Consent: Luck or Law?

INTRODUCTION

The aim of this study was to identify whether clinicians are obtaining a valid consent for surgery, and ascertain the parents'' perception of parental responsibility when giving consent for their children.

PATIENTS AND METHODS

Adults consenting for 100 children were questioned about the possession of parental responsibility, and their understanding of the concept.

RESULTS

Only 4 children had surgery without valid consent, these forms being signed by fathers without parental responsibility. However, only 5% of the sample stated that parental responsibility was required. More than 80% believed that cohabitation was a sufficient qualification to provide consent; fewer than 15% recognising any influence of marital status. It seems that, although 96% of consenters had parental responsibility, the validity of their consent was a product more of luck than of lawful behaviour.

CONCLUSIONS

The results demonstrate a wide gulf between the standards set by the Children Act 1989 and common practice, as perceived by parents. Furthermore, this reveals a significant disparity between the principles behind the statute, and the role that parents believe that they play in the 21st century.     

Responding to Trust: Surgeons’ Perspective on Informed Consent

Background  Every day thousands of surgeons and patients negotiate their way through the complex process of decision-making about operative treatments. We conducted a series of qualitative studies, asking patients and surgeons to describe their experience and beliefs about informed decision-making and consent. This study focuses on surgeons’ views. Methods  Open-ended interviews and focus group discussions were conducted with thoracic surgeons who treated esophageal cancer patients by esophagectomy, and general surgeons who routinely performed laparoscopic cholecystectomy. Their views were analyzed using a qualitative approach, grounded in the perspectives of the participants. Results  Five dominant themes emerged from the analysis: (1) making informed decisions; (2) communicating information and confidence; (3) managing expectations and fears; (4) consent as a decision to trust; (5) commitment inspired by trust. These themes are illustrated by verbatim quotes from the surgeon interviews. Conclusions  Surgeons carefully assess the risks and benefits of treatment before consenting to perform operative interventions. They are influenced by objective findings and by affective factors such as courage and the determination to survive expressed by their patients. They manage risks, doubts, and fears—both their patients’ and their own—relying on trust and commitment on both sides to ensure the success of the surgical mission. The trust of their patients has a strong influence on the surgeons’ decisions and actions.     

A Comparative Study of ‘Fast-Track’ Versus Traditional Peri-Operative Care Protocols in Gastrointestinal Surgeries

Introduction

A ‘fast-track protocol’ in surgery suggests the application of evidence-based practices to expedite patient recovery. It has shown to reduce hospital stay, hasten recovery as well as facilitate earlier return to work. It has a considerable impact in reducing healthcare costs. The basic tenet is to treat the patient’s disease by minimal disturbance of their physiology. The protocol encompasses pre-operative, intra-operative and post-operative interventions which when carried out together would show maximal benefits. The surgeon is usually the leader of the team managing the patient, but it cannot be over-emphasised that this is a multi-disciplinary team approach.

Materials and Methods

We conducted a prospective interventional study to investigate whether ‘fast-track’ surgery protocols improve patient outcome when compared to traditional peri-operative care followed at our institute. By doing so, we observed that the patients who underwent ‘fast tracking’ required lesser analgesia, had earlier ambulation, earlier return of intestinal motility, were free from tubes, catheters and drains earlier and lastly were discharged earlier. This was achieved without a rise in complications or re-admissions.

Results/Conclusion

The results have proved that implementing the fast-track protocol for gastrointestinal surgeries is not only safe and effective, but also improves patient outcome.     

Consent for regional anaesthesia in the United Kingdom: what is material risk?

Legal principles that apply to the process of informed consent have changed in recent years. Patients should now be given the information that they wish to receive, not the information that health professionals may consider reasonable for them. In obstetric practice informed consent is especially important as young, fit patients may request and receive non-essential but potentially life-threatening interventions. The quantity and detail of information parturients desire do not remain static. They vary over time and from country to country. Our paper examines current opinion amongst parturients in the United Kingdom. We asked 100 obstetric patients to choose the complications of regional anaesthesia that they would like to learn about during informed consent. Nearly all women (82-94%) wished to know about common, less severe side effects. A substantial majority (70-77%) also wished to know about rarer but more severe complications, such as permanent neurological deficit, meningitis and high spinal block. Despite the availability of information for patients from sources such as the Obstetric Anaesthetists' Association and the National Electronic Library for Health, there remains little consensus amongst anaesthetists about what information to provide. Frequently some complications that patients would consider important are not discussed. Changing legal and public expectations demand that we adapt our current practice and improve the accuracy and timing of information provided.     

Living donor kidney transplant in Italy: is the underutilization justified?

