cells, organs, tissues and cells may only be taken from living donors who have given written consent and provided that the removal would not endanger their lives. Before giving consent, potential donors must have been provided with understandable information about any risks involved (Goffin et al., 2007). Specific provisions relating to people with incapacity are not mentioned. In case of incapacity, the consent to the donation of organs and human tissue has to be given according to the rules for patients under partial legal incapacity and under full legal incapacity.

Consent to clinical trials

The Act on the Medicinal Products in the Human Medicine states that a patient cannot be involved in a clinical trial until s/he has been informed by beforehand by doctor (member of the research team) and provided with a full explanation of the goals, risks, inconveniences and procedure. The doctor must also have informed the patient of the right to refuse to take part and have reassured the patient that refusal would not result in negative consequences for him/her.

Consent to research

It is stated in article 29 of the Constitution of the Republic of Bulgaria that nobody may be put to medical, scientific or other experimentation without his/her voluntary written consent.

Advance directives

Advance directives do not have legal status in Bulgaria.

Access to information/diagnosis

The right to be informed

In order to enable people to give informed consent, the doctor in charge must inform the patient or his/her proxy decision makers in a timely manner and in the appropriate amount and form (art. 88) of the following:

1. the diagnosis and the nature of the disease;

2. description of the purposes and the nature of the treatment, the reasonable alternatives, the expected results and the prognosis;

3. the potential risks, connected with the proposed diagnostic – methods of treatment, including side effects and unwanted medical reactions, pain and other discomforts;

4. the probability of a favourable outcome, risks for the person’s health of applying other methods of treatment or of refusal of treatment.

Access to medical files

According the last amendments of the Law of Health of 02.06.2009, article 28b, the patient has the right to receive from the hospital health information relating to his/her health, including copies of all medical documents.

As a patient everyone has the right to access medical records related to his/her health (article 86 of the Law of Health).

The right to designate another person to be informed on one’s behalf

Article 92, paragraph 4, of the Law of Health gives patients the right to authorize in writing a person to be informed on their behalf of the above-mentioned information.

According to the new text of article 28b of the Law of Health the patient has the right to authorize in writing another person to examine his/her medical documents and make copies of them.

After the death of the patient his/her relatives have the right to inspect the health information, and to make copies of his/her medical documents.

The doctor’s right to withhold information

There is no legal regulation of the therapeutic exception in Bulgarian law which means that doctor’s cannot withhold relevant information from patients (Goffin et al., 2007). According Bulgarian law the doctor is obliged to tell the patient all information about the disease.

The patient’s right to refuse information

A patient can refuse certain types of information. This includes information about the condition for which he/she has sought medical attention, as well as information about planned medical activities and related risks linked to that condition. Such refusal must be in writing (Article 92 (2-3) of the Law of Health).

Confidentiality/disclosure of information to other people

Article 86 states that patients have the right to protection of data related to their health status. Health information may only be divulged to third parties in specific cases e.g. where the person is going to continue treatment elsewhere, where there is a danger to the health or life of other people or for statistical purposes once the data identifying the patient has been removed etc. (art. 28).

End-of-life care and issues

Palliative care

In the Law of the Treatment Institutions, 59 hospices are registered (of which 7 are not operational). There are no regulations governing the organisation and activities of hospices. There are also some homes for the elderly which provide palliative care (EAPC, 2006).

In the Law of Health of 1 January 2005 (art. 95 and art. 96), it is stated that patients with incurable diseases with unfavourable prognoses have the right to palliative medical care. The aim of such care is to maintain the patient’s quality of life by the reduction or removal of certain consequences of the disease as well as any associated unfavourable psychological and social effects.

Palliative medical care should, according to article 96, include:

 

  • medical observation;
  • health care, aimed at caring for the patient, the removal of pain and the psycho-emotional effects of the disease;
  • moral support of the patient and his/her relatives.

 

The requirements for palliative care are determined by an ordinance from the Minister of Health (art. 96).

Euthanasia

According to the European Association for Palliative Care (2006):

“At the current time, there are no initiatives in Bulgaria that seek the legalisation of euthanasia or assisted suicide. The Bulgarian Orthodox Church and Christian tradition do not allow life to be taken (even in the form of euthanasia). The problem is not discussed because both the medical community and society in general are not ready yet to discuss it.”

