The significance and applications of informed consent

Patient Preferences for Surgery or Antibiotics for the Treatment of Acute Appendicitis

Importance

Studies have compared surgical with nonsurgical therapy for acute uncomplicated appendicitis, but none of these studies have a patient-centered perspective.

Objectives

To evaluate how patients might choose between surgical and nonsurgical therapy for acute uncomplicated appendicitis and to identify targets to make antibiotic treatment more appealing.

Design, Setting, and Participants

This study comprised an online survey and an in-person sensitivity analysis survey. For the web survey, a convenience sample of 1728 respondents were asked to imagine that they or their child had acute uncomplicated appendicitis, provided information about laparoscopic and open appendectomy and antibiotic treatment alone, and asked which treatment they might choose. The web survey was open from April 17, 2016, through June 16, 2016, and was disseminated via email link, a poster with a Quick Response code, and social media. For the sensitivity analysis, 220 respondents were given the same scenario and options. Those who chose surgery were asked whether certain factors influenced their decision; each factor was incrementally improved during questioning about whether respondents would consider switching to antibiotics. These participants were recruited at public venues from June 3, 2016, to July 31, 2016. Web survey data were analyzed from June 17, 2016, to September 21, 2017. Sensitivity analysis data were analyzed from August 1, 2016, to September 21, 2017.

Main Outcomes and Measures

Treatment preferences.

Results

Among the 1728 web survey respondents, 1225 (70.9%) were female and 500 (28.9%) were male (3 [0.2%] either did not answer or responded as "gender fluid" within the comments section of the survey), and most self-reported being between 50 and 59 years of age (391 [22.6%]) and being non-Hispanic white (1563 [90.5%]). For themselves, 1482 respondents (85.8%) chose laparoscopic appendectomy, 84 (4.9%) chose open appendectomy, and 162 (9.4%) chose antibiotics alone. For their child, 1372 respondents (79.4%) chose laparoscopic appendectomy, 106 (6.1%) open appendectomy, and 250 (14.5%) antibiotics alone. Respondents were somewhat more likely to choose antibiotics for themselves if they had education beyond college (105 [12.6%]; P < .001), identified as other than non-Hispanic white (24 [14.9%]; P < .001), or did not know anyone who had previously been hospitalized (12 [15.8%]; P = .02), but they were less likely to choose antibiotics if they were surgeons (11 [5.4%]; P = .008). Of the 220 participants interviewed for the sensitivity analysis, 120 (54.5%) were female and 100 (45.5%) were male, and most self-reported being between 18 and 24 years of age (53 [24.1%]) and being non-Hispanic white (204 [92.7%]). Their responses suggested that improvements in the short- and long-term failure rate of antibiotic treatment-rather than reductions in the duration of hospitalization or antibiotic treatment-were more likely to increase the desirability of choosing antibiotics.

Conclusions and Relevance

Most patients may choose surgical intervention over antibiotics alone in treatment of acute uncomplicated appendicitis, but a meaningful number may choose nonoperative management. Therefore, from a patient-centered perspective, this option should be discussed with patients, and future research could be directed at reducing the failure and recurrence rates of antibiotic treatment for appendicitis.

Using improvement science methods to increase accuracy of surgical consents

The surgical consent serves as a key link in preventing breakdowns in communication that could lead to wrong-patient, wrong-site, or wrong-procedure events. We conducted a quality improvement initiative at a large, urban pediatric academic medical center to reliably increase the percentage of informed consents for surgical and medical procedures with accurate safety data information at the first point of perioperative contact. Improvement activities focused on awareness, education, standardization, real-time feedback and failure identification, and transparency. A total of 54,082 consent forms from 13 surgical divisions were reviewed between May 18, 2011, and November 30, 2012. Between May 2011 and June 2012, the percentage of consents without safety errors increased from a median of 95.4% to 99.7%. Since July 2012, the median has decreased slightly but has remained stable at 99.4%. Our results suggest that effective safety checks allow discovery and prevention of errors.

Informed consent when prescribing medication: a randomized controlled trial

OBJECTIVES/HYPOTHESIS

To determine patient recall of specific risks associated with medication prescription and whether or not handouts are an effective tool to augment the informed consent process.

STUDY DESIGN

Double-blinded, randomized, controlled trial.

METHODS

Informed consent for prednisone prescriptions was studied by comparing the effect of a verbal discussion (describing 10 specific adverse drug reactions) in conjunction with a handout going over same, to a verbal discussion alone. Blinded assessments occurred by telephone interview 2 to 4 weeks following the intervention. Outcomes assessed were the number of risks of prednisone that patients could list and the number of risks they recalled having discussed with their physician. Other demographic details were also collected.

RESULTS

Twenty-five participants were randomly allocated to each group. Without prompting, the median number of risks spontaneously recalled by the handout group was not significantly different than the control group, and both groups had very low recall (two vs. one, P = .24). When provided a list of potential side effects, it was observed that the handout group recalled a higher median number of risks having been discussed with their physician compared to patients in the control group (eight vs. five, P = .003). The groups' demographics were otherwise identical.

