Consent and children

The law relating to consent for medical interventions in children is complex. Children, when they are old or mature enough, can consent for themselves. When they are unable to do so, consent must be sought from someone with parental responsibility. This article discusses consent, and its refusal, to medical interventions by children and adolescents.     

Advance directive use among patients undergoing high-risk operations

BACKGROUND: The Patient Self-Determination Act requires that patients entering hospitals be asked if they have an advance directive. This has led to increased awareness of advance directives, yet surgeons have paid little attention to their use among patients undergoing even major surgery. We sought to evaluate the use of advance directives in patients undergoing pancreaticoduodenectomy and esophagectomy. METHODS: Patients undergoing these operations between 1996 and 2001 at a university teaching hospital were identified and reviewed for statement of advance directive, its presence in the chart, and impact on patient care. RESULTS: A total of 252 patients met inclusion criteria. The number of patients with an advance directive increased, but had little impact on patient care. CONCLUSIONS: More patients having major surgery have advance directives, but the number present in the medical record remains low. Further attention to advance directives would foster increased communication between surgeons and patients and extend patient autonomy.     

Consent: risk assessment,risk communication and shared decision making

The consent process is the foundation of the modern doctor–patient relationship, and can present a challenge to doctors. The consent process can be complex, and often involves the interaction of many different factors, including ethical and legal considerations. A shared decision-making process allows for full consideration of the treatment options available, and takes into account individual patient's concerns and preferences. Ensuring that the patient is fully informed requires a thorough understanding of the risks of an intervention for that particular patient; therefore, individualized risk assessment is of fundamental importance. Using a combination of individual patient information, formalized investigations, and population data, gives the most complete assessment of risk. Communicating that risk information to patients is key, and the doctor should always use clear language and avoid bias. The use of visual aids and information leaflets, and the avoidance of vague language and complex statistical terms, will help the patient to develop a more complete understanding of the risks they face.     

Consent in obstetrics

Medical consent, the process of agreeing the benefits and risks of a treatment or procedure, has specific challenges in pregnancy and labour. Consent should take the form of a discussion about risk and include the alternatives. It should be an ongoing process with the right to withdraw consent or seek further information if the person chooses. Ideally all risks to which the patient might attach significance should be discussed. To consent, a person must have capacity. It is accepted that while labour can involve stress, pain, and fatigue, and will not infrequently be in a time-critical situation, women will normally retain the capacity to consent. This includes the right to make decisions outside of societal norms or which put at risk the life of herself or unborn child. In rare circumstances where an incapacitated woman requires medical intervention in pregnancy this should be done in accordance with appropriate legislation acting in the best interests of the mother.     

Consent

Morally, ‘consent’ allows an autonomous patient to determine what treatments they will accept or refuse. The law relating to medical consent protects such self-determination, and allows for treatment decisions to be made for patients who cannot decide for themselves. Consent is valid if it is given voluntarily by a competent patient and is based on the information provided to them. Information is provided about what is to be done and why, and what the foreseeable risks and consequences of treatment are. The onus is on the clinician to explain material risks that are significant to the patient. Competent patients understand, remember and use the information provided to them to either consent to, or refuse, treatment. Patients lacking capacity are protected by The Mental Capacity Act 2005, which obliges that medical treatment decisions made by third parties (doctors, defined proxies or the courts) to be both necessary and in the patient's best interests, in the absence of a valid advance directive. Consent relating to children, pregnant women, the mentally ill, emergencies and teaching requires special consideration.     

Ethics and law in the intensive care unit

Intensive Care Medicine epitomises the difficulties inherent in modern medicine. In this chapter we examine some key medicolegal and ethical areas that are evolving. The principles of autonomy and consent are well established, but developments in UK caselaw have shown that the courts may be moving away from their traditional deference of the medical profession. We examine some recent cases and discuss the impact that these cases may have on practice in Intensive Care.     

Consent: assessing and communicating risk

The consent process is a cornerstone of the patient–doctor relationship. It can be a complex process presenting challenges to both doctor and patients due to the interaction of multiple different factors, including ethical and legal considerations. Ensuring the patient has informed consent requires a through understanding of the risks of an intervention for a particular patient; therefore risk assessment is of fundamental importance. Accurate risk assessment can be done through assessment of individual patient factors and the proposed procedure combined with population data. Communication of this risk to the patient is key and the surgeon should use clear language to avoid bias or misunderstanding. Use of adjuncts such as visual aids, examples from other areas of life, with avoidance of statistical data and vague terms may help the patient understand the risks more completely.     

Consent in obstetric anaesthesia

Consent to medical treatment is a vital process that should occur prior to any procedure or intervention in a competent adult. There are ethical and legal reasons for doctors to ensure that valid, adequate consent has been obtained from a patient. It is generally accepted that written consent is acceptable, however, discussions regarding consent should be clearly documented, including specific risks discussed. Labouring women may have to consent for procedures when in severe pain, under the influence of strong analgesics, or in a time-pressured situation. However, the parturient is presumed to be competent. A competent pregnant woman may decline treatment for any reason, even if it puts her or her unborn child at risk of harm or death.     

