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

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.     

Angle closure glaucoma precipitated by labour

Acute angle closure glaucoma generally occurs in older hypermetropic individuals, precipitated by pupillary dilation. However it is often forgotten that it can occur in younger people and that it does not occur solely as a result of the use of mydriatics or normal pupillary dilation in response to darkness. It is recognised that it can occur during or shortly after a surgical procedure done under either spinal or general anaesthetic. We describe a case of acute angle closure occurring in a 37-year-old woman, precipitated by labour. To our knowledge no such case has been described in the literature.     

Trichomonal vaginitis refractory to treatment: case report.

A woman initially aged 25 was treated for seven years for symptomatic vaginal trichomoniasis. Throughout that period the patient received 5-nitroimidazoles at conventional and high dosages, antimicrobial agents to eliminate vaginal organisms capable of interfering with treatment, acidifying preparations, and vaccination with inactivated Lactobacillus acidophilus. Despite all the regimens used, the condition remained refractory to treatment.     

Effect of glycated albumin on phenytoin binding in elderly patients with type II diabetes mellitus

We evaluated the effect of glycated albumin on phenytoin protein binding in 36 elderly (age range 63-94 yrs) patients with type II diabetes mellitus (DM) under diet management. Serum was spiked with 15 mg/L phenytoin and incubated. A serum ultrafiltrate was obtained from each sample for determining total and free phenytoin concentrations. Glycated hemoglobin was determined by boronate-affinity chromatography, and glycated albumin was separated from nonglycated fractions with boronate-agarose gel. Glycated hemoglobin in the study group ranged from 4.3-14.6% (mean 7.8 +/- SD 2.1%) and glycated albumin ranged from 3.7-12.5% (7.4 +/- SD 2.6%). We observed no correlation between glycated albumin and the percentage of free phenytoin (r2 = -0.14; p = 0.419). The concentration of nonglycated albumin ranged from 0.66-4.28 g/dl (mean 3.45 +/- 0.67 g/dl) and was calculated from measured total and glycated albumin concentrations. A correlation between the free fraction of phenytoin and nonglycated albumin was not demonstrated (r2 = 0.22, p = 0.22). In addition, a correlation was not observed between total glycated albumin and the free fraction of phenytoin (r2 = -0.095; p = 0.58). We conclude that elderly patients with type II DM under diet control do not have significant alterations in phenytoin protein binding. The use of total serum phenytoin levels therefore appears appropriate for determining phenytoin dosages in elderly patients with well controlled type II DM.     

Retention of "safe" blood donors. The Retrovirus Epidemiology Donor Study

BACKGROUND: There are obvious advantages to increasing donor retention. However, for reasons of blood safety, certain donors may, in fact, be more desirable to retain than others. “Safe” donors are defined as those who provided a blood donation that was negative on all laboratory screening tests and who subsequently reported no behavioral risks in response to an anonymous survey. This study identifies the most important factors affecting the intention of “safe” donors to provide another donation. STUDY DESIGN AND METHODS: An anonymous survey asking about donation history, sexual history, injecting drug use, and recent donation experience was mailed to 50,162 randomly selected allogeneic donors (including directed donors) who gave blood from April through July or from October through December 1993 at one of the five United States blood centers participating in the Retrovirus Epidemiology Donor Study. Before mailing, questionnaires were coded to designate donors with nonreactive laboratory screening tests at their most recent donation. RESULTS: A total of 34,726 donors (69%) responded, with substantially higher response among repeat donors. According to reported intentions only, the vast majority of “safe” donors indicated a high likelihood of donating again within the next 12 months. Only 3.4 percent reported a low likelihood of donating again. A comparison of those likely to return and those unlikely to return reveals significant differences in demographics and in ratings of the donation experience. A higher proportion of those unlikely to return were first-time donors, minority-group donors, and donors with less education. The highest projected loss among “safe” donors was seen for those who gave a fair to poor assessment of their treatment by blood center staff or of their physical well-being during or after donating. CONCLUSION: These data suggest that efforts to improve donors' perceptions of their donation experience, as well as attention to the physical effects of blood donation, may aid in the retention of both repeat and first-time donors.     

