Obtaining Informed Consent in Teaching Institutions
In the contemporary practice of medicine, informed consent is, first and foremost, an ongoing process or dialogue with patients. It is not simply executing a document that outlines the technical terms of a proposed course of treatment or surgery and a laundry list of possible adverse consequences.
True informed consent is a candid exchange of information that includes a clear discussion of the patient’s:
- Existing medical condition in terms that the patient can understand.
- Proposed treatment or procedure, including its nature and purpose.
- Alternatives, regardless of their cost and without regard to whether they will likely be covered by the patient’s health insurance.
- Available treatment options and each option’s associated benefits, risks, and anticipated costs.
- Short-term and extended prognoses.
- Consequences of failing to undertake any treatment.
It is imperative to provide the patient with realistic expectations of what might be achieved by the treatment, therapy, or procedure.
The informed consent process may require multiple discussions. Give the patient or the patient’s representative adequate opportunity to ask questions. The patient’s decisions must be made voluntarily without the appearance of coercion or pressure. The patient must have sufficient information to make reasonable and informed decisions regarding a treatment plan.
The basic principles governing informed consent and informed refusal apply equally for physicians practicing in academic teaching medical centers. However, given the nature of patient care in such institutions—where individuals in training participate to varying degrees—consider the additional factors that follow.
Suggestions for Obtaining Informed Consent in Teaching Institutions
- Have the attending physician and house staff visit the patient together, prior to the procedure. During the ensuing discussion, the attending doctor should clarify the resident’s role in the procedure for the patient and family. Detailed descriptions are not necessary, but the patient must understand that the contemplated procedure is a team effort and that the attending physician will need assistance.
- Spell out the resident’s qualifications as strongly as possible to reinforce patient confidence in the house officer. It helps if, during the bedside discussion, the patient observes the attending physician treating the resident as a colleague and conducting the discussion in a spirit of respect. A relationship of peers rather than one of master and pupil should prevail.
- Clarify that the attending physician will be present at all times in a directly supervisory capacity and that he or she is the responsible doctor.
- Inform the patient of the identity of personnel in the operating room. This is especially important if product representatives will be present during the procedure. Failure to inform the patient could lead to a breach of privacy allegation.
- Prepare for some patients to insist on having the attending physician perform the procedure. This request is often couched in a question like, “You’re not going to let that student doctor operate on me, are you?”
Under these circumstances, the attending physician can:
- Comply with the patient’s wishes.
- Refuse to participate in the patient’s care.
- Convince the patient that it is in everyone’s best interest for the procedure to be performed by the whole team.
- Keep in mind that doubts about the identity or competence of the physician who actually performs a procedure can arise in unexpected ways. Discourage gossip and casual remarks that can plant seeds of doubt that might subsequently trigger an allegation of malpractice.
Document Informed Consent
Attending physicians who do not inform patients, or who imply that they will perform the operation or render the care personally and then delegate substantial parts of the procedure or care to house staff, are putting themselves and the institutions they serve in significant jeopardy. In the event of an untoward outcome—even when a consent form has been used—such cases are difficult to defend.
Therefore, the key consideration is to make absolutely certain that documentation in the patient’s chart accurately reflects the disclosure made to the patient prior to treatment. In a teaching situation, the consent for treatment should always include the resident staff of the institution as well as the attending physician.
It should also be noted that various states have enacted legislation or adopted administrative regulations governing medical consent. Those state-specific rules have different requirements and should be consulted for a more detailed understanding of the law applicable to your practice.
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.