Living donor transplants (LDtx) represent an underutilized resource in Italy. It is, however, a therapeutic option that deserves greater consideration not only due to the increasing gap between the number of uremic patients on waiting lists (6956) and the number (1464) of cadaveric transplants (CADtx), as evidenced in 2002, but also due to the advantages of LDtx over CADtx. The superiority of LDtx include better graft survival, independent of the donor/recipient relationship, less need for dialytic treatment with preemptive transplants and reduced immunogenicity of the graft due to the brain death-related "cytokine storm." Moreover, some emerging procedures namely laparoscopic nephrectomy instead of open surgery and spiral CT instead of renal angiography namely, reduce the physical and socioeconomic burden of the donor. In the light of these considerations, LDtx should be reconsidered in the Italian scenario of kidney transplantation.     

Transplant quality in Italy: analysis of the 1995–2000 period

Evaluation of outcomes is a major step in quality assessment of any health process. In the transplant field, the evaluation of outcome is extremely important for both patients growing demand for health and for the joint commitment the transplant process requires. In this study, the outcome of 12,647 transplants, carried out between 1995 and 2000 were analysed. Graft survival at 5 years was 79% for kidney, 67% for liver, 72% for heart and 38% for lung. Patient survival was 92% for kidney, 76% for liver, 72% for heart and 38% for lung. In comparison to other international case records [Collaborative Transplant Study (CTS) and The United Network for Organ Sharing (UNOS)], results are similar or even better for all transplant programmes. As a whole, survival after solid organ transplant in Italy ranks among the best for both donations and transplantation. The quality of transplants carried out is above European standards. Nevertheless, the growing health needs of patients require improvement in both the procurement process and in the use of available organs.     

Demographic Characteristics and Clinical Outcomes in Patients from Latin America Versus the Rest of the World: A TIOSPIR® Post-Hoc Analysis

Introduction

Geographical variations may impact outcomes in chronic obstructive pulmonary disease (COPD). We evaluated differences in baseline characteristics and outcomes between patients enrolled in Latin America compared with the rest of the world (RoW) in the TIOtropium Safety and Performance In Respimat^® (TIOSPIR^®) trial.

Rhinoplasty—A new approach in the repair of the hump

A variation in Cottle's technique is presented in which the hump is preserved and the difficulties arising out of making fractures in different levels are avoided. A natural look is obtained for the operated nose, mainly from a frontal view.Paper presented at the Fourth International Congress of Aesthetic Plastic Surgery, Mexico City, Mexico, April 1977.     

Diabetic Revascularization: Endovascular Versus Open Bypass—Do We Have the Answer?

Diabetes is an independent risk factor for peripheral arterial disease and, when advanced peripheral arterial disease develops in the setting of diabetes, it portends a greatly increased threat to both life and limb. The management of severe limb ischemia in diabetic patients, particularly those with tissue loss and infection, remains a major surgical challenge in the new millennium. However, advances in multidisciplinary care, including an aggressive revascularization approach, can avoid major amputation in a large percentage of patients. The unique pattern of lower extremity atherosclerosis in diabetes is a critical determinant of the revascularization strategy. Most diabetics with critical ischemia have popliteal/tibial occlusions requiring below-the-knee intervention or bypass grafting. Bypass surgery with vein to crural or pedal arteries remains the gold standard of revascularization, but may be limited by patient risk, conduit availability, and a suitable target. Infrapopliteal angioplasty can have acceptable results for suitable lesions, particularly when there is not extensive tissue loss in the foot. However, restenosis rates after endovascular intervention in these vessels are high, and recent advances in drug-eluting balloons and stents have promise but remain largely unproven. There is limited high-quality evidence to support treatment choices in this arena, with only one randomized clinical trial to date. The available data suggest that patients with life expectancy of at least 2 years and more extensive disease have superior outcomes with open reconstruction. A selective revascularization strategy is advocated, using autogenous vein bypass as the initial approach in a significant percentage of patients, based on its greater overall efficacy and proven durability. However, endovascular therapies have an important role in current practice, which will increase further if restenosis can be overcome. Vascular specialists should understand and be able to apply both types of interventions to optimize patient outcomes.     

Are tree squirrels involved in the circulation of flaviviruses in Italy?

West Nile virus (WNV ), Usutu virus (USUV ) and tick‐borne encephalitis virus (TBEV ) are emerging zoonotic flaviviruses (family Flaviviridae ), which have circulated in Europe in the past decade. A cross‐sectional study was conducted to assess exposure to these antigenically related flaviviruses in eastern grey squirrels (Sciurus carolinensis ) in Italy. Seventeen out of 158 (10.8%; CI _95%: 5.9‐15.6) squirrels’ sera tested through bELISA had antibodies against flaviviruses. Specific neutralizing antibodies to WNV , USUV and TBEV were detected by virus neutralization tests. Our results indicate that tree squirrels are exposed to Culex and tick‐borne zoonotic flaviviruses in Italy. Moreover, this study shows for the first time USUV and TBEV exposure in grey squirrels, broadening the host range reported for these viruses. Even though further studies are needed to define the real role of tree squirrels in the epidemiology of flaviviruses in Europe, this study highlights that serology could be an effective approach for future investigations aimed at broadening our knowledge about the species exposed to these zoonotic infections.