informed consent

chuci

from the thread below of nurses prescribing im just wondering what are health care professionals views on nurses and informed consent? just wondering how many times have you gone into a patient after a doc has been in and they look completely baffled and have no idea what they signed consent for and we end up explaining it to them (not in the same depth as a doctor im sure). before anyone jumps down my throat im not saying docs are sh!te at explaining procedures its just sometimes patients are intimidated by doctors.just said id throw this out there.plus i have to do a debate in class on the subject so any views are welcome

N8

fair point and one becoming increasingly more relevant in an ever more litigious society amongst which is placed an overburdened and understaffed often undertrained and underequipped health care service.

Who pays the price?

Another relevant question is one where what happens if there is an adverse event with care or treatment which may have been addressed in a more conservative and less risky manner.

chuci

im not sure if i toatally understood the end of your post. im just thinking would it make much difference if nurses could consent patients for smaller procedures like colonoscopies,ercp, liver biopsies etc once they had been ordered by the doctor?if the nurses had been deemed competent to inform patients correctly?

tallaght01

I think this is essentially a time issue. I don't think it's helpful to make it into another Drs Vs Nurses issues. Usually when you're explaining a procedure to somebody you're on an 8am ward round where you have to see all the patients for that day's procedure list, and you have to consent them before theatre or whatever starts at 9pm. You might have 6 or 7 patients to consent. That's 10 minutes per patient. When I did surgery I would come in early so I could spend more time consenting, but that's not always possible for people who have kids etc. You could do it the night before, but there's not usually any beds available early enough, and by the time the patient is in it's usually either the morning of the procedure or it's very late the night before.
Neither nurses nor doctors nor physios nor OTs not speech therapists have a monopoly on being able to explain things to patients. There are great and terrible communicators in every single profession in the world. Doctors tend to have less time though. I think that's the issue.

Also, when I've consented somebody for a procedure, I leave, and they often only think of questions later on. That's another element to the problem I guess.
My patients are all babies, so they dont give informed consent, but I feel as though their parents always understand fully what's going on.

N8

chuci wrote:

im not sure if i toatally understood the end of your post. im just thinking would it make much difference if nurses could consent patients for smaller procedures like colonoscopies,ercp, liver biopsies etc once they had been ordered by the doctor?if the nurses had been deemed competent to inform patients correctly?

As I understand the only issue around informed consent is validity (i.e., do they understand the risks and have they been told in a fullsome manner with full disclosure) and it doesn't matter who does that. In fact reading your original post, it could be said that those patients who had no idea what they just signed for had not in fact given informed consent.

tallaght01

N8 is right. The only valid consent is informed consent. Consent should only be obtained by somebody who is competent to do the procedure. At least that's the case in the UK, and I think it's the case in Ireland too, as far as I can remember.

Jimoslimos

Not sure if this is a doctors Vs nurses issue aswell.

IMO the responsibility for IC lies with both parties (doctor/nurse & patient). A doctor can do many things but mind-reading isn't one of them - if a patient indicates/signs that they understand a procedure after being informed then the doctor/nurse has to assume that they do infact understand the risks.

With recent drug trial events I'd foresee that in certain situations patients will be 'quizzed' after IC has been given in order to determine their actual understanding.

r3nu4l

Following on from what Jimoslimos said, the Pharma industry may actually be the ones to begin tightening up on the definitions of IC.

The companies are so terrified of litigation from drugs trials that in some trials doctors in the larger trial centres are now being given guidance as to how to assess patient understanding and how to act on that understanding.

Governments will come on board too but I'd say it will be the FDA and Europe EMEA that will act first.

chuci

the last thing i want to do is turn this into a nurses v doctors pst i was just asking for opinions on the whole area. i know noone is a mind reader and cannot tell when a person doesnt understand unless they say so. i personally think that patients find it easier to talk to nurses so they may feel more comfortable asking them questions rather than asking a doc thats all.if nurses who work in specialized areas who are competent in their field would you trust them to get consent for eg and angio gram/plasty?

tallaght01

chuci wrote:

the last thing i want to do is turn this into a nurses v doctors pst QUOTE]

well, actually, that's exactly what you were aiming to do. I mean "how many times have you gone into a patient after a doc has been in and they look completely baffled and have no idea what they signed consent for and we end up explaining it to them"....come on. Please. I'd have the arrogance police on my tail again if I said something like that about nurses.

