Informed Consent?

[JustPlainBill]

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Ok, so here I am in the middle of a general surgery rotation. Cool, it's a lot of fun and really interesting work.....but there's a side to it that I'm
not digging so much.....

I've seen this happen on more than one occasion ----

Pt. is diabetic and a toe is starting to get nasty -- i.e. discoloration, wound formation, etc. The surgeon pops into the room on rounds
and mentions that an arteriogram indicated the need for a fem-pop
shunt and that the 'toe would probably have to come off'. The patient
reacted as expected to the news of possible amputation. The surgeon responds with,'Well, we'll need to do the shunt and that toe is probably going to have to come off, ok?'.....The patient rather hesitantly noded their head and softly said 'ok'....the surgeon then patted them on the leg
and said that we'd see them tomorrow in surgery to get that done.....

All in about 2 to 5 minutes.....maybe....

Is that really informed consent? It's not what I think of when I think of informed consent......or am I out in the weeds again?

 

[Droopy Snoopy]

Ok, so here I am in the middle of a general surgery rotation. Cool, it's a lot of fun and really interesting work.....but there's a side to it that I'm
not digging so much.....

I've seen this happen on more than one occasion ----

Pt. is diabetic and a toe is starting to get nasty -- i.e. discoloration, wound formation, etc. The surgeon pops into the room on rounds
and mentions that an arteriogram indicated the need for a fem-pop
shunt and that the 'toe would probably have to come off'. The patient
reacted as expected to the news of possible amputation. The surgeon responds with,'Well, we'll need to do the shunt and that toe is probably going to have to come off, ok?'.....The patient rather hesitantly noded their head and softly said 'ok'....the surgeon then patted them on the leg
and said that we'd see them tomorrow in surgery to get that done.....

All in about 2 to 5 minutes.....maybe....

Is that really informed consent? It's not what I think of when I think of informed consent......or am I out in the weeds again?

It's possible that you're not seeing the whole picture. It's often the case that the intern or nurse practitioner comes along later with the signature form and explains things in a bit more detail. Sometimes IC gets done in clinic prior to admission. Regardless of whether this is the case, in utopia every procedure, minor or major, would be discussed with the patient at length by the attending. But nobody has the time that kind of hand-holding requires, and there's no billing BCBS for it either. And particularly in a case such as this when informed consent is really just window dressing -- either the toe comes off or it becomes gangrenous and eventually kills you.

 

[aecuenca2]

I would take this as an experience, and as you are learning see how other physicians perform informed consent, both on the inpatient and outpatient setting.

True informed consent is discussing the risks, benefits, and alternatives and answering your patient's questions. And it should be you, the performing physician who should ideally do it.

But as previously mentioned, some doctors don't practice this way. Consider how you want to practice medicine, and perhaps think about how you would be as the patient.

Just keep in mind that obviously anyone can sue, at any given time, and for any reason they wish, and many of them sue not primarily because of the medical care itself, but how they perceived the physician as uncaring and not willing to take the time to explain things to them.

In the end, you'll find out what style fits you best. Just pick the one you are comfortable with (both personally and legally).

 

[PeepshowJohnny]

I would take this as an experience, and as you are learning see how other physicians perform informed consent, both on the inpatient and outpatient setting.

True informed consent is discussing the risks, benefits, and alternatives and answering your patient's questions. And it should be you, the performing physician who should ideally do it.

But as previously mentioned, some doctors don't practice this way. Consider how you want to practice medicine, and perhaps think about how you would be as the patient.

Just keep in mind that obviously anyone can sue, at any given time, and for any reason they wish, and many of them sue not primarily because of the medical care itself, but how they perceived the physician as uncaring and not willing to take the time to explain things to them.

In the end, you'll find out what style fits you best. Just pick the one you are comfortable with (both personally and legally).

Very well said. I wouldn't make a stink out of it on rounds because it's not going to chance anything and you're going to wind up with some nasty evaluations. But, yeah, we learn from both positive and negative role models.

 

[JustPlainBill]

Thank all....we had just done an AKA and then rolled through on this one. In a prior conversation while walking to the next patient, the surgeon had made the statement that 'we're taking the toe off, we'll get consent' in a 'I've made the decision and we're doing it' type of tone.

While I'm probably not going to do surgery, I'm taking what I can (need to know suturing, hemostatis, and surgery basics) and leaving behind the not so pleasant parts.

