1
|
White EM, Esposito AC, Yoo PS. Should Obtaining Informed Consent Be Considered an Entrustable Professional Activity? Insights From Whether and How Attendings Entrust Surgical Trainees. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2024; 99:897-903. [PMID: 38113443 DOI: 10.1097/acm.0000000000005587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
PURPOSE Because residents are frequently delegated the task of obtaining consent early in their training, the American Association of Medical Colleges describes "obtaining informed consent" as a core entrustable professional activity (EPA) for medical school graduates. However, prior studies demonstrated that residents frequently perform this task without receiving formal instruction or assessment of competency. This study sought to understand how attending physicians decide to delegate obtaining informed consent for surgical procedures to trainees. METHOD The authors conducted a survey of attending surgeons at a university-based health care system of 6 affiliated teaching hospitals (October-December 2020) to collect data about current entrustment practices and attendings' knowledge, experience, and attitudes surrounding the informed consent process. Summary statistics and bivariate analyses were applied. RESULTS Eighty-five attending surgeons participated (response rate, 49.4%) from diverse specialties, practice types, and years in practice. Fifty-eight of 85 (68.2%) stated they "never" granted responsibility for the consent conversation to a trainee, and 74/81 (91.4%) reported they typically repeated their own consent conversation whenever a trainee already obtained consent. The most common reasons they retained responsibility for consent were ethical duty (69/82, 84.1%) and the patient relationship (65/82, 79.3%), while less than half (40/82, 48.8%) described concerns about trainee competency. Reflecting on hypothetical clinical scenarios, increased resident competency did not correspond with increased entrustment ( P = .27-.62). Nearly all respondents (83/85, 97.7%) believed residents should receive formal training; however, only 41/85 (48.2%) felt additional training and assessment of residents might change their current entrustment practices. CONCLUSIONS Attendings view informed consent as an ethical and professional obligation that typically cannot be entrusted to trainees. This practice is discordant with previous literature studying residents' perspectives. Furthermore, resident competency does not play a predominant role in this decision, calling into question whether informed consent can be considered an EPA.
Collapse
|
2
|
Budesa Z, Klar M, Datta S, Moore E, Lamsen L. Evaluating first year residents' communication skills: a health literacy curriculum needs assessment. JOURNAL OF COMMUNICATION IN HEALTHCARE 2023; 16:30-37. [PMID: 36919812 DOI: 10.1080/17538068.2022.2026054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND High quality communication skills are necessary for competent and ethical practice. When patients present with low health literacy, physicians' skills may be lacking, which can put patients' safety and satisfaction at risk. The authors' developed and executed a simulation-based needs assessment following conflicting internal reports about the communications skills of new residents. METHODS The current study recruited first year residents (N = 30) during the 2019 first post-graduate year (PGY-1) orientation at a southeastern university hospital simulation center. The residents completed an Objective Structured Clinical Examination (OSCE) which focused on obtaining informed consent from a patient's health care proxy who presented with limited literacy and health literacy and poor communication skills. After completing the OSCE, the residents, simulated patients (SP), and independent observers assessed the residents' performance. RESULTS Residents assessed their performance higher when compared with the ratings from independent observers and patient raters. Residents who spent more time with SPs were given higher ratings by the SPs and independent observers. Finally, residents' ratings of themselves had a positive correlation with their reported confidence, but no correlation between self-confidence and the ratings provided by SPs or observers. CONCLUSION PGY-1 residents demonstrate a continued need for health literacy and informed consent education, despite faculty believing that these skills were covered enough in medical school. These residents also demonstrated limited self-assessment ability or skills below the expectations of health literacy experts. Curriculum changes included improving the focus on health literacy, communication skills, and additional practice opportunities throughout their internship year.
