Medicolegal aspects of informed consent

How to effectively obtain informed consent in trauma patients: a systematic review

BACKGROUND

Obtaining adequate informed consent from trauma patients is challenging and time-consuming. Healthcare providers must communicate complicated medical information to enable patients to make informed decisions. This study aimed to explore the challenges of obtaining valid consent and methods of improving the quality of the informed consent process for surgical procedures in trauma patients.

METHODS

We conducted a systematic review of relevant English-language full-text original articles retrieved from PubMed (1961-August 2018) that had experimental or observational study design and involved adult trauma patients. Studies involving informed consent in clinical or research trials were excluded. Titles and abstracts of searched articles were reviewed and relevant data were extracted with a structured form. Results were synthesized with a narrative approach.

RESULTS

A total of 2044 articles were identified in the initial search. Only eight studies were included in the review for narrative synthesis. Six studies involved orthopedic surgeries, one involved nasal bone surgeries, and one involved trauma-related limb debridement. Only one study was conducted in an emergency department. Information recall was poor for trauma patients. Risk recall and comprehension were greater when written or video information was provided than when information was provided only verbally. Patient satisfaction was also greater when both written and verbal information were provided than when verbal information alone was provided; patients who received video information were more satisfied than patients who received written or verbal information.

CONCLUSIONS

Many articles have been published on the subject of informed consent, but very few of these have focused on trauma patients. More empirical evidence is needed to support the success of informed consent for trauma patients in the emergency department, especially within the necessarily very limited time frame. To improve the informed consent process for trauma patients, developing a structured and standardized informed consent process may be necessary and achievable; its effectiveness would require evaluation. Adequately educating and training healthcare providers to deliver structured, comprehensive information to trauma patients is crucial. Institutions should give top priority to ensuring patient-centered health care and improved quality of care for trauma patients.

A young man with spinal muscular atrophy and impending respiratory arrest

From a statutory standpoint, the decision-making capacity of adolescents differs significantly from that of adults because adolescents are considered to lack the experience and judgment necessary to make legally binding decisions. Furthermore, in the case of minors, the principle of protection of life tends to outweigh the principle of autonomy. Here we present the hypothetical case of a 16-year-old boy with spinalmuscular atrophy type II who was admitted to the intensive care unit for severe respiratory distress. We focus on the tension that developed among the patient, his parents, and his physicians when the need for emergency mechanical ventilation became apparent. We review the legal and ethical premises under which adolescents are permitted to make legally binding decisions, ie, the emancipated minor and the mature minor doctrines. Finally, we discuss the concepts of protectionism and liberationism as they apply to adolescents' decision-making capacity.

Safety and risk communication to patients

Comprehensive and accurate information about the medicines available to them is a key issue for patients to participate in the decision making process of their own healthcare. One aspect of this information is the patient information leaflet provided by the manufacturer, according to national and international guidelines. The comprehensibility and user-friendliness of these manufacturers' leaflets has been tested and criticised. In addition to this information under the laws of national and international authorities, consumer-oriented websites of self-help groups are becoming a more and more relevant source of information. For most patients, the primary sources of information are healthcare professionals, such as the prescribing physicians and/or nurses or the dispensing pharmacist. The information provided for by healthcare professionals has to be tailored according to the patients' needs, where law suits against physicians often address the comprehensiveness and a lack of documentation. Improvement of individualised drug information has been shown to increase patients' satisfaction and treatment adherence, whereas the overall influence on outcome (i.e., reduction of adverse drug events) has still to be demonstrated. However, in order to achieve such a goal, striking changes in the whole system of pharmacovigilance have to be implemented with special emphasis on patients and consumers representation.

Informed consent for emergency surgery in infants and children

The informed consent process for emergency surgery in children poses a challenge for pediatric surgeons because the child and his/her surrogates (usually parents) must make medical decisions in a relatively short period. The unique circumstances of a surgical emergency create potential barriers to achieving the central goals of the informed consent process, respect for patient autonomy and beneficence. The purpose of this review is to provide a practical guide for pediatric surgeons on the informed consent process as it applies to emergency surgery in pediatric patients. We will also discuss innovative methods of preoperative education that can be adopted in the emergency setting and highlight areas in which further research might help to improve this important aspect of surgical care.

The right of minors to confidentiality and informed consent

Doctor-patient confidentiality is a precept of adolescent medicine. In general, physicians honor the privacy of adolescents unless there is evidence that the youngster is engaging in dangerous activities. An otherwise healthy 16 year old was referred for headache evaluation. During the portion of the interview conducted outside the presence of his mother, the patient revealed using marijuana and cocaine regularly and LSD (lysergic acid diethylamide), hallucinogenic mushrooms, and "Ecstasy" (3,4-methylenedioxymethamphetamine) occasionally. Given this information, and as allowed by North Carolina's General Statutes, the patient was offered confidential treatment for illegal substance abuse; he declined the offer. He also turned down the request to forgo his right to privacy so that his parents could be made aware of his addiction. As a result of the patient's drug use and disregard of its consequences, it was determined that notification of a parent was essential to his life or health; thus, confidentiality was breached. Although substance abuse is a behavior that threatens the abuser's health and life, state and federal laws vary regarding the rights of minors to confidential evaluation and treatment. For this article, laws that govern minors' rights to consent to confidential treatment for illegal substance abuse were reviewed. The aforementioned case is used as a catalyst for discussion.

Selected legal issues in movement disorders

This article explores the long-standing question of whether trauma causes Parkinson's disease, and discusses the impact of informed consent and confidentiality in issues of genetic testing for Huntington's disease. Neurologists are appropriately concerned about the legal aspects of genetic testing, and this article attempts to address that subject from a medical-legal perspective.

National efforts to improve the informed consent process

OBJECTIVES

To inform oncology nurses about several national efforts to improve the informed consent document and process.

DATA SOURCES

A federally funded grant program to stimulate research of informed consent, an initiative from the National Cancer Institute to improve informed consent documents in cancer clinical trials, and a model consent document developed by the National Action Plan on Breast Cancer.

CONCLUSIONS

These initiatives assist investigators and institutional review boards in presenting relevant and understandable information to potential clinical trial participants.

IMPLICATIONS FOR NURSING PRACTICE

These national efforts will raise awareness of providing potential research participants with clear information to assist them in making an educated, informed decision.