RN's obtaining the informed consent

[FCMike11]

I work in an ICU an quite frequently am obtaining consents for various procedures such as carotid endarectomy, CABG, valve replacements so on and so forth. Physicians will write an order for what they want consented for, and then we do it for them.

How could I possibly explain this procedure to the patient, quite frankly it's an injustice to the patient. Is there a law somewhere pertaining to this? I do my best, like the rest of us do, I use an atlas/,med forums on the internet to educate myself and then in return explain it my best to the patient, but seriously WTF?

I mention it to fellow nurses and it's kinda something people except and move on, but it irritates me. You can easily find many lawsuits of patients suing because of improper/lacking consent forms that didn't include all of their risks. An from posts I've read in residency forums states that the consent must be done by someone on the surgery teams?

One case in point. Neurosurgeon orders an MRI on pt A, it indicates pt A needs cervical decompression and fusion , doctor goes in tells patient what he saw, he needs it then comes out writes an order for me about what consent he wants...later I get time to go in with the patient and learn the doctors has explained nothing and he was right in there.... Frankly I think this is ridiculous, I'd like other rn's, med students, residents, attendings, NPs, PAs etc to all chime in. An if I am incorrect in any statement please let me know.

Btw I work in a 283 bed acute care center with a designed stroke and cardiovascular ICU.

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[turkeyjerky]

Yeah, I agree--that is ridiculous and unethical. Also, certainly not typical practice.

Out of curiosity, why do they have you, an ICU nurse, consenting for a lot of those procedures anyway, most of those seem elective rather than emergent.

 

[jwk]

Some nurses write "witness signature only" or something similar when they sign their name. There is a difference between witnessing a signature on an informed consent, which is what our nurses at our hospital do, and explaining and obtaining the consent - that's the surgeon's job.

 

[FCMike11]

Yeah, I agree--that is ridiculous and unethical. Also, certainly not typical practice.

Out of curiosity, why do they have you, an ICU nurse, consenting for a lot of those procedures anyway, most of those seem elective rather than emergent.

Well it happens that i will get a patient on balloon pump for a night until bypass, and sometime for valves patient comes in somewhat early to their room so we know way a ahead of time where they'll be after surgery and we can have our "heart box" and such set up.

An even writing those procedures im not excluding laproscopic procedures or such/ other procedures that go through general surgery.

 

[FCMike11]

Some nurses write "witness signature only" or something similar when they sign their name. There is a difference between witnessing a signature on an informed consent, which is what our nurses at our hospital do, and explaining and obtaining the consent - that's the surgeon's job.

This isnt the case. The instances for me have been the patient knows very little, if anything about the procedure, an definitely not any specific risks. I am the one looking up which sections of the consent to sign, to give blood or not then going in trying to give an accurate explanation of it to the client. If i was writing "witness signature", by that id be implying that the client understands what they are signing.

Thank you for your reply, confirmed what i was thinking and that this the surgeons job.

 

[sarjasy]

Thank you for your reply, confirmed what i was thinking and that this the surgeons job.

They've shoved it down our throats in school - nurses do not obtain informed consent. Only sign as a witness. Something goes wrong, patient's family says they didn't understand the risks, and it is your license and job on the line. It's not fair to the patient either. You are not the surgeon and you cannot sufficiently inform the patient of the procedure and is thus not true "informed" consent.

 

[FCMike11]

They've shoved it down our throats in school - nurses do not obtain informed consent. Only sign as a witness. Something goes wrong, patient's family says they didn't understand the risks, and it is your license and job on the line. It's not fair to the patient either. You are not the surgeon and you cannot sufficiently inform the patient of the procedure and is thus not true "informed" consent.

Thank you so much, i totally agree with you. Talking to my coworkers there was a nurse who planted her foot, doctors threw a fit and things changed for awhile then it went back to the way people accepted it to be.....

Im definitely going to talk to our supervisor and some of the physicians i know personally an see what they think.

 

[jwk]

This isnt the case. The instances for me have been the patient knows very little, if anything about the procedure, an definitely not any specific risks. I am the one looking up which sections of the consent to sign, to give blood or not then going in trying to give an accurate explanation of it to the client. If i was writing "witness signature", by that id be implying that the client understands what they are signing.

Thank you for your reply, confirmed what i was thinking and that this the surgeons job.

When you witness a signature, that's all you're doing - signing your name to say that you watched someone else sign their name. You're not determining whether or not they understood what they signed, simply that they signed it.

A notary public does the exact same thing. A notary doesn't read the document - they simply witness the signature on the document.