CONCLUSIONS

Patients in general did not remember discussing adverse prednisone risks with their physician even a short time after the discussion took place. Although the patient handout resulted in improved recall of risks following the prescription of prednisone, its importance in the informed medication consent process remains an open question.

LEVEL OF EVIDENCE

1b.

The use of multimedia as an adjunct to the informed consent process for ankle ligament reconstruction surgery

BACKGROUND

Obtaining "informed consent" is an integral aspect of surgery that can be fraught with difficulty. This study assessed the efficacy of a multimedia education tool in improving patients' understanding when used as an adjunct to the traditional verbal consent process regarding ankle lateral ligament reconstruction surgery.

METHODS

A total of 56 patients (28 males and 28 females) were recruited with a mean age of 36 years. A standardized verbal discussion regarding surgical treatment was provided to each patient. Understanding was then assessed using a knowledge questionnaire. Subsequently, each patient observed a multimedia educational program following which the knowledge questionnaire was repeated. Additional supplementary questions were then given regarding the ease of understanding and satisfaction with the 2 methods of education delivery.

RESULTS

The patients answered 75% of the questions correctly before the multimedia module compared with 88% after it (P < .001). Patients rated the ease of understanding and the amount of information provided by the module highly (9.5 cm and 9.0 cm on a 10-cm Visual Analogue Scale scale, respectively), and 61% of patients considered that the multimedia tool performed as well as the treating surgeon.

CONCLUSION

Multimedia tools used in sequence after a verbal consent resulted in improved patient understanding of pertinent information regarding ankle lateral ligament reconstruction surgery.

LEVELS OF EVIDENCE

Therapeutic Level II.

Applying a sociolinguistic model to the analysis of informed consent documents

Information on the risks and benefits related to surgical procedures is essential for patients in order to obtain their informed consent. Some disciplines, such as sociolinguistics, offer insights that are helpful for patient-professional communication in both written and oral consent. Communication difficulties become more acute when patients make decisions through an informed consent document because they may sign this with a lack of understanding and information, and consequently feel deprived of their freedom to make their choice about different treatments or surgery. This article discusses findings from documentary analysis using the sociolinguistic SPEAKING model, which was applied to the general and specific informed consent documents required for laparoscopic surgery of the bile duct at Torrecárdenas Hospital, Almería, Spain. The objective of this procedure was to identify flaws when information was provided, together with its readability, its voluntary basis, and patients' consent. The results suggest potential linguistic communication difficulties, different languages being used, cultural clashes, asymmetry of communication between professionals and patients, assignment of rights on the part of patients, and overprotection of professionals and institutions.

Understanding of informed consent and surgeon liability by the public and patients

PURPOSE

To evaluate understanding of the fundamental concepts of informed consent by the public and patients.

METHODS

Questionnaires were distributed to any persons (aged more than 16 years) attending the Palmerston North Hospital (excluding in-patients). The first 1000 completed questionnaires were analysed using the Chi squared test.

RESULTS

The fundamental concepts of informed consent were not appreciated by most respondents; only 18%, 13%, and 5% of them agreed with its implications in terms of self-autonomy, confidentiality, and battery, respectively. 64% of respondents preferred to take sole responsibility to decide which procedure to undergo, 31% preferred to be guided by the surgeon, and 5% by a brief explanation only. 21% of the respondents considered the surgeon liable in the event of an unmentioned rare complication, 43% considered the surgeon not liable, and 34% were undecided.

CONCLUSION

Understanding of medico-legal implications of informed consent (e.g. self-autonomy, confidentiality, and battery) by the public and patients is poor. Their expectations regarding self-autonomy seem unrealistic. It is time for surgeons, legal experts, and the public to confer and make informed consent a practical, user-friendly tool rather than the legal obstacle that it is today.

Informed Consent in Facial Plastic Surgery

OBJECTIVE

To evaluate the effectiveness of oral communication about the risks of facial cosmetic procedures compared with oral and written communication.

DESIGN

A prospective randomized study conducted in an ambulatory surgery center. One hundred twenty consecutive patients were included; they presented for consultation for rhinoplasty, rhytidectomy, or laser resurfacing. Patients were randomly assigned to 1 of 2 groups: (1) those receiving oral discussion of the risks of the procedure and (2) those receiving oral and written communication about the risks. Two weeks after the initial consultation, patients were surveyed for recall of the risks.

RESULTS

The group that received a pamphlet had a better risk recall than the group that did not (2.5 vs1.5 of 5 risks; P<.001). The recall rate in the following groups that received a pamphlet was also better: (1) university-educated patients (P =.02), (2) patients who underwent rhinoplasty (P<.001), (3) patients who underwent laser resurfacing (P =.02), and (4) female patients (P<.001).

CONCLUSIONS

Written disclosure of the risks of cosmetic procedures enables patients to retain and understand more clearly those potential risks. They are, therefore, able to give an informed consent to the proposed procedure. This study also identifies patient groups who may require more intensive presurgical teaching. The medicolegal implications are apparent.