The Republic of Bulgaria does not apply euthanasia (article 97 from the Law of Health).

Assisted suicide

Assisted suicide (either completed or attempted) is punishable by up to three years’ imprisonment (art. 127). The sentence is more severe if the person assisting another to commit suicide knew that he/she was unable to guide his/her acts or did not understand the gravity of the act. If a person leads another (who is dependant on him/her) to commit suicide as a result of cruel treatment of systematic humiliation, the punishment is imprisonment of two to eight years.

Non-assistance to a person in danger

According to the Penal Code, non-assistance to a person in danger is a criminal action.

Whoever puts in jeopardy a person who is unable to protect him/herself due to being a minor, superannuated, sick, or generally helpless, in such a way that his/her life could be in danger and, being aware of it, he/she does not come to his/her assistance, shall be punished by imprisonment of up to three years. (article137).

Whoever deliberately fails to render assistance to a person whom he/she is obliged to take care of and who is in danger of his/her life, and unable to protect him/herself for reasons of being minor, superannuated, sick, or generally helpless, in cases when he/she could have rendered assistance, shall be punished by imprisonment of up to one year or by corrective labour (art.138).

Whoever, in the event of immediate danger to somebody else’s life, does not come to their assistance, even though it could have been rendered without endangering themselves or somebody else, shall be punished by corrective labour for up to six months or by a fine of one hundred to three hundred levs. (art.139).

Homicide

Chapter 2 of the Penal Code (with amendments up to 23.06.2009) covers offences against the person.

Article 115 states that a person who deliberately kills somebody shall be punished for homicide by imprisonment for ten to twenty years. The following article lists cases/situations in which the definition “homicide” would apply. The killing of a person in a helpless state is included in the list. A person who helps someone else to commit homicide or causes the death of another person by negligence may be imprisoned for up to three years (art. 117 and art. 122).

Croatia

The Law on the Protection of the Rights of Patients by the Croatian Parliament was adopted on 19 November 2004 and came into force on 11 December 2004 (published in the Official Gazette no. 169/2004). It covers a variety of issues linked to consent and access to information, and will be referred to in this text as LPRP.

Prior to this law coming into force, the Croatian Association for the Promotion of Patients’ Rights drafted a law proposal. As they have some criticisms of the existing law, the act they drafted as well as a few articles about their concerns can be found at: http://www.pravapacijenata.hr/eng/

Consent

Consent to medical treatment

Patients have the right to accept or refuse proposed medical treatment (including diagnostic and therapeutic procedures) unless such right has been restricted on the grounds of their condition (LPRP, art. 6-7). They can do this by stating their acceptance or refusal of the proposed treatment or by signing a consent form.

Consent to treatment in the case of incapacity

If a person has a severe mental disorder, does not have disposing capacity or is not of legal age to consent, the consent form must be signed by his/her legal representative or guardian (LRPR, art. 17).

Consent in case of emergency

A patient with full disposing capacity does not have the right to refuse urgent medical interventions if doing so would endanger his/her life and health, or cause him/her serious harm (LPRP, art. 16). For people with incapacity, the consent of the guardian or legal representative is not needed if medical treatment or interventions are urgently needed (i.e. failure to provide treatment would directly and seriously threaten the patient’s life or health) (art. 18) .

Consent to clinical trials and research

Under the Health Care Act of 1993, patients had the right to refuse to be observed, examine or treated by students and also the right to refuse to take part in scientific research. This act was replaced by the new Health Act of 2003 but the provisions relating to patients’ rights remain almost identical.

In the Act on the Protection of Patients’ Rights of 2004, it is stated that express consent must be given by patients, in written form, dated and signed, before they can participate in scientific research or be involved in medical teaching. Such consent must be made after the patient has been fully and precisely informed about the nature, risks and consequences of the research in a way that is understandable to him/her. The patient or his/her legal representative or guardian may withdraw consent at any time (art. 19). Article 22 of the LRPR outlines certain conditions which must be fulfilled before people lacking capacity to consent can be involved in scientific research.

