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How do you know if your patient is truly informed?

Copyright © 2003 by the American College of Physicians.

By Jason van Steenburgh

SAN DIEGO—The 70-year-old woman was suffering from severe and disabling rheumatoid arthritis, critical aortic stenosis and progressive renal insufficiency. She complained that her quality of life was declining and that she was completely dependent on her family.

Although her physicians had previously discussed the idea of replacing her aortic valve, she had always refused the procedure. Now, however, after meeting alone with a surgeon, she had signed a consent form and was scheduled for surgery the next day.

The patient's sudden change of heart left her relatives and physicians asking the same question: Did she really want the surgery?

At a presentation during the annual meeting of the Society for Hospital Medicine (formerly the National Association of Inpatient Physicians) in early April, participants used the scenario to explore the sometimes-thorny issues that can surround informed consent.

Thomas E. Baudendistel, ACP Member, associate program director of the internal medicine residency program at the California Pacific Medical Center in San Francisco, used the above case to illustrate some of the key points to obtain consent—and to make sure that patients are truly informed.

  • Take a team approach. Dr. Baudendistel said the woman's hasty decision to go ahead with surgery illustrates the need for physicians and family members to guide patients through the consent process.

    When the woman talked to her surgeon about the procedure, she was alone. Once her family and physicians talked to her about that decision, they realized that she didn't fully understand the procedure's risks and benefits. Once she realized that replacing her aortic valve wouldn't help her arthritis, she changed her mind about the surgery.

    Physicians may be reluctant to bring other health care professionals into family meetings out of a fear of bringing too many opinions to the table. Several audience members suggested that medical staff meet to discuss the patient's case before the family meeting and agree on the basic facts. Disagreement among physicians can often confuse patients who aren't well-versed in medical terminology.

    One audience member commented that "true" consent was obtained in this case only because the primary care physicians disagreed with the surgeon's recommendation. "Consent is rarely double-checked," he said.

    "Perhaps it should be," Dr. Baudendistel responded. He noted that studies show that only 30% of patients queried about risks, benefits and alternatives can correctly recall their options, even a few hours after being counseled by a physician.

  • Establish the risks and benefits. The surgeon had told the woman that she would die without a new valve. While that shocked her into action, her real concern was that her arthritis was causing her to be a burden to her family.

    In addition, the patient didn't know about the possible adverse outcomes of the procedure, such as increased dependency and a lengthy hospital stay. One audience member said that discussing the best and worse likely outcomes often helps patients understand their options more clearly.

  • Advise, but don't push. What's your role when talking to patients about consent? The surgeon in the above scenario, for example, clearly believed that surgery was the best option for the patient. But did he go too far in pushing the patient into surgery?

    Although you must believe a treatment is in the patient's best interest, Dr. Baudendistel recommended involving patients in the discussion early to help clarify their perception of their quality of life.

    "When you give patients the autonomy to make decisions, you have to be prepared for them to make bad decisions—or what you might think are bad decisions," he said. "But they are drawing on their own experiences and values, and that's OK."

    Although physicians can and should make recommendations, there is a fine line between suggestion and coercion. It is ethically unsound to obtain consent by bullying patients.

  • Give patients time. In acute situations, time is critical. But if time permits, give patients with particularly complex issues as much time as possible to decide.

In the scenario discussed at the meeting, the elderly patient returned home. Three days later, she died surrounded by her family.

Some audience members questioned whether the surgeon who pushed for the valve replacement had been right after all. Dr. Baudendistel said it was a decision only she—and her family—could make.

In the end, he said, the family—and presumably the patient—felt good about the fact that a fully informed discussion had allowed her to maintain decision-making autonomy.

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