consent

[Hayduke]

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I am an ED intern with a significant number of surgical rotations in my program. I dig the shoosh out of these rotations and would choose to hang with the ortho/trauma/plastics crowd over everybody except my fellow peeps in the pit.
Unfortunately, when rotating on some of these services there is a certain amount of unchallengaeable scut. This was expected. I am an intern and am a good soldier who works to keep the team going.
What I didn't expect was being asked to consent people for OR procedures of which not only I am not a part, but about which I am frankly ignorant.

"Yeah I'm pretty sure there will be some screws and somebody else will sew a vessel. Sometimes they take a part from somewhere else and then that part gets put in a place they make a hole......it's routine...." (a little exaggeration but I hope you know what I mean)

As an off-service intern, I run their floor, do ED consults and perform stabilizing procedures. A lot of this stuff is in my purview as a future EP.

What I cannot do is undertake a detailed discussion about the interoperative details of their procedure. I have a working knowledge of surgery. My third year rotation led to two 4th year sub-Is. I can talk through most gen. surg. operations. However, I am in a big academic place with some fairly new ortho, transplant and plasics stuff going on.

I personally feel like I am being dishonest to the patient when getting their consent. Am I not a team player?
How about you guys?

 

[Blade28]

That is a tough situation. If you don't feel comfortable consenting a patient (i.e. you don't feel like you can accurately describe the procedure, or present the common potential complications), I'd ask a senior resident for assistance (or at least for guidance in what to cover during the informed consent process).

 

[Pir8DeacDoc]

This reminds me of a subspeciality rotation during my intern year. We were asked to do pre-op H&P a few times a week. Included in this office visit was discussion of risks and benefits and also consent. If I were planning a career in that field, this would seem appropriate. However, I really don't know all the specific terminology related to this field. I get the basics but if people have more than a basic question, I'm hosed. I hated giving a half ass discussion about the case and the operative plan. If you're not going to teach me about the cases and let me participate in the OR with them then I don't feel any specific need to learn about the surgeries for a one month rotation. In fact, some of my fellow interns refused to do these visits. It sucks but I suppose is par for the course.

 

[Winged Scapula]

Unfortunately, it is par for the course and it shouldn't be.

Even surgical interns have trouble consenting patients for procedures they've never seen, never heard of, etc. so your pain is understandable.

You are not "not being a team player". Your team is placing you in an uncomfortable position, placing their patient's at risk for misunderstanding or not being fully consented and most likely is in violation of the hospital and JCAHO policies which require consent to be obtained by a member of the surgical team. Since you will not be operating, it is inconceivable that you would be considered a member of the surgical team. You are a non-surgical resident on an off service rotation. Some hospitals haved moved toward only having the "surgeon of record" (the attending) go over the consent with the patient.

What happens now depends on how comfortable you are approaching your senior or Chief residents, or attendings with this problem. We had similar difficulties with interns, particularly on Peds Surg and Peds CT, being asked to consent patients for procedures they knew nothing about. The policy was changed so that the resident or attending actually doing the case was responsible for the pre-op consent. Perhaps you can talk to your team about that, or at the very least, ask if you may call them on cases with which you have no familiarity or comfort level in consenting patients.

best of luck...

 

[Bobblehead]

I think the OP should explain to a senior member of his team that he does not feel comfortable giving obtaining consent because he is unclear about the exact details of the procedure and the exact complications he should discuss (common, serious). I certainly wouldn't expect the intern to be able to discuss the finer points of the alternatives to the procedure and the expected recovery time all of which are part of the informed consent process.

I would also go as far as emailing your program director and asking him to discuss with the surgical residency director the procedure consent protocols of the hospital. You will need just one case where something went wrong for 'informed consent' that will result in huge amounts of grief for everyone whose names appear on the chart.

 

[Tired]

You could always read about the procedure before you do the consent. Or ask the team what specifically needs to be on it.

 

[docB]

I am an ED intern with a significant number of surgical rotations in my program. I dig the shoosh out of these rotations...

Digging the shoosh out of things was always my least favorite part of my surgical rotations.😀

 

[Arch Guillotti]

Sounds familiar.

I remmeber last summer I went to preop/consent a morbidley ill lady for CABG. She was on a vent, IABP, ef of 10% or something, s/p cardiac arrest. Essentially it was CABG or fester in the ICU for a while before support was withdrawn. I needed consent from the family and was told that members would be there in a few minutes for a "big sit-down pow-wow with surgery" at which time surgery would get their consent as well. Of course it was the surgical intern who knew nothing about the case or the pt. who got sent to do the consent during the aforementioned suposed "pow-wow". So I did all of the talking, and the 'tern was glad for that. Lady walked out of the hospital a couple of weeks later.

 

[madtowngirl]

You could always read about the procedure before you do the consent. Or ask the team what specifically needs to be on it.

I only wish I had time to read about a procedure, risks/benefits/alternatives before doing a consent. Often I have to sprint to pre-op to get these done in between my floor work. And I'm lucky if I can find a resident to help me get the right things on the consent.

 

[Winged Scapula]

I only wish I had time to read about a procedure, risks/benefits/alternatives before doing a consent. Often I have to sprint to pre-op to get these done in between my floor work. And I'm lucky if I can find a resident to help me get the right things on the consent.

yeah....usually the phone call is from some PITA pre-op holding area nurse who says, "we are waiting to take this patient back and the consent is outdated/not done/we can't find it. You have to come NOW!!!"

The best ones are when the consent is in some other part of the chart that they didn't look at.😡

 

[DrDawg]

ED residents rotate with us for Trauma. A few of them spoke up and said they didn't feel comfortable consenting patients for surgery or procedures. No one here really had a problem with that. Most operative trauma is done without it, Neuro surgery and Ortho get their own consent. If they didn't feel comfortable getting consent for lines or chest tubes they didn't get to do them.