Levodopa improves physical fatigue in Parkinson's disease: a double-blind, placebo-controlled, crossover study.

We quantitatively investigated the effect of carbidopa/levodopa (25/100) on physical fatigue during finger tapping and force generation in a double-blind, placebo-controlled crossover study. Parkinson's disease (PD) subjects were randomly assigned to carbidopa/levodopa or placebo for Visit 1 or 2 and participated in the following two studies: (1) Finger tapping. Twenty-five PD patients used their index fingers to strike two keys 20 cm apart on a musical instrument digital interface (MIDI) keyboard. The slopes of the regression line of dwell time and movement time were used to assess the rate of fatigue development. (2) Force generation. Twelve PD patients contracted the wrist extensors maximally to obtain a baseline maximum voluntary contraction (BMVC) force. Then they repetitively contracted the wrist extensors at 50% of the BMVC for 7 seconds and rested for 3 seconds. An interval maximum voluntary contraction (IMVC) was measured every three repetitions. Fatigue was defined as an IMVC of less than 60% of the BMVC. The slope of the regression line of IMVC was used to assess the rate of force decline. These two studies were repeated 1 hour after carbidopa/levodopa (25/100) or placebo. Subjects filled out the Multidimensional Fatigue Inventory (MFI) at the beginning of the first visit. Results showed that the slope of dwell time decreased with levodopa but not with placebo (P = 0.004). The rate of force decline also decreased with levodopa but not with placebo (P = 0.01). The subscores in the dimension of physical fatigue in the MFI did not correlate with the rate changes in dwell time or the rate changes in force decline. We concluded that (1) levodopa improves physical fatigue in finger tapping and force generation, (2) physical fatigue in Parkinson's disease is at least partially related to dopamine deficiency, and (3) the MFI measures different aspects of physical fatigue compared with those measured by finger tapping and force generation.     

The effect of subhypnotic doses of propofol on the incidence of pruritus after intrathecal morphine for Caesarean section

The effect of subhypnotic doses of propofol on intrathecal morphine-induced pruritus was studied in a prospective, randomly allocated, double-blind controlled trial. Fifty-eight women undergoing elective lower segment Caesarean section for a singleton fetus received spinal anaesthesia with 2.5 ml hyperbaric 0.5% bupivacaine and 0.2 mg of preservative-free morphine. They then received propofol 1 ml (10 mg) or Intralipid 1 ml (control group) intravenously after delivery. Pruritus was assessed using a five-point verbal rating scale at hourly intervals for 8 h. A second dose of their allocated treatment drug was administered at the first recording of significant pruritus. The pruritus score was reassessed after 5 min and the treatment was repeated if pruritus remained. There were no differences between the groups in the onset of pruritus or its successful treatment. No adverse side-effects were associated with this dose of propofol. There were no differences in the incidence of post-operative nausea and vomiting between the two groups. Subhypnotic propofol is not an effective treatment for intrathecal morphine-induced pruritus in women following Caesarean section.     

Creating a place for population health: Interpreting the spaces of a new School in Auckland,New Zealand

Although the reconfiguring of health care within the hospital sector has gained considerable attention by social scientists, the tertiary education sector's response to new health philosophies and practices has proceeded largely unexamined. This paper considers the new School of Population Health at the University of Auckland, accounts for its origins and considers the synergies between its design and workplace organisation. The results of a thematic analysis of narratives offered by 24 employees collected in 2004 are then presented. Findings suggest that the amassing of academics from a range of health-related backgrounds is advancing interdisciplinary dialogue even if the nature and purpose of population health remains unclear to some. A key concern of respondents was the openness of the workplace which encourages a collaborative atmosphere but also generates distraction. The degree to which conduct within the new building is perceived as regulated was also of concern. Place clearly matters in the story of the new School: the form of the building (featuring an architecture of openness) complements its function (generating new collaborations and creative thinking about health). However, the question of how ‘salutogenic’ a setting it is remains contested.