Sadiyya Sheik
Sadiyya Sheik

Medical consent: Informed or not?

Have you ever consented to a medical procedure? Did you consider that to be an informed consent? Were you aware of the benefits, risks and complications of the procedure?

Have you ever consented to a Blood Product transfusion? Were you told that the risk of contracting HIV is 1 in 2 million people?

I attended a Medical Ethics presentation recently, which brought to the fore issues about informed consent that have long been contested. The reality is that it is sometimes difficult to ascertain whether a patient is making an “informed” decision or not.

In public hospitals, barriers to informed consent involve differing languages, cultural beliefs and levels of education. As such, the procedure of taking consent is often done by means of a translator and then, with a simplification of the procedure at hand. I have found that even when speaking the same language as the patient and with a simplification of the procedure, retention is very poor. So much so, that when asked a day later, the patient cannot relay information that they seemed to understand the day before.

Another issue is that patients may have reasons for consenting or not consenting to a procedure that the medical staff may be unaware of. I recently took consent from a patient for a debridement and skin graft of burn wounds. He seemed to understand the procedure well and was able to give me a summary of the proposed operation when asked. Unfortunately, the operation was postponed due to a logistical issue. The next day, the patient had changed his mind about the operation and insisted on being discharged from the hospital. No amount of coercing on the part of myself and the nursing staff could reverse this change. Finally, after much probing we learned that he consented to the procedure with the understanding that having the procedure done, would shorten his hospital stay. With the procedure postponed, he no longer saw benefit in the procedure.

In some instances, cultural reasons affect the decisions made by patients. Often, these are practises that medical staff cannot identify with. During my internship, I encountered a patient who presented to hospital with a gangrenous foot that required an amputation. We explained the benefits and risks of the procedure to the patient stressing that an amputation could be life saving. Despite this, the patient insisted on first going home to discuss the matter with relatives and to consult his ancestors before consenting to the procedure. I respect that people have different belief systems and are governed by traditions that I cannot always understand but it is difficult to watch these scenarios play out when I know that delaying the procedure can be very detrimental to the patient.

A colleague presented a solution in the form of a “consent on admission”, meaning that when the patient is admitted to hospital they sign a consent form for medical care as deemed necessary by the medical practitioners. I don’t agree with this method for the simple reason that consenting to medical care does not necessarily mean that you will consent to any procedure. A patient may consent to medical care in the form of blood tests and medicines but may not be willing to undergo a surgical procedure. In some instances, discussing these issues may lead to a middle ground in finding a solution that best fits the patient. Does this then mean that anyone not willing to sign this consent form, will not be helped?

Another scenario is the patient that signs the consent form saying, “Whatever you think is best, you’re the doctor.” Earlier this year, I approached a patient with a consent form, intending to explain the surgical procedure to him. Before listening to what I had to say, he pulled the pen from my hand, ready to sign the form. I forced him to listen to what I had to say before signing, but the decision to consent seemed a foregone conclusion to this patient. The problem with this situation is that had something gone wrong during the operation, the doctor would probably be lambasted for not having thoroughly explained the procedure to the patient, by the patient himself!

There is a new Consent to Procedure form doing the rounds at our hospital now, with a section to be filled in by the patient, explaining in their own words what they understand by the procedure. Unfortunately, we do not get much use out of this form because many of the patients seen cannot write and those that can are often limited to only being able to write their own names.

What are your thoughts on consenting to medical procedures? Do you consider yourself “informed” when signing these forms and do you have any suggestions for improving this process, particularly taking note of the obstacles mentioned?

  • Isabella VD Westhuizen

    Well it is good to see a young colleague blogging here. Consent remains a difficult concept my girl at the best of times. Mix it up with the cultural melting pots of our state hospitals and it is really contentious. Good article.

  • http://thoughtleader riyaaz ismail

    I would have thought that the problem would have been ironed out by now,since the medical regulatory body and dove-tailed with necessary legislation can now admit African traditional doctors after they have written an exam.

    The caveat is that they would practise there traditional medicine with a synergistic relationship with our medical establishment.

    Could this minor impediment not be resolved here?
    The issues brought to light here is serious and does need national debate.What happens if the medical procedure does not have the desired effect?
    Does it mean that the medic at the coalface will suffer a curse,or worse still the entire hospital staff?
    This has to be addressed.

  • MLH

    One can only consent to that which one fully understands. Based on that, I’d suggest that the greater proportion of patients really have little understanding of the procedures for which they sign. Also, the forms are so open-ended that they appear to leave surgeons the benefit of the doubt and one wonders how a child with a sore arm manages to have both legs amputated…the forms depend on surgeons and hospitals being perfectly ethical. While I hate to suggest that their insurance is top-of-mind for some surgeons, this was brought home to me when my son woke from an op muttering about a headache after a piece of metal had fallen on him in the theatre. Everyone except one nurse closed ranks. The nurse admitted it had happened. All he wanted was something for the headache.

  • http://sketchesbyboz37.blogspot.com T Watkins

    Interesting discussion of the issues around consent. You may be interested in reading further about the consent axiom at libsa.wordpress.com

  • ZB

    Thanks for this article (blog) Sadiyya. I think this is quite a hot topic. Not just regarding informed consent (or not) to a life saving procedure, but also regarding informed choice to any medical procedure – life saving, cosmetic, or otherwise!

    For example, many a youth like inserting a gold tooth (or slit) between their teeth in their teens. When they visit a dentist to make an appointment for this, almost all dentists never explain what the procedure entails. One discovers only after getting off the dentist’s chair that this actually involves a (subtantial) grind of one’s tooth to prepare for the insert to be attached. Well, at least that was the discovery for me – only after the fact, unfortunately.

    I am one of those (few or many) young people who feel that i wasn’t well informed (by the dentist) as to what that cosmetic dental procedure entails – of which had i known (or briefly been told by the dentist regarding what he was going to do), I would not have gone ahead with it – even though it was at my request initially.

    I think informing a patient about a medical procedure before he/she goes under the surgeon’s knife is a human right! It is his/her body, so long as the patient’s life is not in any immediate risk (like during child-birth in a maternity ward, or when somebody has a fatal wound, or any like such).

    Keep blogging!

  • Malcolm

    As a doctor-cum-bioethisist (doctorates in both) I find it refreshing that this topic is blogged.
    The notion of consent in the clinical field is an attempt to move away from the traditional paternalistic approach – “doctor knows best”. There normally exists a tremendous knowledge disparity between doctor and patient, translating into a power differential. Supplying information, it is argued, levels the playing field, turning the relation into a contractual one where the normal caveats/requirements for contractuality apply. This then theoretically makes patient decisions fully authentic and autonomous.
    But this can only apply if the patient’s understanding is optimal, and therein lies the rub.
    To start with, there is a vast difference between the words I use and my patient’s eventual understanding, sense-making and internalisation. Many patients do not want to be informed (fully), and often medical information is of a very technical nature.
    Does this mean that informed consent cannot always be optimal, and that some residue of paternalism is inevitable? Probably. Does it mean we should not try and practice it as best we could, given some of the other communication constraints mentioned in the blog (and time-constraints)? No. Is there possibly another approach to the problem? I think so; by accepting moral responsibility for our patients (contractuality is a legal notion).
    My 250 words are almost gone; if anyone is really interested in what I mean I’ll explain in a follow-up response.

  • http://www.thoughtleader.co.za/sadiyyasheik Sadiyya Sheik

    Thank you for the comments and my apologies for the delayed response. Malcolm, I am very interested to hear what you propose, please explain.