 

[Bobblehead]

If they didn't feel comfortable getting consent for lines or chest tubes they didn't get to do them.

You're describing two bedside procedures vs. a more involved procedure involving an actual operating room as has been discussed here thus far. However to address your statement, instead of addressing the actual problem of being uncomfortable/unfamiliar with the procedure, you employ punishment to discourage people from raising concerns? Unless of course there's more to your story than the brief statement you made.

 

[DrDawg]

Sorry if I didn't articulate my point clearly...
At my institution EM residents only rotate through trauma. They expressed concerns about consenting patients for surgery, and no one had a problem with that. It didn't need to go through the division head, or program directors. Even residents understand informed consent. However we would expect them to be able to consent patients for lines, chest tubes, and other bedside procedures. If they didn't feel comfortable consenting for these procedure, we would ENCOURAGE them to become comfortable. This may involve reading, or observing. If you are not comfortable consenting patients for a procedure or surgery you shouldn't do it (the procedure), until you do. Its very difficult to recognize a complication if you don't know its a complication. As I heard often in medical school, the eyes cannot see what the mind does not know.

 

[Pir8DeacDoc]

hard to imagine that they couldn't reasonably manage to get consent for a line or chest tube. Maybe they just didn't want to take on the work of talking to the patient or tracking down the family.

OR procedures are an entirely different ballgame, IMHO. If you're going to keep me chained to the floor doing scut all the time and never able to see your surgeries then it makes it tough to read about or have much idea about what the hell is going on beyond the basics.

 

[Tired]

Most services I have been on have a half-dozen or so "stock" procedures they perform. For example, on General Surgery service I'm on now, it would probably be hernias, lines, chest tubes, benign mass removals, VATS, and appys. Do I know anything about these as an Ortho Intern? Of course not. But it only took me an hour to read up on the basics needed to do informed consent on them. Voila, now I can consent 90% of our patients.

I really don't see why this is a big deal.

 

[Faebinder]

Besides, all surgeries have the risk of bleeding/infection, so two major ones right there.

 

[TysonCook]

Also, you have to look at what the point of the consent is...
Is it a CYA paper, or is it a true legal document.

Coming from a family of both doctors and lawyers, almost all of the lawyer side (including the MD/JD attending at CMC), state that it is useless in court. What it does do is give the patient an extra chance to talk with a MD, ask further questions, and for us to check the stupid box prior to the OR.

But the application of consents in court is a different discussion...

Regardless, I think that for the most part, infection, infection, and infection (including dehisc) covers the vast majority of your complications.

 

[Blade28]

Besides, all surgeries have the risk of bleeding/infection, so two major ones right there.

I always write, at a minimum:

"Bleeding, infection, injury to nearby structures, risks of anesthesia."

 

[3dtp]

Most services I have been on have a half-dozen or so "stock" procedures they perform. For example, on General Surgery service I'm on now, it would probably be hernias, lines, chest tubes, benign mass removals, VATS, and appys. Do I know anything about these as an Ortho Intern? Of course not. But it only took me an hour to read up on the basics needed to do informed consent on them. Voila, now I can consent 90% of our patients.

I really don't see why this is a big deal.

The reason why consent is a very big deal, particularly in non-tort reform states is that when a complication does occur, and that complication is a known complication of a procedure, the doc has a duty to make sure that the patient is aware of that complication, that it may happen, and the consequences of that complication. Otherwise, the med-mal case will hinge, not on the standard of care, but on whether or not the patient was given information about the complication, the nature of injuries possible from the complication/side-effect and what, if anything can be done about it if they occur.


Case 1: the consent form signature was obtained by the resident, witnessed by member of the family, signed later by the attending and a complication occured. Decedent patient's family sued, based on "lack of informed consent about the complication." They prevailed mainly on procedural grounds due to the inability of the surgeon to demonstrate that the process of informed consent had been followed. The patient was gone, the estate was administered by the witness to the informed consent form who testified that the surgeon briefly described the procedure but didn't specifically mention the complication possible, even though it was on the consent form, testified that the decedent was not given the opportunity to read the form, but was asked to sign it by someone who they had never seen before, and they signed it. The jury returned a judgement in favor of the plaintiff for substantial damages, including non-economic damages for failure to obtain proper informed consent.

Case 2: the consent was obtained by the attending in the presence of the resident and a medical assistant, who signed as a witness. The complications were explained in detail, the patient was, in the presence of several witnesses, instructed to read and permitted time to read the form, as was his spouse, only after the patient had read the form in detail was he allowed to sign the form. The patient later died from a known complication, which was documented as possible in the consent. The patient's wife sued for med-mal, the basis of which centered around adequacy of informed consent.

The case hinged around the nature of the informed consent and the process by which the consent was obtained. The attending, resident, MA and the staff all testified that this process was followed on every patient, without exception, prior to non-emergent procedures. The jury returned a no-cause verdict and in its decision making process stated that the complication did occur, that it probably was related to the care delivered, but the patient did know it was a possibility, and accepted the possibility of complication, including a lethal complication in exchange for the chance to be cured of his disease by the procedure.

In a post-hoc legal analysis, the ability to demonstrate the consent process, of which the paper was only one piece of the pie, was of paramount importance in the verdict.

Moral: The goal is to make sure that consent is informed, that the consent process is followed, and if necessary, proof exists that a pattern of consent behavior is followed and identifiable, independently of the person obtaining the consent, and probably even that won't protect you 100%.

The form is not the issue, but the process is.