Patient rights: what nurses must know and apply in daily practice

Informing, obtaining consent, respecting a refusal, consulting a person of trust, locating advance directives, responding to a request for access to the medical record, maintaining confidentiality: patient rights are exercised at every procedure, and often at the patient's bedside. This guide brings together what the Public Health Code and the nursing code of ethics provide, with the practical reflexes to adopt, in healthcare facilities and at home.

Why do patient rights directly concern nurses?

Patient rights are not the sole responsibility of the doctor. The Public Health Code establishes the right of every person to be informed about their state of health, before, during and after care (articles L1111-1 to L1111-9). The nursing code of ethics reflects this: article R4312-13 requires the nurse to implement the right to information, article R4312-14 requires them to seek consent, and article R4312-5 reminds them of professional confidentiality.

A breach engages your responsibility, including disciplinary responsibility. For general rules, consult our guide on the nursing code of ethics.

What information must the nurse give to the patient?

According to the code of ethics, the information provided by the nurse is loyal, appropriate and intelligible, and takes into account the patient's personality. It covers what falls within your remit: the procedure you are about to perform, its purpose, how it will proceed, its foreseeable risks and the consequences of a refusal.

How and when should information be provided?

Information is given during an individual interview, except in cases of emergency or impossibility of informing. It takes place before the procedure, during care, and even afterwards: a new risk discovered later must also be brought to the patient's attention.

Can a patient refuse to know?

Yes. A patient may ask not to know a diagnosis or prognosis. This wish is respected, unless third parties are exposed to a risk of transmission.

Who must prove that information was given?

It is the responsibility of the healthcare professional or the healthcare facility to provide proof that information was delivered, and this proof can be established by any means. This is why it is important to record in the care record the explanations given and the patient's reaction.

How should the patient's consent be obtained?

The principle is established by article L1111-4 of the Public Health Code and reiterated by article R4312-14: the free and informed consent of the person receiving care is sought in all cases.

• Informed: the patient has received loyal, clear and appropriate information that enables them to decide with full knowledge of the facts.
• Free: they decide without constraint, in a state to express their will, and you have verified that they understand.

Consent is sought for each procedure, not once and for all at admission.

What if the patient cannot express their will?

Outside of emergencies, no procedure can be carried out without the person of trust, family members or, failing that, a close relative being consulted. The Order emphasises: consulting does not mean obtaining their agreement. In case of emergency or imminent danger, you act without prior consultation.

Minors and protected adults

For a minor, the consent of those holding parental authority is required, and the child receives information adapted to their maturity. For a protected adult, they remain entitled to information, adapted to their capacity for understanding. Under guardianship, information is provided to the person and their guardian; under curatorship, informing the curator requires the agreement of the protected adult.

What should you do when a patient refuses a procedure?

The refusal of a capable adult patient must be respected, even when it seems unreasonable to you. However, the code of ethics requires you to inform the patient of the consequences of their decision.

1. Listen to the reasons for the refusal: pain, fear, misunderstanding, fatigue. A refusal sometimes masks a need that you can address.
2. Inform the patient of the consequences of their refusal, in simple terms.
3. Give them time to reflect: if the refusal puts their life in danger, they must reiterate their decision within a reasonable timeframe.
4. Alert the prescribing doctor, as the Order recommends.
5. Record the refusal, the information given and the exchanges in the care record.

Point of vigilance: a refusal expressed once is not final. Propose the procedure again later, without insistence or pressure, and note each new proposal.

What is a person of trust?

Provided for by article L1111-6 of the Public Health Code, the person of trust accompanies the patient in their procedures and may attend their medical interviews. If the patient becomes unable to express their will, they are consulted as a priority: their testimony prevails over any other testimony.

How is the person of trust designated?

• by a document signed by both the patient and the designated person;
• at any time, including during a hospital stay;
• without time limit, unless the patient decides otherwise;
• in a revocable and modifiable manner at any time.

