Tuesday 9 October 2012

Deciding versus consenting

The consent process in medicine is serious stuff. Consent forms are fine-tuned every few years to get them just right, and often a negligence suit can hang on the consent form and consent process. Less emphasis is placed on the decision process that led to the patient signing a consent form in the first place. It turns out that the more information a patient receives, the less likely they are to ‘sign up’ for the procedure.

Look at the standard consent form. It has the procedure spelled out along with identifying information – no problem there. It has sections covering the fact that the procedure was explained, and that the result might not give the expected result and that complications may occur (sometimes with a list of possible complications). Often the form includes a statement that the patient has had a chance to ask questions about the procedure. And that’s about it.

What I would like to see, is something along the lines of:

My doctor has provided me with a comprehensive, balanced view of the relative risks and benefits of having this procedure, and discussed the alternatives. Based on this knowledge, the doctor’s advice, and my preferences, I have elected to undergo this procedure.

This may be implied in a standard consent form, but the evidence suggests otherwise. In studies comparing decision aids* to standard care, patients who have received more comprehensive information about the treatment alternatives and the relative risks and benefits are (on average) 20% less likely to choose the treatment. This particular study showed a 26-38% reduction in uptake of hip and knee replacement by simply giving the patients more information. This is not always the case, and it is likely to depend on the procedure in question, but it never goes the other way. It is rarely the case that someone is more likely to choose a treatment once they have received all the information.

In other areas, decision aids have been associated with a reduction in uptake of PSA screening in men, and in the use of menopausal hormones in women.

Things may be better than they were in the past, but surgeons are still as busy as ever, and often they just want to get the forms signed so they can move on to the next patient, particularly if they feel the surgery is justified. The evidence seems to show that the more information patients receive about the proposed treatment, the less likely they are to choose the treatment. So what is the answer? There are options for the busy surgeon, as most decision aids are designed for the patient to review in their own time. I suggest that patients have an initial consultation, be given the decision aids and any other information, and then return for a second consultation having considered the information, with any remaining questions they might have. This already happens in many practices but often patients are simply given time to think, and are not supplied with comprehensive information (decision aids) for the time between consultations.

The benefits of decision aids go beyond the decision itself. Patients receiving decision aids are more knowledgeable about the treatment, have a more accurate perception of risk, have less decisional conflict (they are more sure about their decision), and are more satisfied. Basically: the more information the better -  a rule that will rarely let you down.

*Decision aids may be pamphlets, videos, or web-based tools. They describe the options available and help people to understand these options as well as the possible benefits and harms. This allows patients to consider the options from a personal view (e.g. how important the possible benefits and harms are to them) and prepares them to participate with their health practitioner in making a decision.


  1. "My doctor has provided me ..."

    Which doctor (excuse the pun)? The GP will likely say "hmmmm, serious, I'll send you to a specialist". The specialist will likely say "your doctor was right, I'm going to refer you to a surgeon". The surgeon will say "sign here that you're fully informed as to the risks and that you give your permission".

    One problem is that often the consent form is offered so late in the process. Sometimes when the patient has been prepped and sedated. This is a form of emotional blackmail, as few patients would have the courage to back out at that late stage.

    1. Thanks, and a good point. The doctor with responsibility is usually the one at the end of the line, and the one who will be performing the procedure. In my case, me - the surgeon.

      The emergency situation that you refer to is different, as we have to weigh urgency against information. Also, emergency procedures may be more clear cut than some elective operations.

      Having said that, most "emergency operations (particularly in my field) are not that urgent, and when there is doubt about the procedure it may be worthwhile delaying treatment until the patient (and family) have had time to consider the decision.

  2. I completely agree. People need to be given a better assessment of their potential risk and benefit, based on the available research and data.

    I'd like to link this post to my blog, or better yet, interview you for a post on my site. Might this be possible?


    1. Thanks Barbara,
      Your blog looks good. I will contact you by email.


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