Patient informed consent?

Patient informed consent?
greencart
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Posted Feb 7, 2013 - 6:54 AM:
Subject: Patient informed consent?
Hello,

I'm investigating the subject and I seek some advice. Could you please help me?

The dilemma is: should one (doctor or resident) tell the patient about his limited qualifications, ie that a surgeon is about to cut the patient flesh for the very first time in his career.

On one hand there are substantial arguments for getting informed consent of the patient (Why? Why should individual decide?) - on the other the progress of learning and professional development of doctors would be limited if patients are to decide (most of them, most probably, would ask for only experienced practitioners).

Could you please share your perspective in this area? All and varied voices will be appreciated.

Regards.

(Please excuse my English)
hyena in petticoat
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Posted Feb 7, 2013 - 8:39 AM:

I'm not very sure about this, but aren't new doctors assisted by experienced ones during surgery? Before which they assisted experienced doctors to gain exposure on how things are done in actual? Before which they studied extensively and passed licensure exams to ensure they are qualified to do their job?

I wouldn't say they have limited qualifications, only there are doctors who are more experienced.

Is the consent to be secured as a waiver if things go wrong? But isn't that what doctors try to prevent from happening?

In terms of patient preference, we have no control over that. We often lean towards the expert in the field. All I am saying is, the fact that they are certified, I see no point in subjecting them through a "test" of whether the patient will "hire" them or not. After all, unless the patient is a "medicine person", we're not sure if he or she is in the position to determine the best decision, to arrive at an educated judgment about qualification of the doctor in question.
greencart
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Posted Feb 7, 2013 - 9:15 AM:

Thank you very much. It's all true. And the consent is not only to waive responsibility - is it ethical to "use" a patient to "train" the resident? (it is a fact that residents make more mistakes)

The surgeon situation is just an illustration to the general case where:

1) medical service is delivered by a resident who are qualified to do the intervention, yet that is his first time actually doing that,
2) he is assisted by an experienced md, but it does not change the thing that less experienced one can do harm that more experienced will not do.

So the conflict may be between the ability to deliver top notch service versus the ability to learn how to practice in an environment where people in general will choose a more experienced doctor - if they are asked.

So as it is easier to find arguments for asking people's consent (and ethical guidelines are full of those), I'd like to ask for arguments against too, if you can come up with any.

Edited by greencart on Feb 7, 2013 - 9:24 AM
richrf
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Posted Feb 7, 2013 - 11:24 AM:

More than informed consent, I believe that patients should be much better informed about what they are getting into.

I remember giving the surgeon the third-degree on some experimental surgery that he wanted to try out on my friend's mother. He glared at me, as if to say, "do I really have to answer these questions?". The surgery was botched (excessive scarring) which immediately led to another round of heart surgeries, each compounding the problem even more. My nephew, who recently died of a botched operation, did a lot of homework but still could not avoid the problems of hospitalization.

How to Stop Hospitals from Killing Us

"The world of American medicine is far deadlier: Medical mistakes kill enough people each week to fill four jumbo jets. But these mistakes go largely unnoticed by the world at large, and the medical community rarely learns from them. The same preventable mistakes are made over and over again, and patients are left in the dark about which hospitals have significantly better (or worse) safety records than their peers."

Medical Errors - A Leading Cause of Death

The JOURNAL of the AMERICAN MEDICAL ASSOCIATION (JAMA) Vol 284, No 4, July 26th 2000 article written by Dr Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, shows that medical errors may be the third leading cause of death in the United States.

The report apparently shows there are 2,000 deaths/year from unnecessary surgery; 7000 deaths/year from medication errors in hospitals; 20,000 deaths/year from other errors in hospitals; 80,000 deaths/year from infections in hospitals; 106,000 deaths/year from non-error, adverse effects of medications - these total up to 225,000 deaths per year in the US from iatrogenic causes which ranks these deaths as the # 3 killer. Iatrogenic is a term used when a patient dies as a direct result of treatments by a physician, whether it is from misdiagnosis of the ailment or from adverse drug reactions used to treat the illness. (drug reactions are the most common cause).
BitterCrank
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Posted Feb 7, 2013 - 11:55 AM:

In my experience, "consent" is given by signing a statement before one even gets past the receptionist. This consent form is renewed yearly (assuming one is receiving on-going care) or if one reappears at a clinic after a lapse of more than a year.

