Enhanced Informed Consent in Hand Surgery: Techniques to Improve the Informed Consent Process

Informed Consent and Digit Replantation: Current State and Recommendations for Ethical Patient Care

The importance of informed consent and the value of shared decision-making in hand surgery are well-established and particularly critical in the setting of digit amputation when considering replantation. Informed consent requires an understanding of not only the immediate and long-term risks and benefits of surgery, as well as the risks and alternatives involved, but also the capacity of the patient to make a medical decision. However, patients who have acutely sustained a disfiguring trauma are often in distress and may not fully process the consent discussion. Digit replantation is an "elective emergency"-the decision must be made immediately but is not lifesaving-which poses a difficult dilemma: are surgeons acting in patients' best interests by pursuing replantation if we engage those patients in informed consent discussions when they may not have capacity? This article explores the relevant bioethical principles associated with digit replantation, summarizes updated literature regarding informed consent and shared decision-making, and provides recommendations for patient education materials to standardize informed consent discussions for surgeons approaching patients at this unique intersection of considering revision amputation versus replantation.

Artificial Intelligence as a Consent Aid for Carpal Tunnel Release

Background Hand surgeons have been charged with the use of diverse modalities to enhance the consenting process following the Montgomery ruling. Artificial Intelligence language models have been suggested as patient education tools that may aid consent. Methods We compared the quality and readability of the Every Informed Decision Online (EIDO) patient information leaflet for carpal tunnel release with the artificial intelligence language model Chat Generative Pretrained Transformer (GPT). Results The quality of information by ChatGPT was significantly higher using the DISCERN score, 71/80 for ChatGPT compared to 62/80 for EIDO (p=0.014). DISCERN interrater observer reliability was high (0.65) using the kappa statistic. Flesch-Kincaid readability scoring was 12.3 for ChatGPT and 7.5 for EIDO, suggesting a more complex reading age for the ChatGPT information. Conclusion The artificial intelligence language model ChatGPT produces high-quality information at the expense of readability when compared to EIDO information leaflets for carpal tunnel release consent.

The Impact of a Computer-Based Interactive Informed Consent for Surgery on Decision Conflict

PURPOSE

Informed consent for surgery can address the legal aspects of care while also being simple, informative, and empathic. We developed interactive informed consents and compared them with standard printed informed consents asking: (1) are there any factors associated with lower decision conflict or greater patient-rated clinician empathy including consent format? (2) Are there any factors associated with rating the consent process as informative, comfortable, and satisfying including consent format?

METHODS

Ninety-four adult patients accepted an offer of surgery from one of three hand surgeons to address one of six common hand surgery diagnoses: carpal tunnel release, cubital tunnel release, trigger finger release, plate and screw fixation of a distal radius fracture, removal of a benign mass, including a ganglion cyst, and Dupuytren contracture release. Fifty-three patients were randomized to complete an interactive consent, and 41, a standard written consent. Symptoms of anxiety, depression, and unhelpful thoughts were measured. Patients completed the Decision Conflict Scale and the Jefferson Scale of Patient's Perceptions of Physician Empathy and rated the consent as informative, comfortable, and satisfactory on a scale of 0-10.

RESULTS

Greater decisional conflict was slightly associated with greater patient unhelpful thoughts about symptoms and was not associated with consent format. A higher rating of comfort with the consent process was slightly associated with patient choice to proceed with surgical treatment, but not with consent format. Accounting for potential confounding in multivariable analysis, a higher rating of the consent process as informative was slightly associated with patient preference for surgical over nonsurgical treatment, CONCLUSIONS: The observation that an interactive consent form was not related to decision conflict or other aspects of patient experience suggests that such tools may not have much weight relative to the interaction between patient and clinician.

CLINICAL RELEVANCE

Efforts to improve informed consent may need to focus on the dialog between patient and surgeon rather than how information is presented.

The art of consent: visual materials help adult patients make informed choices about surgical care

Supporting patients in making informed healthcare decisions is a cornerstone of ethical medical practice. Surgeons frequently draw for and show images to patients when consenting them for operations but the value of this practice in informed decision-making is unclear. An audit was conducted in a General Surgery Department. 244 patients completed questionnaires on the value of visual materials when giving consent for surgery. The complexity of the operations was classified into "simple", "moderate" or "complex". 100% of patients felt they had given informed consent to surgery. 62% of patients received at least one form of visual material during the consenting process. All patients who received a drawing, and 99% of those provided with other images, valued these resources. Visual materials were considered more useful to patients when giving consent for moderate or complex operations than simple ones. Approximately one third of patients who did not receive visual materials would have appreciated these when making an informed decision. This research highlights the value of surgeons drawing for, and providing other visual resources to, their patients as part of the consent process. There is a role for further research and training materials in drawing skills for surgeons.