 

[TexasPhysician]

They've shoved it down our throats in school - nurses do not obtain informed consent. Only sign as a witness. Something goes wrong, patient's family says they didn't understand the risks, and it is your license and job on the line. It's not fair to the patient either. You are not the surgeon and you cannot sufficiently inform the patient of the procedure and is thus not true "informed" consent.

Incorrect. By law, the physician performing the procedure is the only one liable for informed consent (at least in TX). Not even other physicians on the team are liable. Laws have been well established here for good reason.

You are only witnessing a signature. The patient does not have to sign your consent. If the patient does not feel informed, feel free to explain that the patient does not have to sign this form and that you can attempt to reach the physician performing the procedure for them.

Your job like mine is not to explain the surgeon's job or whoever else is performing the procedure. Either witness the signature from an informed patient or page the physician to come do his/her job.

 

[chrish0204]

I agree that this is pretty fubarred if you really are obtaining informed consent -- is that really what this is, or just witnessing?

However, I disagree with someone above; it is the responsibility (ethical, not legal) for a nurse to ensure that the consent really was informed. If a nurse watches a surgeon walk into a non-English speaking patient's room, obtain a consent after explaining a procedure that the patient clearly didn't understand, and still let the situation continue, I would say that nurse is doing a pretty piss-poor job (just to give a somewhat exaggerated example).

 

[jwk]

I agree that this is pretty fubarred if you really are obtaining informed consent -- is that really what this is, or just witnessing?

However, I disagree with someone above; it is the responsibility (ethical, not legal) for a nurse to ensure that the consent really was informed. If a nurse watches a surgeon walk into a non-English speaking patient's room, obtain a consent after explaining a procedure that the patient clearly didn't understand, and still let the situation continue, I would say that nurse is doing a pretty piss-poor job (just to give a somewhat exaggerated example).

You're not going to find that listed in a staff nurse's job description. Why? Because the hospital doesn't want the friggin responsibility for it. You're a little overly idealistic in your perspective. It is the surgeon's responsibility to explain the procedure, it's risks, benefits, alternatives, expected outcomes, etc. to the patient. Hell, the nurse may not even be in the room when this is occurring. So what? Again, they sign as a witness. If they're that concerned the patient doesn't understand the procedure, then by all means, call the surgeon and let them know. But it is NOT the job of the nurse to make a determination of whether or not the patient REALLY understood the consent, or if they just KINDA understood it, or whatever.

 

[FCMike11]

The instance here is the surgeons are doing nothing an the nurses are printing the consent, filling it out per MD orders, going into patients room, explaining articles 3a, 6a, 10a (examples), then patient signs it and we sign in our witness spot....

An of course when the patient comes back that day the surgeon has signed it so it looks like he did it, but really it was signed after the fact, likely when he was done and writing post op orders.

 

[TheEarDoc]

The surgeon can obtain the consent. That's not a nurses job. The patient almost always has questions that an RN cannot answer. If policy is written correctly then the patient will have to sign the consent when they meet with the surgeon in pre surgery consult.

 

[ghost dog]

I work in an ICU an quite frequently am obtaining consents for various procedures such as carotid endarectomy, CABG, valve replacements so on and so forth. Physicians will write an order for what they want consented for, and then we do it for them.

How could I possibly explain this procedure to the patient, quite frankly it's an injustice to the patient. Is there a law somewhere pertaining to this? I do my best, like the rest of us do, I use an atlas/,med forums on the internet to educate myself and then in return explain it my best to the patient, but seriously WTF?

I mention it to fellow nurses and it's kinda something people except and move on, but it irritates me. You can easily find many lawsuits of patients suing because of improper/lacking consent forms that didn't include all of their risks. An from posts I've read in residency forums states that the consent must be done by someone on the surgery teams?

One case in point. Neurosurgeon orders an MRI on pt A, it indicates pt A needs cervical decompression and fusion , doctor goes in tells patient what he saw, he needs it then comes out writes an order for me about what consent he wants...later I get time to go in with the patient and learn the doctors has explained nothing and he was right in there.... Frankly I think this is ridiculous, I'd like other rn's, med students, residents, attendings, NPs, PAs etc to all chime in. An if I am incorrect in any statement please let me know.

Btw I work in a 283 bed acute care center with a designed stroke and cardiovascular ICU.

This is actually going on in the United States? The lawsuit capital of the world ?

Wow. This seems like a huge liability. If something goes tits up during surgery - ungood for all involved on the surgical team.

Have you talked to your charge nurse and / or union rep about this ?

 

[TexasPhysician]

This is actually going on in the United States? The lawsuit capital of the world ?

