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Elective Surgery Informed Consent and Shared Decision Making During COVID-19

Kim Hathaway, MSN, CPHRM, Patient Safety Healthcare Quality and Risk Management Consultant, and Julie Ritzman, MBA, CPHRM, Vice President, Department of Patient Safety and Risk Management

Updated May 1, 2020: Restarting elective surgeries and procedures after suspension during the COVID-19 pandemic requires a great deal of planning and consideration of many factors, including those related to patients, locations where you practice, and the larger community. To support those delivering care during this unprecedented time, we are providing recommendations for resuming elective surgeries and procedures—with a focus on keeping you, your staff, and your patients safe.

As you create your individual plan to resume elective cases, clear and deliberate communication with your patients will be a critical step. In addition to the customary informed consent discussion related to the procedure, you will need to have a candid conversation with your patients about COVID-19. The discussion should focus on measures in place to safely undergo the intended procedure, including any risks of becoming infected during the perioperative episode.

Recognizing that medicine is a blend of science and compassion, we highlight the following areas to discuss with patients undergoing elective surgery or procedures:

  • Setting expectations: Discuss any contingency plans related to a resurgence of COVID-19 cases in your community. Your patient’s surgery is scheduled, and the patient is eager to proceed, but it is important to maintain flexibility. Factors exist that can change your plan, including a hospital’s bed capacity or availability of equipment and supplies, forcing you to postpone the care. Due to the limitations of testing and the contagiousness of COVID-19, any member of the team, such as an anesthesia provider, nursing staff, or even a patient may develop symptoms of COVID-19, resulting in more delays. It is best to discuss this up front, so your patient is prepared for all possibilities.
  • Option to defer: Talk to your patient about the benefits and any risks related to delaying the surgery to a time when the local community is more stable in terms of active COVID- 19 cases or a known treatment is available. Make the decision to defer with the patient’s full understanding of the situation and when delaying the care will not alter the outcome.
  • Pre/post preparations: Inform your patient that they will be asked to complete a COVID-19 screening assessment to evaluate exposure to the virus. It is important to consider the patient’s effectiveness in preoperative social distancing and the risks related to their contacts who may have been exposed to COVID-19. If recent COVID-19 exposure elevates the risk, postpone the surgery until the patient has self-isolated for a period of 14 days or until it is safe to move forward with the planned care. Explain to your patients the steps that are being taken at the facility to keep them safe and to protect the surgical team from contracting COVID-19. Instruct patients to wear a cloth mask from home to the facility. If they do not have a mask, provide one on the day of the surgery. Make them aware that for everyone’s safety the staff will all be wearing masks as they greet them and throughout their care.
  • Testing: Alert your patients that they will be tested for COVID-19 prior to the procedure. (Even if they have been tested previously, they may have been exposed after that result was provided.) If their pre-op test is positive, regardless of whether they are symptomatic, their procedure will be rescheduled until there are two negative test results performed 24 hours apart. For more information, see the ASA and APSF Joint Statement on Perioperative Testing for the COVID-19 Virus. In some cases of extended delays, patients may have to repeat tests that were previously performed such as x-rays, lab tests, EKGs, and COVID-19.
  • Elevated risk: Educate patients about the current limitations around testing and about the fact that even with a negative COVID-19 test result, there is up to a 30 percent false negative rate. Discuss the possibility they may contract the illness post-op. Specifically discuss that undergoing the surgery may weaken their ability to fight the COVID-19 virus, and they may be at a higher risk of complications involving intensive care, ventilator support, or death from COVID-19.
  • Changes in facility operations: Discuss any process changes implemented at the care facility because of COVID-19. Examples include a different process for patient drop off/pick up, as well as limiting visitors and screening protocols when they are allowed.
  • Post-op setting: Discuss where the patient will convalesce after the surgery. Will they be able to shelter in place and maintain social distancing in a separate location in the home? Emphasize infection control practices to prevent COVID-19. Also consider the timing of the surgery for the best outcomes.
  • Post-op visits: Consider the use of telehealth for post-op visits. Ensure the patient has adequate technology, and they understand what parts of the body you will ask to see, such as a surgical incision. Also discuss when you may need to see the patient in person.
  • Documentation: Document your discussions with patients and their response related to the inherent risks associated with proceeding with an elective procedure during the initial resumption phase post COVID-19. Also include the clinical judgement that went into the decision to continue with the surgery at this time. If appropriate, document that the patient was given the option of a rescheduling but has chosen to proceed at this time.

Specialty organizations have joined forces to develop detailed recommendations that include administrative and clinical guidelines. The following resources provide detailed information, including a checklist and guidance related to resuming elective surgery:

In supporting the medical profession during these unprecedented times, The Doctors Company continues to listen to our members and work to respond to their unique concerns as part of our mission to advance the practice of good medicine. For the latest updates on our responses to members’ concerns, visit our frequently asked questions page.



The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

05/20

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