Obtaining Consent For procedures
Introduction
Knowledge regarding gaining consent for procedures such as endoscopy and surgery can be tested in a communication OSCE station or through MCQs (where the emphasis will be the legal and ethical aspects). Patients have a legal right to information about their condition and treatment options, and the amount of explanation will differ depending on the situation: for example more will be needed if the procedure carries a high risk of failure. The full GMC guidelines for this are available
here
.
It is best practice for the person performing the procedure to discuss it with the patient, but this can be delegated to others. The GMC recommends that the person providing this information is suitably trained and has "sufficient" understanding of the indications, details and and risks associated with the procedure. Additionally the patient must have "capacity" to consent, and the decision must be given voluntarily. Even if the decision seems irrational to you this is not evidence that they lack consent (a summary of the mental capacity act is given
here
).
Common points to discuss
-
Explanation that they are free to
change their mind
after signing the form at any time: it is not a contract
-
The
options
available
-
Indications:
including perhaps details of his illness
-
Details
of how it is carried out
-
Benefits
for patient: and what will happen if the procedure is not undertaken
-
Risks:
including specific complication rates if known
-
Additional procedures
that may need to be undertaken: for example when the patient is unconscious
Ways to earn more marks
-
Use non-technical language
-
Do not pressure the patient: it is not necessary to get them to agree during their first meeting
-
Drawing a simple diagram may help
-
Questions must be answered honestly: if you do not know the answer say you will get back to them
-
Give a leaflet at the end of the explanation
Specific procedures
Note that it is only the basics that you will need to know for explaining this to the patient: you will not gain marks for being knowledgeable, just for being clear. Here are some of the commoner stations (feel free to
email us
if you want some more).
Upper GI Endoscopy
Indications:
examination, biopsy and possible treatment of the GI system (for example banding varices or dilatation of a stricture.)
Details of procedure:
The patient will be fasted over night and will thus need a cannula and fluids. Sedation is sometimes given beforehand. The patient will be brought to a special room and a camera will be passed through the mouth and down the oesophagus. At the same time the mouth is suctioned to prevent aspiration of secretions. It normally takes 15-30 minutes.
Complications:
Sore throat, complications of sedation (e.g. amnesia, confusion), perforation (<0.1%), cardiorespiratory arrest (<0.1%).
Other information:
If sedation was used the patient is advised not to drive
Permanent pacemaker insertion
Indication:
Symptomatic bradycardia (tiredness, dizziness, loss of consciousness), heart block (specifically complete HB, mobitz type II HB), some tachycardias.
Details of procedure:
Screening bloods, an ECG, and sometimes a CXR are taken and a cannula is inserted. The procedure is often performed under local anaesthetic in an operating theatre. he pacemaker consists of a small metal case and one or two leads. The case is inserted under the skin usually on the upper left of the chest. The procedure takes 1-2 hours and the patient will be in hospital one or two nights. Stiches are removed 7-10 days after the insertion.
Complications:
Discomfort, wound haematoma/dehiscence, pacemaker malfunction, lead fracture, pacemaker interference.
Other information:
The patient should stop their warfarin a few days before the procedure. Driving should be stopped for 1 week after insertion (they should contact the DVLA). Strenuous exercise should be avoided soon after insertion. Interference with most electrical items is unlikely - use simple precautions like using your mobile phone in the opposite hand. Advise to contact doctor if arrhythmias, or signs of infection/bleeding.
Barium Enema
Indications:
Assessment of pathology in the large bowel/terminal ileum e.g. polyps, stricture.
Details of procedure:
The principle is to use a radiodense liquid in the bowel to show its outline. The night before the patient is given strong laxatives and they are nil by mouth after midnight. For the procedure a tube is passed up the anus and barium liquid is passed. They may be given buscopan (a relaxant) and air may be injected to force the barium up. Radiographs are taken. The examination takes 15-20 minutes.
Complications:
Stomach cramps, constipation, blurring of vision (from buscopan), allergic reaction to buscopan, perforation of colon. Radiation exposure is low.
Other informaion:
The patient can go home and eat immediately afterwqrds. The test (like all radiographic tests) should not be performed on pregnant women.
Liver Biopsy
Indications:
Abnormal LFTs, hepatitis, suspected cirrhosis or carcinoma
Details of procedure:
The patient is nil by mouth after midnight. Sedation may be given. The site is cleaned and local anaesthetic is injected. Nowadays the procedure is done under ultrasound guidance. The patient is asked to breath out and hold it for a few seconds whilst the needle is inserted and the biopsy taken.
Complications:
pain, pneumothorac, bleeding (<0.5%), blood transfusion, wound infection, death (<0.1%).
Other information:
The patient should stop warfarin a few days beforehand. Driving should be stopped if sedation given.
References
