Saturday, 28 September 2013

Informed Consent

It was great to see a conversation about informed consent taking place at Stanford's MedX Conference on September 18. I have  put these tweets in a storify called Informed Consent at MedX. It's an important topic and I was happy to collect them in one spot. The MedX stream went so fast it was hard to get much that is verbatim.

Here's my view on some aspects.

In surgery you expect to know what is going to be done during your operation. Consenting to a procedure based on the expected results is not good enough. For instance for a forefoot reconstruction I don't think it is adequate to be told that your toes will be straightened. For my first operation the only way I was aware of the actual procedure used on my toes was to read the file. The only reason I was able to was that I was left waiting in a hall with my file and nothing to do. Needless to say I was surprised.

                                        Imagine this is me in the hall

That happened years ago but it is a more recent example of how not to do Informed Consent.  For this situation I can almost visualize a Walking Gallery jacket. I was having a toe shortened so I would be able to wear shoes more comfortably. Once I was sedated and lying on the gurney outside of the operating room the surgeon came out for a talk about the two possible methods he could use to do the procedure. As a sedated 'people pleaser", I chose the method that was easier for him and signed the consent. I still have to look at the results every day. It's not pretty. Now only doctors and students see my feet.

                                     (and everyone else  in the world)

In market research we often worked on projects for banks about credit card holders. Basically there are two types of customers. Transactors who pay in full every month and Revolvers who pay less than the balance. You might wonder how this relates to informed consent? 

I found a study about consent stating that many doctors look at the informed consent as a transaction, not an ongoing process. It is something that needs to be dealt with because of potential liability. The idea that it is part of patient education has passed them by.

The whole abstract of this interesting paper is included here because the points the points the authors make are so significant. 

Beyond Informed Consent: Educating the Patient
Lawrence H. Brenner, JD, Alison Tytell Brenner, BA, and Daniel Horowitz, MD

Based upon our interpretation of the literature and experience, we make the following recommendations: (1) The informed consent form is not a substitute for educating a patient. It is merely evidence that appropriate discussion occurred. In addition to assuring that the patient has signed the informed consent document, these discussions must occur. (2) The forms should be designed to be understandable, and all care should be taken to ensure that comprehension is achieved, and the process should be viewed as a tool to educate rather than waive liability. (3) The surgeon should avoid the paternalistic approach in dealing with uncertainty and, instead, use uncertainty as the foundation for forming a therapeutic alliance. (4) A well-educated patient does not need to be presented with an exhaustive list of every conceivable complication. Rather, an educated patient needs to be an active participant in a dialogue about the inherent risks of the surgery that are important to the individual decision-making process, ie, the risks that are specifically of concern to that patient. For example, the complications of hand surgery may be more material to a concert pianist than the average patient. (5) An understandable note in the medical record that a discussion has occurred with the patient and/or the family may be far more effective as evidence of the discussion than a lengthy signed but incomprehensible form.

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