Wow. This seems like a huge liability. If something goes tits up during surgery - ungood for all involved on the surgical team.

Have you talked to your charge nurse and / or union rep about this ?

This surprises you?

 

[PrinceVersed]

This exact scenario happened EVERY DAY in my hospital. I agree that the buck shouldn't be passed down to you, but it is. Sorry, it sucks. I think you are doing a fine job by trying to inform them to the best of your ability. That is what we did. And while we (the RN's I worked with and myself) could never explain the surgery as in depth as the doc I do think we did a better job of putting what was going to happen on the patients level.

I bet if you flip to the progress notes you will see that the doc wrote something along the lines of "discussed tx options w pt. pt accepts/understands risk of the surgery and wants to proceed" or some such jazz. What they have been drilling into us in my medical ethics class is that that conversation is the "informed consent" more so than the papers that you get signed.

 

[ghost dog]

This surprises you?

Pretty ridonculous. I wonder what would happen if the RN just outright refused to do this? This is an abuse of the staff; I treat mine well.

Let the scalpel jockey do his own goddamned consents. Otherwise, the RN should get a piece of the pie.

 

[sarjasy]

Incorrect. By law, the physician performing the procedure is the only one liable for informed consent (at least in TX). Not even other physicians on the team are liable. Laws have been well established here for good reason.

Perhaps Texas has rock-solid legal protection, but if a nurse tells the patient something incorrect and the procedure goes south, all that patient needs is a sympathetic jury in most states. Regardless, if a state board of nursing gets wind and decides you were practicing outside your scope of practice, you could lose your license.

 

[TexasPhysician]

Perhaps Texas has rock-solid legal protection, but if a nurse tells the patient something incorrect and the procedure goes south, all that patient needs is a sympathetic jury in most states. Regardless, if a state board of nursing gets wind and decides you were practicing outside your scope of practice, you could lose your license.

Most states? Malpractice suits are on the decline - big time.

Having the patient sign a consent form is not practicing outside a nurse's scope of medicine. If the patient speaks English and signs the form, a jury would have a hard time convicting. If the patient denies having been informed, page the doc to do his/her job. It's simple really.

Think of it like signing a waiver to play paintball and then losing an eye. I can't turn around very easily and claim I wasn't explained the risks well enough. I signed the form.

Hospitals have a huge legal team. They have excellent forms now to avoid lawsuits.

You can't live in fear of stupid malpractice lawsuits. The only way to truly avoid them is to quit healthcare.

 

[fab4fan]

At a hospital where I worked, this used to be the norm until the nurses put their collective foot down and declared it was not their responsibility. For once, the hospital sided with the nurses.

It's the doctors' job to make sure the patient fully understands the risks and benefits of the procedure. The nurse should witness the consent and if the patient has questions, makes sure the physician answers those questions before the patient has surgery.

 

[chrish0204]

You're not going to find that listed in a staff nurse's job description. Why? Because the hospital doesn't want the friggin responsibility for it. You're a little overly idealistic in your perspective. It is the surgeon's responsibility to explain the procedure, it's risks, benefits, alternatives, expected outcomes, etc. to the patient. Hell, the nurse may not even be in the room when this is occurring. So what? Again, they sign as a witness. If they're that concerned the patient doesn't understand the procedure, then by all means, call the surgeon and let them know. But it is NOT the job of the nurse to make a determination of whether or not the patient REALLY understood the consent, or if they just KINDA understood it, or whatever.

I'm sure the hospital does not expect nurses to do any more than the bare minimum in this regard as a condition of employment. I just think that nurses ought to have an ethical responsibility to intervene if it's obvious the patient doesn't understand. What would you think of a nurse who realizes the patient doesn't understand and just shrugs his/her shoulders and says "It's not my responsibility!" I was taught to ask patients if they have any questions or need clarification after they the physician leaves, and if they say "yes," to run and get that physician back in the room. I think that's a pretty good policy.

 

[NYRN]

They've shoved it down our throats in school - nurses do not obtain informed consent. Only sign as a witness. Something goes wrong, patient's family says they didn't understand the risks, and it is your license and job on the line. It's not fair to the patient either. You are not the surgeon and you cannot sufficiently inform the patient of the procedure and is thus not true "informed" consent.

Exactly!!! Holy illegal for a nurse to obtain consent!! We are allowed to witness the informed consent and that is it. If the patient expresses any doubt about having the procedure done, you should not sign as a witness until the patient expresses his/her agreement with the procedure.

I worked at one place as a traveler, and they tried to get the nurses to obtain consent for various things, I outright refused. I'm not going to risk my license! Of course the charge nurse got annoyed, but thats too bad!