Collapse
Affiliation(s)
- Zach Budesa
- Center for Advanced Medical Simulation, Graduate School of Medicine, University of Tennessee, Knoxville, Knoxville, Tennessee
| | - Melinda Klar
- Center for Advanced Medical Simulation, Graduate School of Medicine, University of Tennessee, Knoxville, Knoxville, Tennessee
| | - Sujata Datta
- Department of Anaesthesia, University of Maryland Medical Center, Baltimore, Maryland, United States
| | - Emily Moore
- DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Knoxville, Tennessee, United States
| | - Leonard Lamsen
- Center for Advanced Medical Simulation, Graduate School of Medicine, University of Tennessee, Knoxville, Knoxville, Tennessee
| |
Collapse
|
3
|
Does the standard medical procedure consent process meet the criteria required for informed consent? - A concept analysis. Nurs Outlook 2023; 71:101916. [PMID: 36681563 DOI: 10.1016/j.outlook.2022.101916] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/12/2022] [Accepted: 12/29/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Informed consent is a complex process that is legally required before any surgical procedure. PURPOSE The purpose of this manuscript was to perform a concept analysis of the informed consent process. METHODS The use of dimensional analysis identified three separate yet related perspectives of the informed consent process: legal, health care, and patients. A database search using the Cumulative Index to Nursing and Allied Health Literature and PubMed were performed. FINDINGS A total of 27 publications were reviewed. The legal perspective addresses the requirement of informed consent, which starts with the discussion between the health care provider and the patient undergoing the surgical procedure and ends with a signature on a piece of paper. The health care perspective also addresses the legal requirement but incorporates the goals and objectives of the individual initiating the informed consent discussion. The patients' perspectives also incorporate goals and objectives; however, they differ from that of the health care provider in that they go beyond what happens in the operating room or during hospitalization. DISCUSSION Viewing informed consent through these different yet related perspectives provides insight into this complex process and may enhance the researcher's ability to understand and improve the informed consent process.
Collapse
|
4
|
White EM, Esposito AC, Kurbatov V, Wang X, Caty MG, Laurans M, Yoo PS. How I Learned is How I Teach - Perspectives on How Faculty Surgeons Approach Informed Consent Education. JOURNAL OF SURGICAL EDUCATION 2022; 79:e181-e193. [PMID: 36253332 DOI: 10.1016/j.jsurg.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/24/2022] [Accepted: 09/08/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To understand the variability of surgical attending experience and perspectives regarding informed consent and how it impacts resident education DESIGN: A novel survey was distributed electronically to explore faculty surgeon's personal learning experience, knowledge, clinical practice, teaching preferences and beliefs regarding informed consent. Chi-square and Kruskal-Wallis testing was performed to look for associations and a cluster analysis was performed to elucidate additional patterns among. SETTING Single, tertiary, university-affiliated health care system (Yale New Haven Health in Connecticut), including 6 teaching hospitals. PARTICIPANTS Clinical faculty within the Department of Surgery. RESULTS A total of 85 surgeons responded (49% response rate), representing 17 specialties, both private practice and university and/or hospital-employed, with a range of years in practice. Across all ages, specialties, the most common method for both learning (86%) and teaching (82%) informed consent was observation of the attending. Respondents who stated they learned by observing attendings were more likely to report that they teach by having trainees observe them (OR 8.5, 95% CI 1.3-56.5) and participants who recalled learning by having attendings observe them were more likely to observe their trainees (OR 4.1, 95% CI 1.5-11.2).Cluster analysis revealed 5 different attending phenotypes with significant heterogeneity between groups. A cluster of younger attendings reported the least diverse learning experience and high levels of concern for legal liability and resident competency. They engaged in few strategies for teaching residents. By comparison, the cluster that reported the most diverse learning experience also reported the richest diversity of teaching strategies to residents but rarely allowed residents to perform consent with their patients. Meanwhile, 2 other cluster provided a more balanced experience with some opportunities for practice with patients and some diversity of teaching- these clusters, respectively, consist of older, experienced general surgeons and surgeons in trauma and/or critical care. CONCLUSIONS Surgeon's demographics, personal experiences, and specialty appear to significantly influence their teaching styles and the educational experience residents receive regarding informed consent.
