2017 HSC Section 2 - Practice Management

Informed Consent and the Surgeon

J Am Coll Surg

Childers et al

stances of every patient who needs informed consent. Not to mention, how can anyone but the patient really know the details of the patient’s life and the full spectrum of the patient’s interests? Perhaps the best approach to information disclosure uses a model that combines elements of both the reasonable standard and the subjective standard. Although the reason- able standard has some practical advantages (it does not oblige physicians to know more about their patients than what would be “reasonably” expected), the reasonable stan- dard alone does not go far enough in tailoring the process to patient individuality. In contrast, although the subjec- tive standard may be overly cumbersome, it more ade- quately addresses patient autonomy and the mandate to address the individual needs of each patient. Combining the reasonable and subjective creates a balance between respect for patient autonomy and individual best interest, while reducing some of the practical limitations encoun- tered in the subjective standard. Under a combined subjec- tive and reasonable standard model, physicians would be encouraged to communicate with and learn about their patients to the greatest extent possible, but with an under- standing that time limitations and a duty to other patients may prevent knowing all the details necessary to giving adequate disclosure. Adequate disclosure must be based on a patient’s values and interests, but both physician and patient need to identify which values and interests take precedence over those of lesser importance to the patient, so that decisions are practically made. Achieving adequate information disclosure is often not easy and requires the physician to be especially attentive to the language used while communicating with the patient. When disclosing information, it is not enough simply to use lay terminology, diagrams, or similar strategies to edu- cate the patient and evaluate the patient’s understanding. Rather, the specific choice of words used by the physician is critical. In disclosing information, the surgeon’s word choice can exert an unintended influence over the patient’s overall decision-making process, an ethically problematic process called “framing.” 8 For example, telling a patient, “your quality of life will be horrible if we do not do this procedure in the near future” may reflect the honest belief or experience of the surgeon. But framing the information in this way may diminish the patient’s ability to synthesize true objective data into a decision that reflects the patient’s interests and values. Instead, telling a patient, “there is good evidence that patients have a lower chance of full recovery and have poor functional outcomes if they wait X amount of time before having this procedure,” liberates the patient from potential bias because it allows a more objective as- sessment of the clinical situation. Each patient and the

Gestalt that accompanies the situation at the time of such a discussion, however, have to be individualized. Although surgeons should try to avoid “overframing” the discussion, they do need to provide information based on their clinical experience and expertise to help the patient make a truly informed decision. Framing is often unintentional, but a more intentional type of framing can occur in which the physician provides an unnecessarily negative outlook for a patient’s procedure or prognosis, called “crepe hanging.” 17 Although providing patients with accurate prognostic information is impor- tant, painting an unreasonably bleak picture of a patient’s chances to either appear correct if the outcomes are partic- ularly poor or exceptional if the outcomes are good should be avoided. Despite being rife with ethical peril, crepe hanging may be tempting to the rare physician who seeks protection from negative outcomes. Both this and more subtle forms of framing that can occur during the informed consent process must be avoided. In general, the language used by the physician in the information disclosure process should be as objective as possible. Of course, many patients still want their surgeon’s more subjective opinion of their clinical situation. In general, it is best that the surgeon withhold an opinion until after disclosure is complete, and only on the direct request of the patient. Information disclosure is a critical part of informed con- sent, but subsequent active assessment of the patient’s un- derstanding of the disseminated information is similarly important. Before the decision-making process can begin, patients need to understand fully the realm of outcomes possible with each of their therapeutic options (cognitive understanding), and fully recognize how their beliefs and values relate to the therapeutic options and associated po- tential outcomes (evaluative understanding). 8,10 To ensure cognitive understanding, it is often helpful for the surgeon to ask patients to reiterate in their own words their under- standing of the rationale, risks, and benefits of the proce- dure. The idea here is not to quiz the patient, but rather to encourage an open exchange of information and encourage the patient to participate and to ask any necessary ques- tions. If the patient is reluctant to ask questions or asks questions that suggest an incomplete or incorrect under- standing of the circumstances, the surgeon should engage in further discussions with the patient to ensure that any misunderstandings are rectified and that the patient’s val- ues and interests are being respected. Surgeons should also be aware that some patients may value not asking ques- tions, and this should be respected within reason. Although surgeons are responsible for engaging patients in this dialog, patients have a similar ethical obligation. That is, patients should be active partners in the informed

67

Made with FlippingBook flipbook maker