Anyway, to get back on topic, I think the person doing the procedure would prefer to keep obtaining consent. It's a responsibility issue. Many cases of litigation surrounding procedures involve patients claiming they weren't aware of a particular risk, or it wasn't explained clearly to them. I think if I was doing the op, or whatever, I'd want to make sure it was me who was giving the patient the info, as it's likely to be me in the dock if it all goes wrong.

Also, sometimes the same procedure will have different risks, which will be understood best by the doc who's performing the surgery. For eg, back in the old days I worked in a unit where we did bowel surgery on a lot of very high risk patients. So when explaining the risks to a 90 year old patient with eisenmengers syndrome and COPD, it would be a very different chat than when explaining the risk to a 40 year old in excellent health.

On a final note. In my experience, I've found that the patients often like you to say hi before they undergo surgery. It's a nice opportunity to reassure somebody who's nervous. And it's a courteous thing to do. Everybody in the health service is usually too exhausted to put courtesy at the centre of their care, and this is a good oppportunity to provide some "customer service". I also don't believe that patients have difficulties in talking to doctors. I very often have the "tears and hankies" chats with parents in my unit. I think I'm as empathic as the next person. Just liek there are in the general population, there are good and bad communicators in every profession.

DrIndy

Consent is different in its form and yes nurses do have to get consent!

Whenever you touch a person for any reason you need their consent to do so or it is battery (assault is when you are in fear of battery! To be legally precise....)

Every time a nurse does something, it is instinctive for them and doctors to say, can I lift your arm up etc....

This is in fact consent - in a verbal form.

Likewise when I am giving an injection, it is also consent as I have said to the patient they need this and is it alright to give it?

Written consent is the next stage of formality - explaining the risks of the procedure. Technically, this should only be done by the person who is doing the procedure - but often gets delegated to others. There is no reason why a nurse cannot consent a patient for a medical procedure provided they are informed sufficiently themselves, fully, to be able to explain clearly to the patients the pros and cons of the procedure and what the benefit would be. Nurses have started to lead endoscopy units where they do all the consents for patients.

In addition, you have to make the person understand what they are going through and there is a big difference between giving an injection and consenting for something like an oesophagectomy where they will spend two weeks in ICU, 6 weeks recovering in hospital and have a lung collapsed, their heart irritated, fed entirely through a vein in their neck and their stomach pulled into their chest cavity to make up the gap. In addition to this the complication rate is huge.

Some patients don't actually want to hear everything that is bad - but they have to receive a realistic picture of what to expect - sometimes without all the gory details.

Doctors also have to have the best interest of their patients at heart and if they need the procedure to stay alive or to do well, then it is their and therefore our interest not to scare them off this path.

In addition, only the person who is receiving the procedure, or the parent or guardian of the minor (after the child themselves have been informed and given their consent) which is legally binding. Relatives of patients who are very infirm or have dementia cannot consent them. They are involved and sign the form which is important to keep them on board, but it is the doctor who in fact decides what they need and does the actual consent signing. If a mentally incompentent patient needs a procedure to stay alive and the family refuse it, then the onus is on the doctor to consent them anyway for the procedure against the families wishes in the best interest of their patient.

wheresthebeef

Doctors also have to have the best interest of their patients at heart and if they need the procedure to stay alive or to do well, then it is their and therefore our interest not to scare them off this path.

I don't know if i'd agree with this Indy. Are you saying that you'd obscure the truth if you felt a patient would opt out of a treatment that you felt was very beneficial?

A strange one that I came across regarding consent, was the issue of restraint. Seemingly, to restrain a patient, the patient must consent to be restrained. I was asked to bandage a patients hands up to prevent him from removing an NG feeding tube that he didnt/couldnt consent to. The patient couldn't speak due to a CVA (stroke), and had a history of dementia, and so the doctor deemed it would be suitable to insert the NG and bandage the patients hands up to prevent him from removing it. I had to refuse to restrain the patient as I couldn't be sure that the patient was not actively refusing the treatment, and that the restraint was the only avenue of approaching the problem. So another nurse did the procedure instead.

DrIndy

This is where medical ethics comes into the issue and it is never black and white, but simply shades of grey and a decision taken in one situation is wholy correct and in another very similar situation is very wrong.

It is difficult at times, but then we are all informed specialists in our field and should act in the best interests of our patients. We know more about a procedure and about the long term consequences of not having it and if it is in the best interest of a patient, then we should advocate it and encourage them to undertake it - so long as we also warn of alternative treatment and hazards.

