2017 HSC Section 2 - Practice Management
Vol. 208, No. 4, April 2009
Informed Consent and the Surgeon
Childers et al
formed” component. Although this is clearly not desirable, it unfortunately may often be the case that patients consent to procedures or interventions without properly being in- formed. Having a patient simply sign an informed consent form to satisfy a legal requirement does not necessarily reflect that the patient understands the goals of care or whether these goals are aligned with their values and inter- ests. As such, although written consent is a routine and necessary part of the informed consent process, surgeons should not overly focus on the paper while ignoring the process. Still, the patient’s signature is almost always necessary for an operation to proceed, so some form of documenta- tion must exist. 18 Sometimes the essential elements of the information disclosure are carried out before the patient signs the consent document. It is permissible for the actual signature to be obtained by residents, physician assistants, or other properly trained staff after the surgeon has prop- erly informed the patient, 19 but it is generally preferable that both components of informed consent be carried out together. In addition, although the process ideally should occur during a preoperative clinic visit to allow adequate time for questions, the surgeon should also see the patient and personally confirm his or her consent on the day of the operation. The actual informed consent document needs to fulfill a number of criteria ( Table 2 ). First, the informed consent document should provide a clear description of the planned procedure and its attendant risks and benefits. Second, the document must adequately articulate antici- pated outcomes, both positive and negative, in the near and distant future. Third, there should be some notation of the questions asked by the patient during the informed consent process — a particularly important element considering that for some patients, a more complete understanding is achieved only on reading the informed consent form. Sim- ilarly, the physician’s response to these questions should be noted, for example, in the surgeon’s preoperative clinic note. The documentation should also record the presence of all individuals involved in the informed consent process. Last, the patient must authorize the surgeon and the surgi- Table 2. Essential Components of Documenting Consent 1. Clear description of the planned procedure and its risks and benefits. 2. Details of possible alternative therapies, including the option of no treatment, as well as their attendant risks and benefits. 3. Documentation that patient had chance to ask questions (eg, clinic note “patient had chance to ask questions and all were answered to their satisfaction”). 4. Authorization with signature of patient or surrogate decision- maker. Confirmation of patient authorization with signature of physician and witness.
consent process. Patients may understand the information presented, but some patients may decide not to decide and choose to rely solely on their surgeon’s recommendation. In general, patients should be encouraged to be more active participants in the decision-making process, with the sur- geon avoiding being the person actually making decisions for the patient. Even though recommendations are permis- sible, outright declarations of what “should be done” ought to be withheld. 8,10 In general, surgeons should avoid mak- ing declarations of “what to do,” but surgeons can still offer clear recommendations and attempt to persuade patients about a certain course of therapy if it seems clearly in the patient’s best interest to do so. This does not mean that the patient’s choices will be ignored, but rather that in discuss- ing options with patients, the surgeon can still be clear that a particular choice may appear to be a “poor” one in the surgeon’s judgment. After disclosure of information from the physician to the patient, patients must then synthesize everything they have learned from the treating surgeon, other consulting physi- cians, family, friends, and any independent research to make a final decision. It is important to remember that patients need adequate time to process information, reflect on their values and interests, and make an informed choice. Surgeons similarly need time to learn enough about a pa- tient’s life story, values, and priorities to help guide patients in their decisions. The time and place in which the in- formed consent process could be initiated include a variety of conceivable scenarios, from the outpatient clinic setting to the inpatient bedside. Depending on the type of opera- tion for which consent is being obtained and the level of discussion that the patient requests, the process of in- formed consent may be best facilitated over the course of multiple preoperative visits, during which enough time can be allocated for the surgeon and patient to achieve a col- laborative understanding of the patient’s best interests. Be- cause informed consent is not a static event but rather an ongoing process, several preoperative visits (or phone calls) are preferable to a single preoperative visit. In addition, viewing informed consent as an ongoing process serves to strengthen the physician-patient relationship and improves patient compliance. 8 Obviously, in the situation of a surgi- cal emergency, much of this process may be lost because of the urgency of the situation. The surgeon should keep in mind, however, that in these situations the informing pro- cess can also occur after the operation as part of the ongoing development of the physician-patient relationship. Obtaining consent from the patient The second component of informed consent is the “con- sent” process. The consent process can technically be done without satisfying any of the essential elements of the “in-
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