This may be a parent, a close relative or the attending physician. An adult under guardianship must obtain authorisation from the judge or family council to designate one.

Trusted person or person to be notified?

Do not confuse them. The person to be notified is simply alerted in case of emergency; they have no role in care decisions. Check in the file who was designated, and in what capacity.

What are advance directives and what is the nurse's role?

Advance directives allow any adult to express in writing their wishes regarding the continuation, limitation, cessation or refusal of treatments or medical procedures, should they become unable to express themselves (articles L1111-11 and L1111-12).

• The document is dated and signed, with name, surname, date and place of birth. An official template exists, though it is not mandatory.
• If the person cannot write, two witnesses attest that the document expresses their wishes.
• Their validity is unlimited; they are reviewable and revocable at any time.
• They are binding on the physician, except in life-threatening emergencies whilst the situation is being assessed, or when they appear manifestly inappropriate, following a collegial procedure.

The HAS reminds all professionals, including nurses, that they may inform patients of this possibility and support them in their reflection, at their own pace. With a person whose cognitive abilities are declining, raise the subject whilst they can still express their wishes.

Good to know: advance directives may be kept in Mon espace santé, in the attending physician's file, in hospital, in a social care facility or entrusted to the trusted person. Ask the patient where they are kept and note this in the file.

Can the patient access their file, including the nursing care file?

Yes. The nurse establishes for each patient a nursing care file containing relevant information and protects it against any breach of confidentiality (article R4312-35). These elements form part of the information the patient may consult.

What are the communication timescales?

• 8 days at most after the request, and not before a reflection period of 48 hours;
• 2 months when the information is more than 5 years old.

Access is free. The patient may consult on site or receive a copy; they may also go through a physician of their choice. After death, the heirs, cohabitant or civil partner may access certain information to ascertain the causes of death, defend the deceased's memory or assert their rights, unless the person expressed opposition during their lifetime.

How long is the file retained?

In a healthcare facility, the file is retained for at least 20 years after the last admission. For self-employed professionals, no legal retention period is set.

What does the nurse's professional confidentiality cover?

Confidentiality is binding on every nurse (article R4312-5) and stems from article L1110-4 of the Public Health Code. It covers all information concerning the person that comes to your knowledge: what you have been told, but also what you have seen, heard or understood. Nurses who are public servants are also bound by it under the General Civil Service Code.

Can information be shared with the team?

Yes, within precise limits. Professionals in the same care team may exchange information strictly necessary for care coordination or continuity. Outside the care team, the patient's prior consent is required. The patient may object to the exchange of information concerning them.

When can confidentiality be breached?

Article 226-14 of the Criminal Code authorises disclosure in cases of abuse of a minor or vulnerable person, or domestic violence threatening life. The code of ethics goes further: faced with a person who is a victim of abuse, the nurse implements the most appropriate means to protect them and, if it is a minor or vulnerable person, alerts the judicial, medical or administrative authorities (article R4312-18).

Point of vigilance: breach of confidentiality is punishable by one year's imprisonment and a fine of €15,000 (article 226-13 of the Criminal Code), without prejudice to disciplinary sanctions. Corridors, lifts, personal messaging and social media are the most common places where breaches occur.

On the consequences of a breach, consult our guide on the nurse's liability. Care without consent in psychiatry is subject to specific rules, detailed in our guide on practice in psychiatry and mental health.

Who should a patient who feels wronged contact?

If the patient is refused access to their file, they may refer the matter to the CADA if it is a public facility, or to the CNIL for a private facility or self-employed professional. For any questions about their rights, they may contact the Santé Info Droits helpline on 01 53 62 40 30.

Official sources

• Service-public: Information for the patient on their state of health, The trusted person in healthcare, Advance directives, Medical record
• National Order of Nurses: Patient consent, Legal factsheet on professional confidentiality, Code of ethics for nurses
• High Authority for Health: Advance directives, a document for healthcare professionals