Collapse
Affiliation(s)
- Erin M White
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Andrew C Esposito
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Vadim Kurbatov
- Yale University School of Medicine, Department of Surgery, Department of Genetics, New Haven, Connecticut
| | - Xujun Wang
- Yale University School of Medicine, Department of Genetics, New Haven, Connecticut
| | - Michael G Caty
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Maxwell Laurans
- Yale University School of Medicine, Department of Neurosurgery, New Haven, Connecticut
| | - Peter S Yoo
- Yale University School of Medicine, Department of Surgery, New Haven, Connecticut.
| |
Collapse
|
5
|
de Guzman GS, Amosco MD. Patient experience and decisional satisfaction with the informed consent process for elective gynecologic surgeries: A cross-sectional study. Ann Med Surg (Lond) 2022; 81:104551. [PMID: 36147082 PMCID: PMC9486853 DOI: 10.1016/j.amsu.2022.104551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/22/2022] [Accepted: 08/27/2022] [Indexed: 11/02/2022] Open
Abstract
Background The informed consent process is a vital component of daily medical practice. It involves providing patients with sufficient, accurate, and understandable information to decide on a contemplated therapy. The study aims to evaluate the patient experience and satisfaction with the preoperative informed consent process. Methods A cross-sectional study was performed on adult women admitted for elective gynecologic surgery in a tertiary training hospital. Participants were recruited on their second postoperative day and were asked to answer a structured questionnaire assessing decisional satisfaction and experience with the informed consent process. Satisfaction was measured using a 6-item Satisfaction with Decision Scale. Knowledge of the surgery and experience with the informed consent were measured using an Informed Consent Questionnaire. Bivariate associations between highly satisfied and not highly satisfied groups were tested using Fisher exact test. Results A total of 150 patients were enrolled in the study with a mean age of 44.5 years. The resident-in-charge provided the information and assisted in the documentation of the informed consent in 86.7% and 67.3% of patients, respectively. There was an overall high decisional satisfaction with a mean score of 27.4 and 52.7% of patients strongly agreeing to all statements of the Satisfaction with Decision Scale. The majority of the respondents were informed and acknowledged comprehension of the surgery including its risks, benefits, and alternative treatment options. Knowing the success rate and benefits of the procedure as well as being informed of the need for postoperative catheterization were significantly associated with high satisfaction. Conclusion Knowledge and understanding of the key components of informed consent influence patient satisfaction. The current study highlights the high decisional satisfaction rates of patients who underwent elective gynecologic surgery. Strategies to further improve this patient-physician encounter include the establishment of standard policies on personnel involved, timing, and quality of information given to patients. Patient satisfaction should serve as an indicator of the quality of healthcare rendered and guide for continuous improvement of services.
Collapse
Affiliation(s)
- Glaiza S. de Guzman
- Department of Obstetrics and Gynecology, University of the Philippines Manila - Philippine General Hospital, Philippines
| | - Melissa D.L. Amosco
- Department of Obstetrics and Gynecology, University of the Philippines Manila - Philippine General Hospital, Philippines
| |
Collapse
|
6
|
Alomar AZ. Confidence level, challenges, and obstacles faced by orthopedic residents in obtaining informed consent. J Orthop Surg Res 2021; 16:390. [PMID: 34140032 PMCID: PMC8212467 DOI: 10.1186/s13018-021-02531-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/08/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES The objective is to evaluate the opinions of orthopedic residents on current practices, experiences, training, confidence level, difficulties, and challenges faced when obtaining informed consent. DESIGN This is a cross-sectional, multi-center, and questionnaire-based study. SETTING The study was done in forty-four training centers across Saudi Arabia. PARTICIPANTS In total, 313 orthopedic residents participated. MATERIAL AND METHODS The web-based questionnaire examined the perceptions of residents regarding practices, experience, training, difficulties, and challenges surrounding the obtention of informed consent, as well as residents' confidence in obtaining informed consent for different orthopedic situations and eight common orthopedic procedures. RESULTS Most residents were allowed to obtain consent independently for all emergency, trauma, primary, and revision cases at their institution (92.7%). Only 33.5% of the residents received formal training and teaching on obtaining informed consent, with 67.1% having believed that they needed more training. Only 4.2% of the residents routinely disclosed all essential information of informed consent to patients. Inadequate knowledge (86.3%) and communication barriers (84.7%) were the most reported difficulties. Generally, 77.3% of the residents described their confidence level in obtaining informed consent as good or adequate, and 33.9% were confident to discuss all key components of the informed consent. Residents' confidence level to independently obtain informed consent decreased with procedure complexity. Receiving formal training, senior level (postgraduate year (PGY) 4 and 5), and being frequently involved in obtaining informed consent correlated with increased confidence level. CONCLUSION Many residents incompletely disclosed key information upon obtaining informed consent and reported lacking confidence in their ability to perform the procedure in their daily practices. To improve patient care and residents' performance and overcome these difficulties and challenges, institutions should develop effective strategies to standardize the informed consent process, provide formal training for obtaining informed consent, and provide supervision for residents during obtention of informed consent.