 

[ZagDoc]

Thank all....we had just done an AKA and then rolled through on this one. In a prior conversation while walking to the next patient, the surgeon had made the statement that 'we're taking the toe off, we'll get consent' in a 'I've made the decision and we're doing it' type of tone.

Just curious, was it an older surgeon? Medical education has shifted drastically the last 20 years. Paternalism was the way many physicians were taught was the 'proper way to practice medicine' back before advocacy for patient autonomy really worked its way into our curriculum. We're a result of our training, and maybe that's how he was trained.

I second the point that you should file it away in your "things I want to do when I practice vs. things I won't do" cabinet of your brain.

 

[Instatewaiter]

In the end, is there really informed consent for a patient that hasnt thrown in the towel yet? the surgeon/team comes in and says what he thinks is best- gives the benefits and risks- which have already been weighed in his decision and asks the patient what they want to do. Most are just going to go along with the surgeon b/c everything is really so over their head.

Yeah sure they are informed of the benefits and risks but do they really have a choice in the matter?

 

[ZagDoc]

Yeah sure they are informed of the benefits and risks but do they really have a choice in the matter?

Another intriguing question is whether some patients can truly be "informed." I watched a cardiologist spend almost 45 minutes trying to explain cardioablation to a patient and they still didn't have the faintest idea. They eventually just gave up trying to understand and said "Sure doc do whatever you need to." A lot of patients don't have enough of a grip on relative risk and prevalence to truly understand how likely or unlikely they are to have an adverse outcome. A lot of patients don't comprehend that certain adverse outcomes result in lifelong disability, or how severe or mild certain outcomes are medically.

Explaining medicine in layperson terms is something we have to learn, but man, sometimes its like trying to explain quantum physics to a chia pet.

 

[JustPlainBill]

I've also thought about the fact that most, not all, but most, people are so busy that they don't have time to look for valid alternatives. I've got a colleague who has compiled a plethora of well written, solid science research articles concerning vitamin D therapy for HTN that basically achieves the goals of at least one standard HTN med. I have yet to see it recommended even though the research is out there.

My point being: when we as physicians issue our information concerning options/risks/benefits we're really giving the options that WE know of, not necessarily all valid options. Something to keep in mind.....

Yes, he is an older surgeon (in his 50s) and comes from a 'surgical' family....

 

[aecuenca2]

In the end, is there really informed consent for a patient that hasnt thrown in the towel yet? the surgeon/team comes in and says what he thinks is best- gives the benefits and risks- which have already been weighed in his decision and asks the patient what they want to do. Most are just going to go along with the surgeon b/c everything is really so over their head.

Yeah sure they are informed of the benefits and risks but do they really have a choice in the matter?

Yes they do. If they are of sound mind and judgment, they always have a choice.

 

[Ashers]

In the end, is there really informed consent for a patient that hasnt thrown in the towel yet? the surgeon/team comes in and says what he thinks is best- gives the benefits and risks- which have already been weighed in his decision and asks the patient what they want to do. Most are just going to go along with the surgeon b/c everything is really so over their head.

Yeah sure they are informed of the benefits and risks but do they really have a choice in the matter?

I've seen an informed consent where the patient decided he didn't want the surgery. It was with a spine surgeon with a patient with spondylolisthesis, and he decided to live with the symptoms rather than have another surgery. The surgeon was totally cool, didn't push him, and basically said, if the symptoms got worse and he changed his mind, call him, and they'll talk about it again.

 

[PeepshowJohnny]

<SNIP>
Explaining medicine in layperson terms is something we have to learn, but man, sometimes its like trying to explain quantum physics to a chia pet.

One of my favorite scenes in House is where Foreman is getting informed consent for some procedure on a kid from his parents. He starts explaining the pathogenicity of the disease, what they're going to do, what the risks are when he stops. He basically says what you said, that it's pretty silly that they think people can ever really be truly informed with. (I'm paraphrasing)

"This is dangerous. He might die. You should do it"

I've seen an informed consent where the patient decided he didn't want the surgery. It was with a spine surgeon with a patient with spondylolisthesis, and he decided to live with the symptoms rather than have another surgery. The surgeon was totally cool, didn't push him, and basically said, if the symptoms got worse and he changed his mind, call him, and they'll talk about it again.

That's good, but I've seen it another way. Surgeon basically "decides" the patients having the surgery and gets "informed consent", patient decides to back out or delay the next day, surgeon is pissed that his schedule is messed up now. If he'd actually TALKED to the patient I think the whole situation could have been fixed.