Taking consent for Surgery

My practice

A patient consults me for a gynaecological condition. I take  her history and  conduct a physical examination. I then, perform an ultrasound scan. I may sometimes do other investigations. Based on all these findings, I explain to her the condition she is suffering from and offer her all the options available. This may include surgery. I will give her the benefits and risks of each option and some of the possible complications that might happen in every option. I will then tell her to go back and think about the discussion and to call me back if she decides to undergo the procedure under my care. I usually offer her the opportunity of a second opinion.

Several weeks or sometimes months later she will call and decides on surgery. My nurse books her for the surgery. We will give her instructions as to what to do prior to the surgery. On the day before the surgery she sees me in the clinic. I will look at her notes to see what I have told her. To refresh my memory I usually re-examine her and perform another ultrasound. I will then go through the surgical procedure with her.  This is usually a quick consultation because  I had already done that previously,  during the first consultation. I give her some patient information leaflet or links she can search herself.

I then consent her with a witness using a standardised hospital approved consent form

I perform the surgery the next day. In a majority of cases everything will go on as scheduled and she will be discharged well one to three days after the surgery. However, on rare occasions a complication may occur during the surgery. I deal with the complication as best as I can. When the patient returns to the ward, I will inform her that a complication had occurred during the surgery and that I had dealt with it. I wonder if  she understands the explanation given and whether legal action will be taken.  I chide  myself for not reminding her of all the possible complications the day before the surgery, even though it was told during the first consultation. Have I made a mistake?

Difference between Government hospital and Private practice

This is a common scenario in private practice.

How much should you tell a patient when taking consent for surgery? When should you tell them and how often? This is a difficult topic to address in private practice.

Why is it difficult? Is it because it is tricky ?

“Tell the patient everything: this includes even the possibility of death. In that way you are covered if a complication occurs” ” – says a senior specialist working in a government hospital. It is easy for a government specialist to say this because he gets his salary whether the patient undergoes the surgery or not. However,  this is not the same in private practice.

In private practice, it is my job to convince the patient that I am the best doctor for her. I need to give just the right amount of information to tell her about her condition and the various options of treatment. To some patients too much information and options may make me look like I am incompetent and unsure of myself. These patients want me to help them make the decision for them. However this group of patients may become upset and take legal action if  a complication occurs because I did not inform them of the  possibility of complications before the surgery.

The second group of patients are the ones who want all the information and options. If I give them minimal information, it may appear like I am patronizing them. After getting all the information, they will make up their mind as to which option they want to choose.

The art is in the ability to understand the patient sitting in front of me and deciding which category she  falls into. The amount of information must be sufficient to satisfy her but not too much to frighten her. This can be a challenge. It only comes with experience. I don’t think it can be taught.   

I am most comfortable operating when I have informed the patient of all the possible complications that could happen during a surgery. I can operate in peace because if a complication does occur, she had been informed earlier. This is especially so when I am performing complicated surgeries such as endometriosis where there is a possibility of bowel, ureteric or bladder injury.

Even if I have told the patient everything, when there is a poor outcome, the patient can still sue me. She can tell the court that she did not understand the implications of the complication when she was told.

My advice

So what advice can I give you, young doctors venturing to private practice?

1. Listen to the patient and her relatives. Try to understand their expectations of you. Then, act accordingly. If they appear like people  who want to be told everything, inform them everything including every possible complication. If they appear like they want you to help them come to a decision, help them decide.
2. Document everything that you have said. Lawyers love documentation but we doctors hate to write
3. Spend time explaining to your patients all the pros and cons of a procedure. Repeat it before their surgery to reinforce it. Sometimes the accompanying person during the first consultation may be different from the one who comes before the surgery, so reinforce what you have said.
4. Spend ample time with the patient explaining before the procedure. We are all busy and sometimes hard pressed for time and do not spend enough time with our patients especially when it comes to explaining possible bad outcomes.  I am also guilty for not being diligent in this area.
5. Provide her reading resources eg information leaflets
6. Offer her the option of consulting you at any time if she needs more information. Keep the door open.
7. Explain the complication and be honest about it. Patients can sense when you are trying to hide information.

Whenever I take consent, I tell the patient that I am not asking her to do this procedure but she is requesting me to perform the surgery on her. This will reinforce to her that I am doing the procedure at her request. This really sounds good. Alas, when there is a poor outcome, whatever you have said before the surgery will not matter. It will all depend on what they perceive as the cause of the poor outcome: whether you were  inefficient and therefore negligent. The courts are also generally in favour of the plaintiff.

Selva

30/6/2021