James W. Roach, MD
Ethics Committee Chair
“What are the ethical considerations for informed consent in a teaching hospital; is it ethical for house staff to obtain consents?”
As we indicated in the December 2012 Ethics Committee article, orthopaedic surgeons make ethical decisions every day, often without a great deal of deliberation. The vast majority are consistent with good patient care and occur because of common sense and appropriate judgment. Nevertheless not all decisions in medicine are straight forward and some present physicians with complex issues, having potential ethical implications. In our first article we presented a group of moral principles to be considered when assessing an issue with ethical elements. In this letter we present another hypothetical case to further illustrate ethical decision making.
As a junior resident finishes a pre-operative history and physical, the nurse asks if the informed consent was completed and says that Dr. X expects the house staff to obtain it. The resident has just left a service where the attendings always obtained their own consents. The resident wonders which way is better.
While all four moral principles, non-maleficence, justice, respect for autonomy and beneficence are applicable, informed consent is mostly about autonomy. The principle of respect for autonomy necessitates that the physician respect the patient as an individual, who, when given adequate information, should be able provide autonomous choices regarding treatment. The important parts of an informed consent process include disclosure, understanding, and voluntary authorization. The activity should be a process, not just the formality of obtaining a signature on a form. Disclosure is achieved during a conversation between the surgeon and the patient which includes a description of the anticipated benefits as well as the possible risks involved in the procedure. The Professional Practice Standard of informed consent requires disclosing facts considered necessary for a reasonable person to be able to accept or refuse a physician’s recommendation. In the instance of non-emergency surgery, it is important that the conversation does not seemed rushed and the patient is given sufficient time for questions to be asked and answered. The surgeon should ask enough questions to assess the patient’s level of understanding. The patient is then given time to evaluate the information and to decide whether or not to proceed. The entire process is predicated on the patient being sufficiently mentally competent to make rational decisions. There are time constraints about how close to the actual surgery the informed consent document must be completed. In many states an informed consent is valid if it has been signed within a few weeks of the intended surgery.
Returning to our question, “What are the ethical considerations for informed consent in a teaching hospital; is it ethical for house staff to obtain consents?” the Ethics Committee would say it is, assuming the resident-in-question has sufficient knowledge to provide the proper disclosure and is reviewing with the patient what the attending has documented in the record. Obtaining an informed consent is an important teaching experience for the resident and if resident-informed consents are done properly, all three informed consent elements can be accomplished and perhaps the process can even be enhanced.
In a typical office practice patients are evaluated and elective surgery scheduled days or weeks in the future. This is a perfect situation to create an enhanced informed consent process. The initial conversation between the patient and surgeon at the time of the surgical recommendation should include a thorough description of the anticipated benefits and the common procedure risks. The surgeon or resident should summarize this conversation in the office progress note, including which benefits and risks were mentioned. When the patient comes to the hospital for the procedure the house staff reiterates the risks and benefits and obtains the signed consent. The attending surgeon is then able to examine the patient, answer any further questions and review the consent document prior to surgery. This process enhances understanding as it provides the patient, over an extended period of time, three individual discussions of potential risks and benefits.
In this analysis, the use of house staff in obtaining consents does not produce any ethical concerns and actually could help patient understanding of the proposed procedure. A final caveat regarding house staff completion of the informed consent document is the risk that the planned procedure might not be accurately recorded on the document. This can be especially problematic if the patient is an adult and the consent error is not discovered until after the patient has been anesthetized. Nevertheless this problem is easily avoided if the surgeon examines the patient and the chart preoperatively, with careful attention given to the consent form and as happens in many hospitals, the nursing staff reconciles the permit with the posted case before the patient is anesthetized.
Chair: James W. Roach, MD Committee Members: J. Abbott Byrd Jr., MD; M. Wade Shrader, MD; Michael J. Bolesta, MD; Richard E. McCarthy, MD; Brian G. Smith, MD.