Collapse
Affiliation(s)
- Abdulaziz Z Alomar
- Division of Arthroscopy & Sports Medicine, Department of Orthopaedic Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.
| |
Collapse
|
7
|
Jochum SB, Venkatramani M, Ritz EM, Favuzza J, Hayden DM, Saclarides TJ, Bhama AR. Surgical Residents' Perspective on Informed Consent-How Does It Compare With Attending Surgeons? J Surg Res 2020; 260:88-94. [PMID: 33333384 DOI: 10.1016/j.jss.2020.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/27/2020] [Accepted: 10/31/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The informed consent discussion (ICD) is a compulsory element of clinical practice. Surgical residents are often tasked with obtaining informed consent, but formal instruction is not included in standard curricula. This study aims to examine attitudes of surgeons and residents concerning ICD. MATERIALS AND METHODS A survey regarding ICD was administered to residents and attending surgeons at an academic medical center with an Accreditation Council for Graduate Medical Education-accredited general surgery residency. RESULTS In total, 44 of 64 (68.75%) residents and 37 of 50 (72%) attending surgeons participated. Most residents felt comfortable consenting for elective (93%) and emergent (82%) cases, but attending surgeons were less comfortable with resident-led ICD (51% elective, 73% emergent). Resident comfort increased with postgraduate year (PGY) (PGY1 = 39%, PGY5 = 85%). A majority of participants (80% attending surgeons, 73% residents) believed resident ICD skills should be formally evaluated, and most residents in PGY1 (61%) requested formal instruction. High percentages of residents (86%) and attendings (100%) believed that ICD skills were best learned from direct observation of attending surgeons. CONCLUSIONS Resident comfort with ICD increases as residents advance through training. Residents acknowledge the importance of their participation in this process, and in particular, junior residents believe formal instruction is important. Attending surgeons are not universally comfortable with resident-led ICDs, particularly for elective surgeries. Efforts for improving ICD education including direct observation between attending surgeons and residents and formal evaluation may benefit the residency curriculum.
Collapse
Affiliation(s)
- Sarah B Jochum
- Rush University Medical Center, Department of Surgery, Chicago, Illinois
| | | | - Ethan M Ritz
- Rush University Medical Center, Bioinformatics and Biostatistics Core, Chicago, Illinois
| | - Joanne Favuzza
- Rush University Medical Center, Division of Colon and Rectal Surgery, Department of Surgery, Chicago, Illinois
| | - Dana M Hayden
- Rush University Medical Center, Division of Colon and Rectal Surgery, Department of Surgery, Chicago, Illinois
| | - Theodore J Saclarides
- Rush University Medical Center, Division of Colon and Rectal Surgery, Department of Surgery, Chicago, Illinois
| | - Anuradha R Bhama
- Rush University Medical Center, Division of Colon and Rectal Surgery, Department of Surgery, Chicago, Illinois.