The doctor doing the procedure is the ONLY one who should be getting consent. The ER doc is not obtaining informed consent for the appendectomy that he/she diagnosed in the ER, the surgeon is. The anesthesiologist is getting his/her own consent signed, not the surgeon, etc.

 

[Promethean]

Necrobump, but in a couple of hours I am quitting a job that I've had for two days, in large part because I am extremely uncomfortable with what they are asking me to do.

I'm supposed to shove a consent form into the hand of a patient who is already on a stretcher in the procedure room and say "Here, sign this so that we can perform the procedure." Then, just before the CRNA pushes the propofol, the proceduralist, who they are meeting for the first time at that very moment, comes in to talk to them about the procedure and give them risks and benefits.

Also, they want me to have pre-filled out all the charting before the patient comes in the room, and to sign off on forms without reading them myself, because that is the way they do it there and they are too busy to do it the right way.

And the staffing firm suggested that I am the one who is unprofessional for refusing to risk my license by leaving this assignment early? I swear I will go wait tables until medical school before I will let a patient come to harm because it was inconvenient to do the right thing.

 

[deleted480308]

Necrobump, but in a couple of hours I am quitting a job that I've had for two days, in large part because I am extremely uncomfortable with what they are asking me to do.

I'm supposed to shove a consent form into the hand of a patient who is already on a stretcher in the procedure room and say "Here, sign this so that we can perform the procedure." Then, just before the CRNA pushes the propofol, the proceduralist, who they are meeting for the first time at that very moment, comes in to talk to them about the procedure and give them risks and benefits.

Also, they want me to have pre-filled out all the charting before the patient comes in the room, and to sign off on forms without reading them myself, because that is the way they do it there and they are too busy to do it the right way.

And the staffing firm suggested that I am the one who is unprofessional for refusing to risk my license by leaving this assignment early? I swear I will go wait tables until medical school before I will let a patient come to harm because it was inconvenient to do the right thing.

I'm with you on not having them sign consent before being advised of risks/benefits

 

[fab4fan]

Necrobump, but in a couple of hours I am quitting a job that I've had for two days, in large part because I am extremely uncomfortable with what they are asking me to do.

I'm supposed to shove a consent form into the hand of a patient who is already on a stretcher in the procedure room and say "Here, sign this so that we can perform the procedure." Then, just before the CRNA pushes the propofol, the proceduralist, who they are meeting for the first time at that very moment, comes in to talk to them about the procedure and give them risks and benefits.

Also, they want me to have pre-filled out all the charting before the patient comes in the room, and to sign off on forms without reading them myself, because that is the way they do it there and they are too busy to do it the right way.

And the staffing firm suggested that I am the one who is unprofessional for refusing to risk my license by leaving this assignment early? I swear I will go wait tables until medical school before I will let a patient come to harm because it was inconvenient to do the right thing.

Sounds like a job I briefly had. I found out that for almost two months they were signing my name as the "circulating nurse" for ESIs, even though I was never even in the room. I raised holy hell and had them pull the charts, line out my name and put whatever they wanted there...Mickey Mouse for all I cared. Got fired for "unprofessionalism" shortly after that. There was some other crap they pulled, but it's been ten years now, so I don't remember everything.

Guess who got a lawyer?

Consider yourself lucky to be rid of them.

 

[Promethean]

Tomorrow I have an interview with a different staffing agency. I haven't heard back from the one that sent me to the GI Lab of Doom. They were supposedly going to find me other work, but no one has made a peep at me since. Meh. Good riddance. That was so unimaginably bad.

They told me that I was required to return to the job site to resign, or else face being blackballed from that entire hospital system. So, I went there shortly after posting the above. I had been told to meet the unit director at 8am at a specific spot. So I went there. I texted her around 7:55 to tell her I had arrived. 20 minutes later, she texts me, Wait, are you not reporting to work? I told her that I was not, and she was like, well if you aren't here to work, then you need to leave the premises immediately, I don't have time to meet with you, no one told me that you were quitting or to expect to meet with you, etc. All by text.

The recruiter said that he was told that she had met with me in person. When I showed them that I had travelled all the way there just to have her refuse to meet me even briefly, that our conversation had been conducted via text message, he changed his tune. Suddenly, they seemed to understand that maybe I wasn't the source of any unprofessionalism in the situation. Vindication was nice. A paying gig would be better. I'm not hurting for cash, but I really hate not working. I get crafty.