So we should encourage them

Regarding restraints, this is a very thorny issue indeed. You cannot know if when they are acutely confused or demented that they would not have agreed to it in sane mind and body in the past. It is very tricky, we have to respect a patients autonomy, yet at the same time, act in their best interests. However restraining a patient in any way is an affront at the same time to the professions that we are in. It is degrading to a patient and does not respect their free will. Would it be better to let the patient starve to death than to insert an NG tube against their will? Should you respect their autonomy?

The difficult decision is to decide when that is.

wheresthebeef

DrIndy wrote:

Regarding restraints, this is a very thorny issue indeed. You cannot know if when they are acutely confused or demented that they would not have agreed to it in sane mind and body in the past. It is very tricky, we have to respect a patients autonomy, yet at the same time, act in their best interests. However restraining a patient in any way is an affront at the same time to the professions that we are in. It is degrading to a patient and does not respect their free will. Would it be better to let the patient starve to death than to insert an NG tube against their will? Should you respect their autonomy?

The difficult decision is to decide when that is.

I agree with you. I just personally felt that the restraints were seen as the easy option to the problem, and that other interventions were not neccesarily exhausted to their maximum. For example, one on one nursing (specialing) could have been used to supervise the patient, combined with more communication with the patient (possibly difficult if receptive dysphagia was present). I completely see where you are coming from, however I was not happy being the one who restrained the patient.

Wishbone Ash

Nurses frequently have to obtain consent for medical procedures. For example, if a person is a resident in an institution and does not have the cognative ability to give consent, a community nurse is usually required to obtain consent from the person's next of kin. If the person does not have a next of kin or they are unknown, the Medical Officer in charge of the centre may give consent on behalf of the person.

whosyadaddy

wheresthebeef wrote:

I completely see where you are coming from, however I was not happy being the one who restrained the patient.

Your right, this is a difficult issue,

Nurses provide a lot of intimate and invasive care, to patients confused and lucid, is it that you were not comfortable restraining any patient, or this particular case

And if your fellow nurses were prepared to, and you felt there was something ethically wrong....do you have a duty of care, to protect the patient, in either sense, so stop the restrainment or witness thats its completed safely.

Also, would you restrain a patient under the direction of a doctor?

wheresthebeef

I just wasnt comfortable restraining this particular patient at this time. I have restrained other patients in other ways, in accordance with the restraint policy.

I spoke to the staff nurse and the ward sister about the restraint and said why I didn't feel it was appropriate in this case. They noted my concerns, and agreed in some ways, but the consultant was adamant that the patient be restrained as he was unwilling to ask his registrar to keep replacing the NG and wasn't willing to request one to one supervision for the patient from nursing administration. I did witness the restraint but was still uncomfortable with it. I documented the whole issue in my portfolio for that placement (leaving out names etc...) and my Clinical Placement Co-ordinator agreed that I acted appropriately. I felt i would've been acting outside my scope of practice to proceed with the restraint, so i let the staff nurse carry the can. As a student, you have the oppurtunity to do that.

The Nurse is always the patients advocate and can refuse to perform a procedure, even if directed by a doctor providing there is a satisfactory reason. In the event of a dispute like this, i believe the practice is for the doctor to come and do the procedure himself/herself so that then they are responsible. it probably doesnt happen very often.

PoleStar

Wishbone Ash wrote:

Nurses frequently have to obtain consent for medical procedures. For example, if a person is a resident in an institution and does not have the cognative ability to give consent, a community nurse is usually required to obtain consent from the person's next of kin. If the person does not have a next of kin or they are unknown, the Medical Officer in charge of the centre may give consent on behalf of the person.

Wishbone, while this may be done in practice, i.e. a nurse, or anyone in fact, giving consent or obtaining consent from a next of kin for a procedure to be performed on an individual who does not have the capacity to do so themselves, this consent is completely invalid and meaningless.

By law, the only people that may give consent are the individual themselves, or the courts. This however is not often the case in practice. And of course in the case of minors the issues become even more clouded.

From my own experience in medicine, just to illustrate the problem with regard to who gives consent. In the UK, and I think this should be practiced everywhere, only someone who will perform or has performed the procedure may consent. The reaosn for this is related to understanding. Just to illustrate the point. After 6 years of medical training in college, I had as an intern the responsibility of consenting patients for many procedures. While I had witnessed many of these, I had never performed them and thus had difficulty explaining everything to the patient. Also while I was able to give the most important information, when it came to question time, the "what if's.....", I had to refer to senior colleague.