| |
Collapse
|
8
|
White EM, Miller SM, Esposito AC, Yoo PS. "Let's Get the Consent Together": Rethinking How Surgeons Become Competent to Discuss Informed Consent. JOURNAL OF SURGICAL EDUCATION 2020; 77:e47-e51. [PMID: 32753261 DOI: 10.1016/j.jsurg.2020.07.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Eliciting informed consent is a clinical skill that many residents are tasked to conduct without sufficient training and before they are competent to do so. Even senior residents and often attending physicians fall short of following best practices when conducting consent conversations. DESIGN This is a perspective on strategies to improve how residents learn to collect informed consent based on current literature. CONCLUSIONS We advocate that surgical educators approach teaching informed consent with a similar framework as is used for other surgical skills. Informed consent should be defined as a core clinical skill for which attendings themselves should be sufficiently competent and residents should be assessed through direct observation prior to entrustment.
Collapse
Affiliation(s)
- Erin M White
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut.
| | - Samuel M Miller
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Andrew C Esposito
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| | - Peter S Yoo
- Yale School of Medicine, Department of Surgery, New Haven, Connecticut
| |
Collapse
|
9
|
Reconsidering the Process of Informed Consent in Assisted Reproductive Technology: Experiences and Implications for Practice. PSYCHOLOGICAL STUDIES 2020. [DOI: 10.1007/s12646-019-00542-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
10
|
Kearns C, Kearns N, Paisley AM. The art of consent: visual materials help adult patients make informed choices about surgical care. J Vis Commun Med 2019; 43:76-83. [PMID: 31799883 DOI: 10.1080/17453054.2019.1671168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- Ciléin Kearns
- General Surgery Department, University of Edinburgh College of Medicine and Veterinary Medicine, Edinburgh, Scotland.,General Surgery Department, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, Scotland.,General Surgery Department, Artibiotics, Wellington, New Zealand
| | - Nethmi Kearns
- Orthopaedic Surgery Department, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Anna M Paisley
- General Surgery Department, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| |
Collapse
|
11
|
Gabay G, Bokek-Cohen Y. Infringement of the right to surgical informed consent: negligent disclosure and its impact on patient trust in surgeons at public general hospitals - the voice of the patient. BMC Med Ethics 2019; 20:77. [PMID: 31660956 PMCID: PMC6819415 DOI: 10.1186/s12910-019-0407-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 09/06/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There is little dispute that the ideal moral standard for surgical informed consent calls for surgeons to carry out a disclosure dialogue with patients before they sign the informed consent form. This narrative study is the first to link patient experiences regarding the disclosure dialogue with patient-surgeon trust, central to effective recuperation and higher adherence. METHODS Informants were 12 Israelis (6 men and 6 women), aged 29-81, who underwent life-saving surgeries. A snowball sampling was used to locate participants in their initial recovery process upon discharge. RESULTS Our empirical evidence indicates an infringement of patients' right to receive an adequate disclosure dialogue that respects their autonomy. More than half of the participants signed the informed consent form with no disclosure dialogue, and thus felt anxious, deceived and lost their trust in surgeons. Surgeons nullified the meaning of informed consent rather than promoted participants' moral agency and dignity. DISCUSSION Similarity among jarring experiences of participants led us to contend that the conduct of nullifying surgical informed consent does not stem solely from constraints of time and resources, but may reflect an underlying paradox preserving this conduct and leading to objectification of patients and persisting in paternalism. We propose a multi-phase data-driven model for informed consent that attends to patients needs and facilitates patient trust in surgeons. CONCLUSIONS Patient experiences attest to the infringement of a patient's right to respect for autonomy. In order to meet the prima facie right of respect for autonomy, moral agency and dignity, physicians ought to respect patient's needs. It is now time to renew efforts to avoid negligent disclosure and implement a patient-centered model of informed consent.