More "consent" may be given by signing declarations later on -- such as before beginning major-league cancer treatment or big-time surgery. I usually receive care at University clinics, and once when I was having a skin cancer removed, a student under the surgeon's supervision asked if she could make the initial excision of the basal cell growth (we're not talking major surgery or a melanoma). I declined, noting that I understood her eagerness but I was apprehensive enough as it was.

"Consent" usually isn't all that informed. If we need open heart surgery, for instance, or chemo/radiation for cancer, we aren't likely to know very much about the consequences of proceeding forward. Maybe diet, exercise, and medication could help the heart as much as a by-pass, especially in an elderly person. An oncologist might tell us that chemo can be "unpleasant" but the word "unpleasant" may not begin to describe what sort of hell we could go through.

Patients are, by definition, vulnerable when they are injured or sick and they want to get fixed up or cured. We aren't likely to begin quarreling with hospital staff about what "consent" means when we are laying flat on a gurney with a big tumor, high fever, or broken leg. At that moment we sign forms just to keep things moving forward.

I wonder what "consent" means to the doctor: Is it full speed ahead and damn the torpedoes, is it a blank check, or a legal necessity and nicety? Personally, I don't want the doctor to feel too inhibited to consider all possibilities.

Edited by BitterCrank on Feb 7, 2013 - 12:01 PM
greencart
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Posted Feb 8, 2013 - 5:03 AM:

Thank you very much.

And what do you think about an argument that if patients are to decide there will be hardly any learning going on as everyone tends to want experienced doctors and not residents to receive treatment from?
hyena in petticoat
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Posted Feb 8, 2013 - 9:32 AM:

While the new doctors get to learn through actual practice of what they know already theoretically, the experienced ones continue to learn depending on the variety and gravity of cases they work on. I would think the advancement is not dependent on whether a newbie gets to try a new operation. It is likely that the first few cases he will handle are less complicated than what the experienced ones do. Further, the latter are often the ones who handles difficult cases from which advancement usually stems from. In fact, in "rare"/ abnormal situations, the experienced doctors becomes newbies themselves - facing a case they have little clue about.

Not to mention that some patients actually do allow themselves to become "test subjects" for medical advancement's sake. Patients who are informed and willing.

In short, medical advancement argument against patient informed consent is weak. Not that I see any strong argument in favor of it either.

Botched cases are horrible, saddening and unfortunate. But botched cases are not a result of lack of experience, but carelessness.
nano
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Posted Feb 8, 2013 - 10:32 AM:

To the OP - I feel you need to clarify your questions and also do your homework a bit more. A patient has a right to expect a reasonable standard of care, but that does not include cherry picking. The hospital has a duty to provide a reasonable standard of care. That includes monitoring whether any doctor has sufficient ability to perform a particular duty. That means that the doctor can perform the operation to a level of competence that a reasonable body of medical opinion would deem adequate.

Informed consent is a different matter to a large extent. You must have been given enough information, be able to understand it and be able to retain that information long enough to make a decision.

The first dilemma is a medical decision, and not one which the patient is qualified to make.

The second is an ethical decision, and not one the doctor is qualified to make.

If you are looking at English practice, 'Bolam's law' is the appropriate legal angle from which to understand it (a correct parameter for determine medical competence and an incorrect one for determining ethical competence.)

If you are talking out with the NHS and choosing and paying for the doctor, then some different rules additionally apply. Some of these are based on contract as I understand it rather than duty of care alone.

Hope that helps. smiling face
nano
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Posted Feb 8, 2013 - 12:22 PM:

There's also a (free) article in the current issue of Cambridge Quarterly of Healthcare Ethics on Consent which may even be of interest.
journals.cambridge.org/acti...A&fileId=S0963180112000369
greencart
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Posted Feb 9, 2013 - 3:48 AM:

hyena in petticoat and Nano,

Thank you both. Yes, I am at the beginning of the road smiling face

The Estlund's concept of the normative consent is very interesting and broadens my understanding of the problem. I appreciate your input very much.

Edited by greencart on Feb 9, 2013 - 8:38 AM
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