June 11, 2015

The “Less Is More” Medical Campaign – Part 3



The latest campaign of "less is more" leaves a lot to be desired.  Doctors love to leave patients is the dark and ill prepared for medical procedures.  They claim that there is a fair amount of uncertainty about the potential benefits and risks of the vast majority of medical procedures.  In an ideal world, patients would learn about all the risks and benefits of a treatment and its alternatives, including doing nothing, through the process of informed consent and shared decision-making.

But, unfortunately, we have a fundamental problem with informed consent as it is practiced today.  What could be a platform to promote the idea of "nothing about me without me" has devolved into a perfunctory exercise by medical personnel to ensure that the "chart" has the proper paperwork.  Meanwhile, consent forms are often completed with patients being minutes away from a procedure, commonly supine, and even sometimes sedated.

This is not informed consent and smacks of decision by decree, often initiated by the doctor.  I have been fortunate with some of my doctors that actually took time to explain what would happen, what was expected to happen, and the worse case of what could happen.  Then I was questioned about what I wanted accomplished and if I agreed.  This was what happened before my gall bladder surgery and even though I knew my gall bladder removal was necessary, time was allowed in a meeting before the surgery to ask questions and have the procedure explained several days before the actual surgery.  I was given a sheet of instructions on eating and fasting to prevent potential problems and my diabetes regimen with changes was discussed. 

When the actual day of the surgery arrived, a brief discussion took place and I was allowed questions if I had any.  This was very reassuring and put me at ease for the surgery or anesthesia.  When I became aware after the surgery, a nurse was there to explain how the surgery had gone and that I would be allowed some broth after a few hours.  I was allowed water almost immediately and my CPAP was set up and made ready if I wanted to sleep. 

It is true that the consent form was a standardized form and it was readable by me even with a paragraph of medical jargon.  It is a shame that consent forms are not written for patients to understand and even more shameful that the consent process is not respected by surgeons and their staff. 

This is true because the medical culture has not promoted shared decision and the time allowed by the system is against this.  Then most patients do not easily understand the tools needed.  It is physicians' responsibility for elective procedures to be sure that patients understand their options and recognize their power to make choices.  The physicians need help to make this meaningful for the patients.

Patients need to know that there is a choice and they have permission to make a choice.  Patients should be made aware that the choice is not set in stone.  The patient's preferences are as important as the facts about risks and benefits.  Patients deserve personalized estimates of what the potential risks and benefits of various strategies may be.  They deserve information about the medical team's experience with different strategies and outcomes.  Patients deserve to know what a procedure will cost them out of pocket if everything goes well.  All of this information is vital and ought to be part of informed consent.  In fact, the obligation is that doctors need to ensure that patients know that two people presented with the same information may make different choices and still be right.

Finally, the informed consent should be taken out of the time just before the procedure and have time allowed for questions and answers.  Doctors should be prepared to teach their patients and know that the system supports the patients.

To be continued next week.

1 comment:

Jane Reel said...

Bob, the issue of informed consent and your post today really hit home. In April I was admitted for a scheduled spinal surgery. The informed consent was given to me & I signed it, but checked a box saying I didn't want transfusions. No one said I couldn't have the surgery without transfusions. The surgeon sees this checked and has the nurse come and explain that I need to rescind this. I do of course But, I'd already been given sedatives. When the doctor found out the sequence of events, he stopped the surgery from happening that day. He was correct to stop the surgery, but the consent form should've been reviewed prior to starting the sedatives. The timing was a huge deal & my surgery had to be rescheduled. This was a major thing for me because a friend had traveled 1200 miles to stay with me during a specified time of recovery. My job was expecting the recuperation for a specified time as well. Thanks for posting on this.