This brings me on to the most important point. If after 6 years of training, I had difficulty imparting this information, then how can the patient fully understand it. It is difficult no matter how good a communicator you are to give the patient a full enough understanding of any procedure to really know what they are letting thhemselves in for. And this arises from the lack of ability to understand the concept of risk. If I say to a patient due to get their appendic out that there is a 5% chance of having a post operative infection which may require further surgery, and a prolonged hospital stay, they often perceive this like the lottery. Yeah I enter everyweek but it will never happen to me, I wont win. Unfortunately when we sya 5% that means it WILL happen if 100 patients get their appendix out 5 WILL get the complication. Thus the patient is often gobsmacked when it happens to them. Thus I sometimes wonder about consent and its real usefullness.

Also importantly, from a medicolegal point of view, consent means almost nothing. Just because you tell a patient about a complication, doesnt mean they wont sue. It only protects agains issues arising specifically from consent eg "if I had known the risk was 5% of gettin an infection from the operation I wouldnt have gone through".

Where does this finally lead me? I guess to the issue of responsibility. Consent is a very serious matter with a high level of responsibility. Is this a responsibility the nurse is willing to, or should have to take. Should the nurse be the one to take the stand and say "yes your honour I did tell the patient". And people might reply that, but certain low risk procedures have little risk and these might be ok. Well i have to say that there are very few medical interventions that do not carry very serious risks, even if these occur uncommonly.

wheresthebeef

i agree, the consent should be gained by the person performing the procedure both for legal reasons and as a courtesy to the patient. your points about the person doing the procedure being the best to gain the consent and explain the procedure are quite true. also, the consent should be gained as close to the procedure as possible in order to ensure validity. consent is a very interesting area of healthcare. i would say there are a lot of instances of healthcare practice where valid consent is not achieved for many reasons.
nurses should gain consent for nursing procedures, doctors should gain consent for medical or surgical procedures. nursing staff may of course assist in getting further clarification on issues for the patient, or in being the patients advocate as to whether the patients consent is valid. but thats where the book stops. nurses gaining consent for patients to have surgical procedures will be nothing more than a time saving/cost cutting exercise. both the doctors/surgeons and nursing staff have a role in this area.

Wishbone Ash

PoleStar wrote:

Wishbone, while this may be done in practice, i.e. a nurse, or anyone in fact, giving consent or obtaining consent from a next of kin for a procedure to be performed on an individual who does not have the capacity to do so themselves, this consent is completely invalid and meaningless.

By law, the only people that may give consent are the individual themselves, or the courts

If it is invalid and meaningless, why do doctors/hospitals request it?

PoleStar

Wishbone Ash wrote:

If it is invalid and meaningless, why do doctors/hospitals request it?

Very good point Wishbone. And the reasons which most doctors would probably agree on are as follows:

1. It forces the doctor to seriously consider what they are doing and involve the family in what is often a life or death situation. As you can imagine, these patients are often elderly, with many medical problems, often with memory impairment and with not so great a future outlook anyway. Thus I guess it spreads the responisbility.

2. It gets the family on board. Usually the doctors are in agreement with the family anyway.

3. In the case of any future litigation, forexample if the family say that the patient underwent an unnecessary procedure, the consent demonstartes that the family were in agreement at the time.

And I am sure you are gonna ask, well why bother at all though since legally it is meaningless and why arent the courst involved more perhaps ore all the time in these cases. The doctor is allowed to advocate and act in the best interests of the patient and it is usually assumed that this is the case. And often the courts will attempt to reason out what a "reasonable person" would do if of sound mind.

And just to clarfy, this is not my opinion, it is the law. And yes you are right it does make you think about all those consents that are signed and are legally wishy washy but the main reasons are as above.

Wishbone Ash

PoleStar wrote:

Very good point Wishbone. And the reasons which most doctors would probably agree on are as follows:

1. It forces the doctor to seriously consider what they are doing and involve the family in what is often a life or death situation. As you can imagine, these patients are often elderly, with many medical problems, often with memory impairment and with not so great a future outlook anyway. Thus I guess it spreads the responisbility.

2. It gets the family on board. Usually the doctors are in agreement with the family anyway.

3. In the case of any future litigation, forexample if the family say that the patient underwent an unnecessary procedure, the consent demonstartes that the family were in agreement at the time.

And I am sure you are gonna ask, well why bother at all though since legally it is meaningless and why arent the courst involved more perhaps ore all the time in these cases. The doctor is allowed to advocate and act in the best interests of the patient and it is usually assumed that this is the case. And often the courts will attempt to reason out what a "reasonable person" would do if of sound mind.

And just to clarfy, this is not my opinion, it is the law. And yes you are right it does make you think about all those consents that are signed and are legally wishy washy but the main reasons are as above.

Thanks for the replies PoleStar.