E Oburu, P Oroko
informed consent, orthopaedic consent
E Oburu, P Oroko. An Audit Comparing Consent Taking In Elective And Trauma Patients In The Orthopaedics Department. The Internet Journal of Law, Healthcare and Ethics. 2006 Volume 4 Number 2.
The purpose of the study was to identify if any, differences between the quality of consent obtained from elective and trauma patients. Data was prospectively obtained by questionnaire from elective and trauma patients. 28 elective patients and 21 trauma patients were interviewed postoperatively. All elective patients understood the nature of their operation as compared to 71% of the trauma patients. 86% of the elective patients were aware of the complications of the operation as compared to 48% trauma patients. Only 57% of elective patients and 29% of the trauma patients read the consent prior to signing. Patients who underwent emergency surgery had less understanding of the procedure and associated complications than patients who underwent elective surgery. Elective patients were better consented than trauma patients. However in both groups, the process needs improvement if the standard that is set by the department of health is to be met.
Support Received: None
Informed consent provides an opportunity for both patient and the doctor to discuss the various options regarding management .Anecdotally the principal author had noticed the process was not adequate especially for trauma patients The importance of consent taking cannot be over emphasised. An informed consent provides a patient an opportunity to be involved in the decision making aspects of his or her health. The department of health has provided an excellent guide on how to take an informed consent. (1) The patient should understand the procedure that will be performed on them. They should also understand the associated complications. Consent taking in elective surgery is usually a more elaborate than in emergency conditions (2) and other specialties have shown that patients undergoing elective surgery had a better understanding of the procedure than those in for emergency surgery. (2, 3) It is to this effect that we compared consent taking between patients who having elective surgery and those in for trauma surgery in orthopaedics.
To determine whether there is a difference between the quality of consent taken in elective and trauma surgery and whether or not they met the requirements set by the department of health.
This was a descriptive audit. Data was obtained prospectively with the use of a questionnaire. Appendix one. Patients admitted for trauma and those for elective surgery were interviewed post operatively. The consent was obtained by members of staff in the department. The consent was obtained in the ward, accident and emergency and day surgery unit for trauma patients. It was obtained in the preassesment clinic and the day surgery unit for the elective patients. Specific questions were answered by patients in the postoperative period with the use of a questionnaire as to whether they understood the nature operation, the complications associated with it and whether they read the consent form. The setting was the orthopaedic department of Hairmyres hospital which is a district general hospital in South Lanarkshire. The patients were seen in the ward, in the clinics and in the day surgery unit following surgery. The interviewer was mainly the principal author with the assistance of staff at the day surgery unit. None of the medical staff who took consent was informed of the study with the exception of the supervising consultant. All patients who did not have the capacity to consent signed were excluded from the study.
There were 49 patients interviewed during the study with 28 elective patients and 21 one trauma patients. The grades of the doctors who took the consent are shown graphically below.
Table 1 and table 2 below shows the results of the 3 principle questions asked i.e. as to whether or not they understood the operation, were aware of the complications and they read the consent form.
Our study shows that consent is usually taken by the junior doctors which was 86% in this case. This has far reaching implications in the consent taking process because it means that the doctors have to be aware of necessary requirements as determined by the department of health (1) for an adequate consent. Singh and Mayahi (4) in their series found that in 53 of 110 cases, the most junior member of the orthopaedic team took the consent, and patients were not being warned about specific complications and risks associated with surgery. This may be due to the fact that the junior doctors may be new to the department and may not be aware of the complications or the lack of uniformity in the various procedures especially those involving trauma. To circumvent this problem, Nixon et al (5) recommended the use of standardised and structured consent forms which allowed the senior staff retains responsibility for consent while improving the standard of informed consent
Our results show that patients who under went emergency surgery had less understanding of the procedure than patients who under went elective surgery. They we also less aware of the complications and were less likely to read the consent form before signing. All the elective patients understood the surgical procedure they had done as compared to 71% of those who had trauma surgery. Consent taking is a process rather than a single act and in the a patients who had elective surgery the procedure was explained several times due to repeated contact with all levels of the doctors before the surgery. This included their first clinic visit, their reassessment and the day before or hours before the surgery. Further more elective patients had the benefit of having a booklet distributed to them before the surgery out lining and explaining the procedure with its associated complications.
Trauma patients had less contact with various medical personnel especially the senior personnel prior to surgery as compared to their elective counter parts. In some cases the only the junior doctor reviewed the patient in the ward or prior to surgery. This may contribute inadequate information being relayed to the patient. Junior doctors have been shown to convey inadequate information to patients. (4, 6) Some patients who underwent trauma surgery reported that they perceived they had no choice but to sign their consent as they were in a desperate situation. No consent for them meant no treatment. This concurs to what Akadd et al (3) showed that patients who underwent emergency surgery in their speciality likely to have read or understood the consent form, and were more likely to report they felt they had no choice about signing the consent form, and that they would have signed regardless of its content.
The final aspect was whether the patient read the consent form or not. Despite the fact that the form used by the trust explicitly informs the patient to read it carefully before signing, only 43% of the trauma patients and 71 % of the elective patients read the consent prior to signing it. The situation is worse in patients who underwent trauma surgery because unlike their elective counter parts they did not have any booklet to read regarding their operation. It important for doctors to realise that consent taking takes time (7). Time spent taking an informed consent is never wasted. Unless an informed consent in accordance to the guidance provided the department of health(1) it will be difficult to defend one self in court of law.
Ultimately the responsibility rests with the operating surgeon. In a study of 28 malpractices brought against orthopaedic surgeons Bhattacharyya et al (8) showed that fifteen plaintiffs alleged that the underlying orthopaedic condition was not adequately described and thirteen plaintiffs alleged that they experienced a complication that had not been described preoperative. Therefore it is imperative that no aspect of the guide lines provided for by the department of health should be ignored.