 

[NPinProgress]

I know this is an old thread, but informed consent is the conversation between the doctor and patient, not just the piece of paper.
The consent is signed by the patient (or someone duly authorized to give consent) and witnessed by someone. It can be the nurse, a family member, a secretary. Just not by someone involved in the procedure (otherwise that would appear to be coersion).
An order to have the patient sign a consent for XYZ surgery/procedure does not mean that they expect you to explain the procedure, or the risks, benefits, and alternatives of the procedure. They wouldn't even want you to try. If a patient doesnt understand or has further questions, I encourage them to wait until they have all their questions answered at a later time (in pre-op, when anesthesia shows up, you can page the doc, etc.). This isnt a big deal because you are just witnessing that the patient signed, not the cousin or daughter or ABC person.

 

[deleted480308]

I know this is an old thread, but informed consent is the conversation between the doctor and patient, not just the piece of paper.
The consent is signed by the patient (or someone duly authorized to give consent) and witnessed by someone. It can be the nurse, a family member, a secretary. Just not by someone involved in the procedure (otherwise that would appear to be coersion).
An order to have the patient sign a consent for XYZ surgery/procedure does not mean that they expect you to explain the procedure, or the risks, benefits, and alternatives of the procedure. They wouldn't even want you to try. If a patient doesnt understand or has further questions, I encourage them to wait until they have all their questions answered at a later time (in pre-op, when anesthesia shows up, you can page the doc, etc.). This isnt a big deal because you are just witnessing that the patient signed, not the cousin or daughter or ABC person.

It's one of the first things we cover in medical school ethics....benefits/risks are always part of informed consent

 

[Promethean]

I know this is an old thread, but informed consent is the conversation between the doctor and patient, not just the piece of paper.
The consent is signed by the patient (or someone duly authorized to give consent) and witnessed by someone. It can be the nurse, a family member, a secretary. Just not by someone involved in the procedure (otherwise that would appear to be coersion).

I do understand that the informed consent is not the piece of paper. However, the paper is a legal document which verifies that informed consent was obtained. By signing it, the patient is agreeing that they understand and accept the risks/benefits of the procedure.

What I was being asked to do was to obtain a signature, witness it, and then fill in the blanks about what was going to be done. Only after that point would the physician meet the patient for the first time and have the informed consent conversation. When you are already on the procedure table, with a stick of propofol screwed into your IV, and someone you've never seen before comes in and tells you that they are going to stick a scope up where the sun doesn't, okay? It could make the bleeding worse and possibly perforate your bowel, but we need to see what is going on up there. See you when you wake up! After you've already signed the form? That isn't informed consent.

I wouldn't have minded obtaining a signature and witnessing it, if the physician had actually discussed anything with the patient first. Instead, the only conversation regarding consent that was had with the patient prior to that signature was "Here, sign this so we can perform the procedure."

You cannot believe that is actually an acceptable practice? You surely must have misunderstood my complaint.

What kills me is that it would have required such a trivial amount of extra effort to just do things the right way. It would have even made the day run more smoothly. Laziness is not the same thing as efficiency.

EDIT: I re-read what you wrote. It sounds like you are caring for the patient on a floor, away from the procedure area, and that you do exercise discretion regarding ensuring that the patient does really consent prior to signing. That is a very different situation than patient on the table with sedation in line, ready to be pushed. You know how they teach us in nursing school about responsibility rolling down hill, so that the last provider to touch the patient often gets the blame for a whole series of systemic failures?

As a circulating nurse in the OR / Procedure area, I'm where the buck stops. They could pay 1/3 as much for an unlicensed tech to do the tasks of the job. The reason nurses are required in that role is that we have the training and the duty to know when a process is wrong and to refuse to allow it to go forward. I do tasks, set up equipment, help the doctors, but my real job is to act as a safety monitor, and to put the brakes on when necessary.

I can't even count how many things are wrong with a patient for an elective procedure not getting to meet the proceduralist until after they are on the table. There were several opportunities prior to that moment for things to have been done the right way. I was just the last person who could either let the momentum carry the cases forward, or else balk and refuse to give my blessing to a wrong. If I were a regular employee there, I'd have stayed to have the fight. As a contractor, I would have been shown the door anyhow, had I questioned their practice.

I finished out the shift, called the staffing agency to explain, and gave feedback on my concerns to the agency and the facility. For this, I was told that I was behaving unprofessionally (for not continuing the assignment despite my concerns) and that I would be blackballed from the entire hospital system. I've since carried my complaints further, and been vindicated. Still, I won't be going back into a procedure area as a contractor. The liability is too great and the empowerment and support needed to do the job properly is just not there.

It would really suck to lose my nursing license just as I was beginning to obtaining one in medicine. I can't imagine that would go over well.