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?