Collapse
Affiliation(s)
- Gillie Gabay
- Behavioral Sciences and Psychology, College of Management Academci studies, 7 Rabin Blvd, 97150 Rishon Letzion, Israel
| | - Yaarit Bokek-Cohen
- Nursing Sciences, Tal-Aviv Jaffa Academic College, 7 Rabin Blvd, 97150 Rishon Letzion, Israel
| |
Collapse
|
12
|
James JT, Eakins DJ, Scully RR. Informed consent, shared-decision making and a reasonable patient's wishes based on a cross-sectional, national survey in the USA using a hypothetical scenario. BMJ Open 2019; 9:e028957. [PMID: 31366653 PMCID: PMC6678025 DOI: 10.1136/bmjopen-2019-028957] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE In approximately half the states in the USA, and more recently in the UK, informed consent is legally defined as what a reasonable patient would wish to know. Our objective was to discern the information needs of a hospitalised, 'reasonable patient' during the informed-consent process. DESIGN We performed a cross-sectional study to develop a survey instrument and better define 'reasonable person' in relation to informed consent in a hypothetical scenario where an invasive procedure may be an option. SETTING A 10-question survey was administered from April 19 through 22 October 2018 to three groups: student nurses (n=76), health professions educators (n=63) and a US national population (n=1067). PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was the average intensity, on a 5-point scale, by which survey groups wished to have each of 10 questions answered. The secondary outcome was to discern relationships between survey demographics and the intensity by which participants wanted an answer. RESULTS Despite substantial demographic differences in the nursing-student group and health-professions-educator group, the average intensity scores were within 0.2 units on nine of 10 questions. The national survey revealed a strong desire to have an answer to each question (range 3.98-4.60 units). It showed that women desired answers more than men and older adults desired answers more than younger adults. CONCLUSIONS Based on responses to 10 survey questions regarding wishes of people in a situation where an invasive procedure may be necessary, the vast majority want an answer to each question. They wanted to know about all treatment options, risky drugs, decision aids, who will perform the procedure, and the cost. They wanted their advocate present, periodic review of their medical record, a full day to review documents and expected outcomes and restrictions after the procedure.
Collapse
Affiliation(s)
- John T James
- CEO, Patient Safety America, Houston, Texas, USA
| | | | | |
Collapse
|
13
|
Moeini S, Shahriari M, Shamali M. Ethical challenges of obtaining informed consent from surgical patients. Nurs Ethics 2019; 27:527-536. [PMID: 31296111 DOI: 10.1177/0969733019857781] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Informed consent can be obtained by various methods, by various people, and with use of various types of consent forms. Persistent effort is necessary to reveal the practical realities of informed consent to improve ethical and legal standards. OBJECTIVE To determine the ethical challenges of obtaining informed consent from surgical patients. METHODS The present study was a descriptive cross-sectional study using two researcher-made questionnaires and a checklist for data collection. Data were collected from nursing personnel (n = 95) and surgical patients (n = 203) on the surgical wards of three university hospitals in Isfahan, Iran. Data were analyzed using descriptive statistics, Spearman's rank correlation, Pearson's correlation coefficient, and the t-test. ETHICAL CONSIDERATIONS The study was approved by the Ethics Committee of Isfahan University of Medical Sciences (No: 396478). RESULTS The mean scores (maximum 100) of awareness, competency, and authority were 36.3, 67.7, and 57.6, respectively. The overall quality of the informed consent was poor (score 53.9 of 100). The higher educational level in patients was correlated with lower awareness of and less authority to give informed consent. Only 12.6% of the nurses stated that patients were given sufficient information to assure informed consent. In 89.2% of the consent forms, the risks of the treatment were mentioned. However, alternative methods and risks and advantages of rejecting the treatment were not mentioned in any of the forms. CONCLUSION Ethical challenges to obtaining informed consent include patients' poor awareness of their rights, a failure to provide adequate information to patients, absence of consideration of patients' educational level, an unclear definition of who is responsible for obtaining informed consent from the patients, time constraints, and use of unclear language and medical jargon. Constructing an ethical framework may guide nursing staff in dealing with the ethical challenges involved in obtaining informed consent.
