What does informed consent mean to you?
Working on one side of the health care street may not quite prepare you for the other side. Like many of us, you probably believe you know hospitals, nurses, and doctors. You may further assume you understand x-ray, housekeeping, pharmacy, patient advocates, medical records, and admitting. There's no reason to think otherwise, as long as you stay healthy.
Not until you become a consumer of health services in what you thought was a system you knew, do you find out how unaware and possibly vulnerable you are.
The following are true-life scenarios. Read each as if it were your own medical situation or that of a close relative, and think about how you would handle the problems presented from a patient's point of view. We will discuss the informed-consent issues and your options in each scenario.
Scenario 1. A section of the consent form you are asked to sign upon admission to the hospital states: "I understand that this is a teaching hospital and that I may be subject to any and all technologies, treatment, and procedures chosen in the course of my hospitalization.'
Possible response. You are not comfortable with that statement. Do you have a choice? Yes, you may cross out any part of the form where you do not choose to give consent. Be sure to initial and date the changes.
As an alternative, you can present your own version of an informed consent form to the hospital. The sample outline in Figure I can be used to develop consents as needed for each operation, procedure, treatment, or medication.
The form includes the name of the physician treating you, the nature and purpose of the proposed treatment, your understanding of possible risks and benefits, feasible alternative treatments, and the possible outcome if no treatment is undertaken.
If it is a surgical consent, then anesthesia and its risks should be included. If the consent is for an elective surgical procedure, it should indicate whether the opportunity for a second opinion is being exercised. It should also be stated that consent can be withdrawn up to the time treatment starts.
Scenario 2. Following your D & C, your ob/gyn tells you that you have endometrial cancer. He has consulted with the pathologist and the radiation oncologist. Their decision is that the best treatment for you is a uterine radiation implant under general anesthesia, requiring a three- to four-day hospital stay, to be followed six weeks later by a hysterectomy.
Possible response. Your doctor's recommendation in this case requires two hospital admissions and two general anesthesias. You conclude that a local implant is unnecessary; if the cancer is in situ, it will be removed via hysterectomy. An informed consent should offer you the opportunity for a second opinion. If it doesn't, state that you want to get one.
You consult a specialist who is not connected with your doctor and will not be influenced by his or her opinion. You have all your medical information and laboratory test results sent to the second physician. After this consultation, you decide to have only a complete hysterectomy.
Scenario 3. You are under observation in an acute-care community hospital for an inflamed mass in your colon. Your internist has called in a surgeon, and surgery is being urged upon you. You are visited daily by your internist, the consulting surgeon, and two other surgeons whose vis its last no longer than three to five minutes each.
Possible response. You question the need for three surgeons and all their charges per visit, and you request that they do not attend. Surgery is a decision that must be considered carefully. Your informed consent form lists feasible alternatives, including treating the mass conservatively with dietary changes. You choose that course, and surgery is postponed, if not avoided.
Scenario 4. You discover a small painful lump in your breast and are referred to a surgeon who recommends a mastectomy. When you state that you want a lumpectomy only, the surgeon tells you that you are trying to dictate his practice of medicine.
Possible response. Here we have an example of a paternalistic physician/patient relationship. You are trying to establish a more collaborative relationship, which is denied.
Every patient should be told the risks of not undergoing the recommended procedure. After weighing those risks, you can insist on your decision. If this surgeon refuses, find another one who will honor your wishes. Although mastectomy is still being urged as the only conventional approach, recent literature provides other options in many cases.
Scenario 5. The growth removed in a lumpectomy proves to be cancerous. Three surgeons say you should have a mastectomy. You decide on an axillary node dissection, and if lymphatic spread is found, you may opt for radiation therapy. The nodes turn out clean, so you elect not to have radiation. The radiation oncologist argues that you must have radiation because you have a fatal disease.
Possible response. As in the preceding scenario, it is your body, your decision. Major research has recently been published on mastectomy alone, lumpectomy alone, and lumpectomy followed by radiation. While percentages for positive outcome vary among the three procedures, the important point to note is that there are choices and alternative treatments in many medical situations. These must be explained to you with their associated risks. Then you, in consultation with your physician, can make the best choice at that time and circumstance in your life.
Scenario 6. You have a sudden unilateral hearing loss that leads your clinician to think "worst case'--acoustical neuroma. He suggests you have a CAT scan. A second opinion agrees with the diagnostic procedure but calls for the use of air contrast via spinal injection instead of radioactive iodine. Although you are concerned about the risks of the x-ray procedure, you are told that the newer diagnostic technique of magnetic resonance imaging is not available in your geographic area.
Possible response. Communication in the medical field is not always optimal. In a similar situation, two physicians at a northern California teaching hospital were not aware that a magnetic resonance imaging system was in place at a hospital in southern California.
Conduct your own investigation of the state of the art and where it is being offered. As a health care professional, you have access to a wide array of medical journals and data. Don't hesitate to consult the literature and ask questions about anything you fail to understand. Don't be put off by physicians who tell you that you cannot grasp the information because you didn't go to medical school.
In his book, "The Healing Heart,' Norman Cousins tells how he searched for a doctor who would accept his desire to avoid surgery. Health insurers support this kind of quest with requirements for second, and in some cases third, opinions. Additional opinions can not only save money but also lessen the incidence of trauma.
Informed consent is abused when patients unknowingly sign away their rights or when pertinent information is omitted or abbreviated. Be as specific as you can about your wishes without blocking efforts by the hospital or physician to provide essential medical care.
Photo: Figure 1 Outline for informed consent
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|Title Annotation:||health care workers who become care receivers|
|Author:||Day, Carmel Marti|
|Publication:||Medical Laboratory Observer|
|Date:||Jan 1, 1988|
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