Nurses taking consent!

[gasp]

---

Members do not see this ad.

So there was a previous post on how demented patients come to the OR and are DNR/DNI and cannot consent. I would like to share some things that I've been seeing and get everyone's thoughts on these everyday occurrences.

At a couple of hospitals that I have covered with a significant elderly population, there is a surgical consent and a separate anesthesia consent. We get old 90+ demented patients who are very sick with multiple comorbidities and obviously high risk for any procedure. Sometimes they come in for emergency cases (no consent needed), Semi-urgent cases (ORIF of hip fracture), and completely elective cases (lipoma removal). I have seen multiple times where surgical consent is there (either from surgeon speaking to fam/POA, 2 physicians signing, and most times NURSES consenting family/POA and signing the "witness" portion of the consent form and surgeon signs on the day of surgery in holding). Separate from that, we have an anesthesia consent form.

I have seen on multiple occasions NURSES signing the "witness" portion of the consent form for anesthesia when NO anesthesiologist has ever spoken to the family/POA regarding risks and benefits of anesthesia. Then the pt comes to holding and we try to get a hold of the fam/POA to explain the risks but they cannot be reached at the time. They expect the anesthesiologist to SIGN the anesthesia consent form now to take the pt into surgery because the NURSE who signed the witness portion (the day before) already "explained about the anesthesia." When delaying these cases for anesthesia consent, the surgeons get upset that we are delaying the case even tho "anesthesia consent is there." Can anyone here relate and how do you handle the situation for elective or semi-urgent cases like ORIF of hip fractures?

 

[fakin' the funk]

Those are some serious shenanigans.

Tell the surgeons that if they can't wait for you to consent the patient or patient's representative, i.e., your duty as a physician, they can do the case without your assistance. 😀

 

[chocomorsel]

I feel like surgeons sometimes are a way more lenient about the consents than we are. At some of the hospitals I know of, the nurses routinely get the surgical consent. I totally find that weird.

 

[SouthSideSteve]

My understanding is the nurse is only signing that they witnessed the pt/family member sign the consent, not that they are consenting the patient. The physician's signature is demonstrating actual informed consent.

 

[pulmoblast]

My understanding is the nurse is only signing that they witnessed the pt/family member sign the consent, not that they are consenting the patient. The physician's signature is demonstrating actual informed consent.

Spot on. The responsibility of informed consent and the legal consequences of the failure to obtain it rests solely with the physician. I can just picture the said nurses breaking down into tears on the witness stand saying how she was pressured into signing witness for the doctors...then a multimillion dollar malpractice lawsuit for the physicians...maybe even criminal assault and battery charges...and then you will find in the fine text of your malpractice insurance, clauses for exclusion of gross negligence; such as failure to take informed consent

 

[IlDestriero]

That wouldn't fly where I work.

 

[teeva]

It's not uncommon in my experience. Shrug.

However, I still get consent regardless, no exceptions (unless it's emergency an no consent needed or 2 docs provide administrative consent), 100% of the time, no matter what's been pre-signed, always following the legal order of family/POA/custodian. Always. NO EXCEPTIONS. EVER.

 

[deansrv72]

Pre-op nurses at one of the facilities I work at routinely sign as a witness, to the anesthesia consent, before any consent/explanation has been obtained/established. They do this so they can move on to the next task, and save time. I'm not in favor of this practice.

As to the "issue" of informed consent, the issue of consent is that it be obtained, not that a form is signed. As we know, signing a form is not giving informed consent.

In the legal realm, the form can serve as limited evidence that an element of informed consent was obtained, but is neither proof of informed consent nor a substitute for it.

And to add.. an attorney once stated that "...simply including a given complication on a "consent form" is not a waiver of liability. It does not immunize the provider from a lawsuit if that complication occurs as a consequence of negligence, although defense counsel usually imply that it does."

Just some food for thought.

 

[CodeBlu]

It's not uncommon in my experience. Shrug.

However, I still get consent regardless, no exceptions (unless it's emergency an no consent needed or 2 docs provide administrative consent), 100% of the time, no matter what's been pre-signed, always following the legal order of family/POA/custodian. Always. NO EXCEPTIONS. EVER.

100% agree.


All it takes is one time... and you're backed up into a corner medicolegally with your derriere in the air and some barrister saying... "So, doctor... you placed this block and the patient had a nerve injury... they were not properly consented. How do you plead?"

 

[Laryngophed]

At our place, the witness line is only used when consent was obtained via a surrogate decision maker. And the nurses here will sign it, but they typically will ask the POA or NOK if they have any questions, understood the explanation, and wish to go forward with the procedure. I have never seen a nurse consent for a procedure or anesthetic. And I'm positive the attendings would not let that fly.

 

[Impromptu]

The charge doctor who pre-ops the add-on cases will obtain the consent from the patient or POA.

 

[RxBoy]

When delaying these cases for anesthesia consent, the surgeons get upset that we are delaying the case even tho "anesthesia consent is there."

Our nurses fill out the paperwork and have the patients sign consent. I dont deal with the anesthesia form period and in a fast pace OR, Im glad I dont. Consents are absolutely worthless documents that have no legal merit in our corrupt system. I always explain the anesthesia plan, risk and if possible involve my patients in informed decisions (spinal vs general, pca vs epidural, ect).

However just because I explain epidurals and risk of hematoma... and the patient gets an epidural hematoma and losses function of their legs, do you think a defense lawyer will care that the patient signed consent? Its a meaningless document. Hell even if you took the time and explained everything to the patient yourself and wrote the consent up yourself in your own handwriting, it still wont make a difference. The patient will simply deny the conversation ever took place regarding that complication or didnt understand it (which is what the lawyer will coach them to say). 99% of patients dont read the consent form. Its just mindless bureaucracy and an extra step in meaningless hospital paperwork, so I say leave it to the nurses.

 

[teeva]

I don't disagree. That's why when I get consent 100% of the time, it is brief, like a 30-60 seconds most of the time. I mention the common side effects of anesthesia (n/v, sore throat), possible headache with spinal or epidural, and when needed death/MI/CVA or inability to extubate and ICU admission. I know some people do routinely, but I don't routinely mention death/PE/MI/CVA/anoxic brain injury/nerve injury unless it's a really sick patient.

Essentially I go through the motions. It's a no-win situation if anything bad happens, no matter what you do. Knock on wood.