Collapse
|
14
|
Rosenfeld EH, Lopez ME, Yu YR, Justus CA, Borges MM, Mathai RC, Karediya A, Zhang W, Brandt ML. Use of standardized visual aids improves informed consent for appendectomy in children: A randomized control trial. Am J Surg 2018; 216:730-735. [DOI: 10.1016/j.amjsurg.2018.07.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/23/2018] [Accepted: 07/17/2018] [Indexed: 11/30/2022]
|
15
|
Heaney RM, Murray M, Heaney AM, Doherty EM. ‘All by myself’: interns’ reports of their experiences taking consent in Irish hospitals. Ir J Med Sci 2018. [DOI: 10.1007/s11845-018-1782-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
16
|
Koller SE, Moore RF, Goldberg MB, Zhang J, Yu D, Conklin CB, Milner RE, Goldberg AJ. An Informed Consent Program Enhances Surgery Resident Education. JOURNAL OF SURGICAL EDUCATION 2017; 74:906-913. [PMID: 28238705 DOI: 10.1016/j.jsurg.2017.02.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/18/2016] [Accepted: 02/03/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE First-year residents often obtain informed consent from patients. However, they typically receive no formal training in this area before residency. We wished to determine whether an educational program would improve residents' comfort with this process. DESIGN Our institution created an informed consent educational program, which included a didactic component, a role-play about informed consent, and a simulation exercise using standardized patients. Residents completed surveys before and after the intervention, and responses to survey questions were compared using the signed-rank test. SETTING This study took place at Temple University Hospital, a tertiary care institution in Philadelphia, PA. PARTICIPANTS First-year surgery and emergency medicine residents at Temple University Hospital in 2014 participated in this study. Thirty-two residents completed the preintervention survey and 27 residents completed the educational program and postintervention survey. RESULTS Only 37.5% had ever received formal training in informed consent before residency. After participating in the educational program, residents were significantly more confident that they could correctly describe the process of informed consent, properly fill out a procedure consent form, and properly obtain informed consent from a patient. Their comfort level in obtaining informed consent significantly increased. They found the educational program to be very effective in improving their knowledge and comfort level in obtaining informed consent. In all, 100% (N = 27) of residents said they would recommend the use of the program with other first-year residents. CONCLUSIONS Residents became more confident in their ability to obtain informed consent after participating in an educational program that included didactic, role-play, and patient simulation elements.
Collapse
Affiliation(s)
- Sarah E Koller
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania.
| | - Ryan F Moore
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Michael B Goldberg
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Jeanette Zhang
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania
| | - Daohai Yu
- Department of Clinical Sciences, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| | - Charles B Conklin
- Department of Risk Management, Temple University Hospital, Temple University Health System, Philadelphia, Pennsylvania
| | - Richard E Milner
- Temple University Lewis Katz School of Medicine, William Maul Measey Institute for Clinical Simulation and Patient Safety, Philadelphia, Pennsylvania
| | - Amy J Goldberg
- Department of Surgery, Temple University Hospital, Philadelphia, Pennsylvania; Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
17
|
Lamont S, Stewart C, Chiarella M. Capacity and consent: Knowledge and practice of legal and healthcare standards. Nurs Ethics 2017; 26:71-83. [PMID: 28093938 DOI: 10.1177/0969733016687162] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION: Healthcare practitioners have a legal, ethical and professional obligation to obtain patient consent for all healthcare treatments. There is increasing evidence which suggests dissonance and variation in practice in assessment of decision-making capacity and consent processes. AIMS: This study explores healthcare practitioners' knowledge and practices of assessing decision-making capacity and obtaining patient consent to treatment in the acute generalist setting. METHODS: An exploratory descriptive cross-sectional survey design, using an online questionnaire, method was employed with all professional groups invited via email to participate. Data were collected over 3 months from July to September 2015. Survey content and format was reviewed