Access to information/diagnosis

The right to be informed

The right to be informed is part of the right to accept or refuse treatment as patients must have received the relevant information before giving or refusing consent. Information must include details about any risks and benefits of having or not having the proposed treatment, examinations or procedures as well as what would be involved and this must be done in a way that is understandable and suited to their age, level of education and mental capacity. They must also be informed that they have the right to decide on the proposed treatment. Such information must be provided in a way that is in keeping with the patient’s age, mental abilities and education (LRPR, art. 8).

Rusinovic and Proso (2005) draw attention to article 9 of the LRPR in which it is stated that the patient’s right to be informed by the doctor is dependent on the patient’s “spoken demand”. This clearly discriminates against people who cannot make such a demand or who have difficulty communicating but who do not necessarily have a legal representative or guardian to ask on their behalf.

According to article 11, patients also have the right to be informed after each examination, procedure or surgery of its success or failure and of the possible reasons for results being different to those expected.

Access medical files

Patients are entitled to consult and copy (at their own cost) the parts of their medical files relating to their diagnosis and treatment (art. 23). This right extends to the marital or extramarital partner, adult children, parents, adult sisters and brothers and the guardian or legal representative of the patient upon the death of the latter unless he/she previously prohibited this in a statement made before a notary public (art. 24).

The right to designate another person to be informed on one’s behalf

People can designate another person to receive health-related information on their behalf.

The patient’s right to refuse information

Patients can refuse information about their condition and the expected outcome of treatment unless not knowing about the nature of their condition could result in them possibly endangering the health of other people (art. 14-15).

Confidentiality/disclosure of information to other people

Patients have the right to confidentiality of information linked to their health and to the protection of personal data. They may make a verbal or written statement indicating which people may be informed of their condition and of their hospitalization as well as those to whom such informaiton should not be revealed (art. 25)

End-of-life care and issues

Assisted suicide

According to article 96 of the Criminal Code, whoever induces or assists another in committing suicide which is accomplished or attempted shall be punished by imprisonment for six months to five years. The sentence would be for one to eight years should the person’s ability to understand or control his/her own will be significantly diminished. If such ability is totally lacking, the sentence would be the same as that for murder (i.e. not less than 5 years).

Non assistance to a person in danger

Whoever fails to render aid to a person in imminent mortal danger, although he/she could have done so without subjecting him/herself or another to serious danger, shall be punished by a fine or by imprisonment not exceeding one year. If the mortal danger was caused by the person in question, the punishment would be of a fine or imprisonment not exceeding three years (article 104 of the Criminal Code).

Deserting a Helpless Person

A person who deserts a helpless person in his/her trust or for whom he/she is responsible for unassisted and in circumstances which represent a danger to the health or life of the former shall be punished by imprisonment of between three months and three years. Should such behaviour result in the death of the helpless person or serious bodily injury or serious impairment, the sentence shall be for one to five years’ imprisonment (article 105 of the Criminal Code).

Murder at the request of the victim

Article 94 of the Criminal Code states that whoever kills another upon his/her express and earnest request shall be punished by imprisonment for one to eight years.

Murder

A person who kills another person is guilty of murder and may be punished by not less than five years’ imprisonment (article 90 of the Criminal Code). In case of manslaughter (i.e. when the killing occurs on the spur of the moment in a state of strong irritation or fright brought on by another person’s attack, maltreatment or serious insult), the punishment would be for one to ten years (article 92 of the Criminal Code). In case of death caused by negligence, the sentence would be from six months to five years (article 95).

Bibliography

Babić-Bosanac, S,, Borovečki, A and Fišter, K (2007), Patients’ rights in the Republic of Croatia – between the law and reality, Medicinksi Glasnik , Vol. 5, no. 1, January 2008

Rusinovic-Sunara, D. and Proso, M. (2005), Legal issues of the protection on patients rights in Croatia, accessed online on 11 October 2009: http://www.pravapacijenata.hr/eng/pdf/Stradovi/LegalIssuesPPRightsCro.pdf

 

 
 

Last Updated: mercredi 27 avril 2011

 

 
  • Acknowledgements

    Alzheimer Euriope gratefully acknowledges the support of Fondation Médéric Alzheimer which made possible the data collection and publication of the country reports in our 2009 Yearbook.
  • Fondation Médéric Alzheimer
 
 

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