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Informed consent and the anaesthesiologist

Article in Indian Journal of Anaesthesia · January 2003

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Indian J. Anaesth. 2003; 47 (2) : 94-96
94
INFORMED CONSENT AND THE ANAESTHESIOLOGIST
Dr. S. P. Kalantri
Every human being of adult years and sound mind has a right to determine what shall be done with his body; and a surgeon who
performs an operation without the patient’s consent commits an assault for which he is liable to damages.
Informed consent is a commendable concept: it
gives patients the power of participating in decisions
concerning their own management, to a greater degree
than ever before. The qualifying adjective is superfluous,2
for the word consent (cum, together; sentire, to feel,
perceive) clearly implies sharing of information. Patients
do have problems understanding the nature of their illness
and management plans. It is the duty of the doctor to
ensure that the patient is helped to make a rational decision.
What do patients want? The priority is honest,
unbiased, up-to-date information about their illness, its
likely outcome, and the risks and benefits of different
interventions. They also want help to identify and secure
their treatment preferences. When uncertainty exists they
want a full and frank discussion, no omissions or glossing
over, and an advice explicitly supported by the best
available evidence.3
Ethics apart, according to law, to treat a competent
adult without obtaining his/her consent, amounts to battery
or assault – a punishable offence. To be able to give an
informed consent,4 the patient must: (a) be mentally
competent to make the decision; (b) have adequate
information upon which to base the decision; (c) reach a
decision voluntarily, without duress or undue influence
from health professionals, family or friends.
The Association of Anaesthesiologists of Great
Britain and Ireland (AAGIB)5 and the General Medical
Council (GMC)6 guidelines provide succinct information
for obtaining informed consent in surgical procedures and
anaesthesia.
Who
According to GMC guidelines,6 the onus of
obtaining consent for interventions lies on the doctor
providing treatment and capable of performing the
procedure. In busy public hospitals we may delegate these
tasks to the residents provided we ensure that they are
1. MD, Professor of Medicine,
Mahatma Gandhi Institute of Medical Sciences,
Sevagram – 442 102. Maharashtra.
INDIAN JOURNAL OF ANAESTHESIA, APRIL 2003
94
ETHICAL FORUM
– Cordoza1
suitably trained and qualified; have sufficient knowledge
of the proposed investigation or treatment, and understand
the risks involved. To obtain meaningful informed consent,
some surgical departments of hospitals ask their doctors,
nurses and social workers to talk with patients scheduled
for elective surgery at different times and under different
settings. An endeavour is also made to update evaluation
of the patient’s wishes just before wheeling the patient to
the theatre.
A simple information booklet in a patient-friendly
style, which provides information on some of the
interventions that may be necessary during the patient’s
stay, serves several useful functions. First, it helps junior
staff members provide consistently accurate information
to needy patients. Second, it tells patients what is about
to come and what awaits them in an operation theatre.
This reduces the rate of last minute cancellations, shortens
the stay of length, increases patient satisfaction and speeds
recovery. Third, it documents that the information has
been read and understood, improves recall of information
and makes the process of obtaining consent more
transparent.4
Where
Consultations between surgeons, anaesthesiologists,
physicians and patients often take place in circumstances
least conducive for obtaining an informed consent. Patients
have no privacy and doctors, often in a tearing hurry,
have neither time nor enough skills to explain what awaits
their patient in an operation theatre.
Dr Franz Ingelfinger’s two-decade-old description7
seems to come straight from one of our busy wards:
Even if a physician takes pains to use appropriate
language, he may still lack empathy if he is not acutely
sensitive to the emotional needs of the patient seeking
consultation. Distraught by anxiety, fear and perhaps
suspicion, the patient hears the sounds but not the meaning
of words; reassurances that cancer is an unlikely diagnosis
and a barrage of tests to prove this point may convince
the patient that the opposite is true. ‘We shall not need
another operation’ is recorded in the patient’s mind as
‘another operation’.
KALANTRI S. P. : INFORMED CONSENT
The AAGBI5 strongly recommends that the best
place for obtaining consents is pre-operative assessment
clinics.
How
Calnan8 extols the virtues of a good interviewer:
Sensitive to his listener. Strives to make the other respond.
Looks interested. Always allows the other to speak when
he wishes. Follows the lead indicated by the other. Is
entertaining, has humour. Uses language with feeling and
sensitivity. Discovers topics which interest the other. Is
a good listener. Knows when to stop.
He further suggests: “Courteous conversation
8 our displeasure.
at a time convenient to the patient and yourself will go
a long way in reducing complaint. A warm, friendly
attitude; sensitivity to his worries and aches; clear, simple
sentences; truthful answers with acknowledgement of
deficiencies in one’s knowledge and expertise and leaving
behind room for optimism - even if be merely the
expectation of comfort over the remaining days - will
reassure most patients”.
According to GMC guidelines,6 patients must be
given sufficient information in a way that they can
understand, in order to enable them to exercise their
right to make informed decisions about their care. We
need not explain every risk of every component of the
anaesthetic technique nor must we recite all the
complications and hazards of the drugs. An informed
consent should help and not hurt the patients. Some
patients may like to be told a detailed account of risks
and benefits. Others, who are either not willing to, or are
not able to comprehend details, would prefer to settle
for comforting words. Most patients in our public
hospitals leave the decision making entirely to their doctors.
They do so because details of the procedure add to their
fear of anaesthesia and surgery.