by the liaison psychiatry team and subsequently contained five sections (demographics, general knowledge and practice, delirium context, legal aspects and education/training). Descriptive, univariate and bivariate analysis of quantitative data and qualitative content analysis of qualitative data were undertaken. ETHICAL CONSIDERATIONS: The study was approved by the institutional Human Research and Ethics Committee and informed consent was taken to be provided by participants upon completion and submission of the de-identified survey. RESULTS: In total, 86 participants engaged the survey with n = 24, exiting at the first consent question. Almost two-thirds of respondents indicated that all treatments required patient consent. Knowledge of consent and decision-making capacity as legal constructs was deficient. Decision-making capacity was primarily assessed using professional judgement and perceived predominantly as the responsibility of medical and psychology staff. A range of patient psychological and behavioural symptoms were identified as indicators requiring assessment of decision-making capacity. Despite this, many patients with delirium have their decision-making capacity assessed and documented only sometimes. Uncertain knowledge and inconsistent application of legislative frameworks are evident. Many participants were unsure of the legal mechanisms for obtaining substitute consent in patients with impaired decision-making capacity and refusing treatment. CONCLUSION: The legal context of decision-making capacity and consent to treatment appears complex for healthcare practitioners. Professional, ethical and legal standards of care in this context can benefit from structured education programmes and supportive governance processes. An understanding of why 'duty of care' is being used as a framework within the context of impaired decision-making capacity is warranted, alongside a review of the context of Duty of Care within health policy, guidance and faculty teaching.
Collapse
|
18
|
Wood F, Martin SM, Carson‐Stevens A, Elwyn G, Precious E, Kinnersley P. Doctors' perspectives of informed consent for non-emergency surgical procedures: a qualitative interview study. Health Expect 2016; 19:751-61. [PMID: 25212709 PMCID: PMC5055244 DOI: 10.1111/hex.12258] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The need to involve patients more in decisions about their care, the ethical imperative and concerns about ligation and complaints has highlighted the issue of informed consent and how it is obtained. In order for a patient to make an informed decision about their treatment, they need appropriate discussion of the risks and benefits of the treatment. OBJECTIVES To explore doctors' perspectives of gaining informed consent for routine surgical procedures. DESIGN Qualitative study using semi-structured interviews selected by purposive sampling. Data were analysed thematically. SETTING AND PARTICIPANTS Twenty doctors in two teaching hospitals in the UK. RESULTS Doctors described that while consent could be taken over a series of consultations, it was common for consent to be taken immediately prior to surgery. Juniors were often taking consent when they were unfamiliar with the procedure. Doctors used a range of communication techniques to inform patients about the procedure and its risks including quantifying risks, personalizing risk, simplification of language and use of drawings. Barriers to effective consent taking were reported to be shortage of time, clinician inexperience and patients' reluctance to be involved. DISCUSSION AND CONCLUSION Current consent processes do not appear to be ideal for many doctors. In particular, junior doctors are often not confident taking consent for surgical procedures and require more support to undertake this task. This might include written information for junior staff, observation by senior colleagues when undertaking the task and ward-based communication skills teaching on consent taking.
Collapse
Affiliation(s)
- Fiona Wood
- Cochrane Institute of Primary Care and Public HealthSchool of MedicineCardiff UniversityCardiffWalesUK
| | - Sean Michael Martin
- Cochrane Institute of Primary Care and Public HealthSchool of MedicineCardiff UniversityCardiffWalesUK
| | - Andrew Carson‐Stevens
- Cochrane Institute of Primary Care and Public HealthSchool of MedicineCardiff UniversityCardiffWalesUK
| | - Glyn Elwyn
- The Dartmouth Centre for Health Care Delivery ScienceDartmouthNHUSA
| | - Elizabeth Precious
- Cochrane Institute of Primary Care and Public HealthSchool of MedicineCardiff UniversityCardiffWalesUK
| | - Paul Kinnersley
- Cochrane Institute of Primary Care and Public HealthSchool of MedicineCardiff UniversityCardiffWalesUK
| |
Collapse
|