Consent for anaesthesia

Current professional guidelines concerning information and consent for anaesthesia are a fair representation of English law. However, they reject the need for specific, written consent for anaesthesia, a position which is in accordance with other Western jurisdictions. This is understandable, as there would be a number of problems inherent in such an approach: the consent process would be unnecessarily labour and time intensive, the generic nature of the information to be disclosed would not allow for operator-dependent variables, and many of the disclosable risks continue to be of uncertain incidence. Moreover, written consent is not needed in order to defend cases of assault by anaesthetists. However, for the very reason that there are a large number of risks associated with anaesthesia (risks that are unknown to the majority of surgeons), together with the possibility of the courts moving towards a reasonable patient standard of information disclosure (as a result of the introduction of human rights legislation into English law), it is our view that the Association of Anaesthetists of Great Britain and Ireland should change their guidelines and advise anaesthetists to obtain separate, written affirmation from patients that certain risks and consequences of anaesthesia have been explained to them. In addition, a standardised consent form for anaesthesia may prove invaluable in retrospectively defending a claim of negligence founded around information disclosure, by recording exactly the risks and consequences of interventions discussed by the anaesthetist and the patient.     

Consent issues and pediatric regional anesthesia

The need for consent to regional anesthetic procedures varies considerably between countries. It is likely that legislation and professional guidance will tighten consent procedures, and in several countries detailed written consent is required for regional blockade. This article discusses aspects of consent to regional anesthesia in children.     

Consent to clinical trials in anaesthesia

In order to evaluate satisfaction with, and recollection of, the consent process, we sent a postal questionnaire to 204 patients who had taken part in one of six clinical trials. Three trials were multicentre commercial studies and three were 'in house'. The readability of the different patient information sheets was compared. Seventy-seven per cent of patients responded, of whom 82% remembered having an information sheet. Most (99%) thought this was easy to read and understand. Five patients claimed that they had felt pressurised to take part in the trials. Nearly all patients (97%) realised that participation was voluntary and that other treatment would not be affected; 83% knew they could have changed their minds. There were no differences in the response patterns between the patients taking part in the different trials although the patient information sheets produced by pharmaceutical companies were longer and more complex than the 'in hospital' variety. We conclude that increasing the amount and complexity of information does not alter patient satisfaction. Taken overall, patients were content with the way they were approached when asked for consent for clinical trials.     

Informed Consent for Obesity Surgery

A patient cannot consent to an operation without being adequately informed. There are a number of different operations in use today for treatment of severe obesity. The variations are designed to (1) limit food intake and/or (2) create malabsorption. The surgeon has a duty, according to the law of informed consent, to provide all of the information necessary for a reasonable person to decide whether to consent to the operation recommended. Changes in anatomy, function and risk therefore need to be explained. When only limitation of intake is planned, as in vertical banded gastroplasty (VBG), the patient should know how large the pouch will be and how the outlet will be stabilized. When both intake restriction and malabsorption are planned, as in Roux-en-Y gastric bypass (RGB), or biliopancreatic diversion (BPD), the patient should know whether there will be a larger pouch (less restriction) and a short common channel (more malabsorption) as in BPD or a smaller pouch and less malabsorption. Patients should know that if they have an operation that uses maximum malabsorption to bring weight to a nearly normal level, the risk of malnutrition will be increased, which may require further hospitalization and possible operative treatment. When the duodenum is to be bypassed, the patient should know that this will impair iron and calcium absorption, and that access to this area for radiologic and endoscopic procedures may not be possible. Simple drawings can be used to explain what is planned and how the operation will determine body weight, side-effects, and risk.     

Anaesthesia consent considerations in children and young people

The law relating to consent for medical interventions in children is complex. Children, when they are old or mature enough, can consent for themselves. When they are unable to do so, consent must be sought from someone with parental responsibility. This article discusses consent, and its refusal, to medical interventions by children and adolescents.     

AAGBI: Consent for anaesthesia 2017

Previous guidelines on consent for anaesthesia were issued by the Association of Anaesthetists of Great Britain and Ireland in 1999 and revised in 2006. The following guidelines have been produced in response to the changing ethical and legal background against which anaesthetists, and also intensivists and pain specialists, currently work, while retaining the key principles of respect for patients’ autonomy and the need to provide adequate information. The main points of difference between the relevant legal frameworks in England and Wales and Scotland, Northern Ireland and the Republic of Ireland are also highlighted.     

A Preadmission Telephone Call to Initiate the Consent Process for Clinical Anesthesia Research

Consent for a clinical anesthesia research trial is frequently sought in hospital on the day of surgery. This time is often associated with increased anxiety, diminished privacy, and limited opportunity for reflection. Our objective was to determine whether a preadmission telephone call on the day before surgery resulted in greater satisfaction compared to the traditional practice of initiating the consent process on the day of surgery. We randomized 124 patients eligible for participation in a minimal-risk clinical anesthesia trial to receive either a preadmission telephone call on the day before surgery to initiate consent (Telephone group; n = 62), or no telephone call (Control group; n = 62). In the Telephone group, 21 patients (33.9%) were successfully contacted by telephone, whereas 41 patients (66.1%) were not contacted. Both the Telephone and Control groups reported similar understanding regarding the purpose of the trial. Both groups similarly agreed that the time and setting of recruitment and consent were appropriate. Patients in both groups reported having enough time to consider their participation in the trial. Few patients in either group reported feeling anxious at the time of consent or pressured to participate in the trial. Finally, patients in both groups were equally satisfied with the consent process. Implications: A preadmission telephone call on the day before surgery to initiate the consent process for a minimal-risk clinical anesthesia research trial does not improve satisfaction among consenting patients compared to initiating consent in hospital on the day of surgery, and can be an impractical method to initiate the consent process.