How can we facilitate open communication
with patients?9 We must sit down, attend to patient
comfort, establish eye contact; listen without interrupting;
show attention with nonverbal cues, such as nodding;
allow silences while patients search for words;
acknowledge and legitimize feelings; explain and
reassure during examinations; and ask explicitly if
there are other areas of concern. While giving information,
we should use language, simple and free of medical
jargon, and appropriate to the patient’s circumstances;
personality, expectations, fears, beliefs, values and
cultural background. Also, we should use visual aids to
explain complex aspects of the anaesthesia or a surgical
procedure.
95
We should know that our patients have a right
to:8
l Accept or reject our advice.
l Make a choice on where they will undergo the
procedure or treatment.
l Reflect on opinions, ask more questions, and consult
with the family, a friend or advisor.
l Change their minds about a decision at any time.
l Seek a second opinion elsewhere without incurring
What
Voluntary agreement to a course of action can
never be valid till the patient has been provided full and
frank information on it. Whilst the patient cannot be
educated to understand his illness or the procedure as
well as does his doctor, he can be assisted to make a
rational decision.
We must describe the problem as simply and
accurately as possible, using evidence obtained by
examination and investigation. We should analyse the
situation, explain the need for further tests or other
procedures and the line of treatment being advised.
Alternatives need to be discussed, the pros and cons
explained and the best solution under the circumstances
prescribed.
We should normally discuss the following with
patients:
l details of the surgical procedure involved, including
subsidiary treatment such as methods of pain relief;
l how the patient should prepare for the procedure;
l details of what the patient might experience during or
after the procedure including common and serious
side effects;
l the name of the surgeon, and anaesthesiologist who
will have overall responsibility for the treatment;
l the extent to which students may be involved during
peri-operative period;
l the likely consequences of not choosing the proposed
diagnostic procedure or treatment, or of not having
any procedure or treatment at all;
l details of how long the operation would last- and
cost.
96
How much
The best approach to the question of how much
information is enough is one that meets both our
professional obligation to provide the best care and
respects the patient as a person.10 According to the Bolam
principle11 “doctors will not be found negligent if they
have acted in accordance with a practice accepted as
proper by a body of responsible and skilled medical
opinion.” This standard allowed the doctor to determine
what information is appropriate to disclose. Because the
typical doctor tells the patient very little, courts in England
and Australia now demand much tougher standard to the
information that doctors should give their patients- what
would this patient need to know and understand in
order to make an informed decision.12 This standard is
the most challenging to integrate into practice, since it
requires tailoring information to each patient during our
pre-operative visits: we are expected to make an assessment
of what our reasonable patient would want to be informed
about.
When to withhold information
We may withhold information if we feel on
reasonable grounds that the patient’s physical or mental
health might be seriously harmed by the information. We
should give the patient basic information about the illness
and the proposed intervention even if he directs us to
make the decisions, and does not want the offered
information.
What to do in an Emergency
In an emergency, when immediate intervention is
necessary to preserve life or prevent serious harm, it may
not be possible to provide information. We may provide
medical treatment to anyone who needs it, provided the
intervention is limited to what is immediately necessary
KINDLY NOTE !
New Address of ISA Secretariat
Dr. J. RANGANATHAN
Post Box No. 567, B-30 (11/30)
Bharathiyar Street, Subramaniya Nagar,
Salem – 636 005 (T.N.) India
Tel: 0427-2335336 (Offi.), 0427-2341536 (Resi.)
Fax : 0427-2335337, Mobile: 98427-03318,
Email : drjrsalem@yahoo.co.in
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INDIAN JOURNAL OF ANAESTHESIA, APRIL 2003
to save life or prevent significant decline in the patient’s
health. We should tell the patient what has been done,
and why, as soon as the patient has recovered enough to
understand.
References
1. Schloendorf vs. Society of New York Hospital. 1914; 105
NE 92.
2. Laurence D, Carpenter J : A dictionary of Pharmacology and
Clinical Drug Evaluation. London: VCL Press, 1994.
3. Entwistle VA, Sheldon TA, Sowden AJ, Watt IA. Supporting
consumer involvement in decision-making: what constitutes
quality in consumer health information? Int J Quality in
Healthcare 1996; 8: 425-37.
4. Langdon IJ, Hardin R, Learmonth ID. Informed consent for
total hip arthroplasty: does a written information sheet improve
recall by patients? Ann R Coll Surg Engl 2002; 84: 404-08
5. Association of Anaesthetists of Great Britain and Ireland. Pre
Operative assessment. The role of Anaesthetist. AAGBI.
London. 2001.
6. General Medical Council. Seeking patient’s consent. The
ethical considerations, General Medical Council. London.
1998.
7. Ingelfinger FJ: Arrogance. N Eng J Med 1980; 303: 1507-11
8. Calnan J: Talking with patients - a guide to good practice.
London: William Heinemann Medical Books, 1983.
9. Department of Health. Twelve key points on Consent. London:
Department of Health, 2001.
10. Ethics in Medicine. University of Washington school of
Medicine. Available from: URL: http:/ eduserv. hscer.
washington. edu/bioethics/topics/consent.html (accessed on 22
March 2003)
11. Bolam vs. Feiern Hospital Management Committee. 1957 All
England Reports, 118-28.
12. Skene L, Smallwood R. Informed consent: lessons from
Australia. Br Med J 2002; 324: 39-41.
CORRIGENDUM
Ref. : ISA – AWARDS AND MEDALS 2002
Indian J. Anaesth. 2003; 47(1): 49
The name of Dr. A. Pavendhan (Chennai)
was wrongly printed as
Dr. Pavradhan (Channai).
Mistake regretted.