Consent and Information for Patients
Competent adults have a fundamental right to give or withhold their consent to medical examination, investigation or treatment. Other than in specific or exceptional circumstances, anaesthetists must therefore at all times have been given the valid consent of their patients. Several important points must be borne in mind when considering consent. Is it given freely? Does the patient have the requisite information to make a decision? Do they have the capacity to make this decision?
In clinical anaesthetic practice, the vast majority of consent is implied consent. The person’s consent is inferred from his or her actions (or inactions). If an anaesthetist asks to check a patient’s pulse and he or she offers his/her wrist, then consent is implied. The same principle of implied consent applies to documenting the patient’s history in the medical notes, attaching monitoring, insertion of a venous cannula or positioning a patient for a local anaesthetic block. Conversely, refusal to participate in these acts would imply that the patient did not give his or her consent at that time.
Verbal consent may be simply an extension of implied consent. The anaesthetist may ask the patient if it is all right to insert a venous cannula and the patient says yes. At the other extreme, verbal consent may be a very thorough process in which the anaesthetist has explained specific risks and benefits of a proposed procedure in great detail and, following some deliberation, the patient agrees verbally.
Written consent involves the patient agreeing to the proposed procedure and confirming this in writing. This is most commonly facilitated by a pre-printed consent form for operative procedures, but there may be occasions on which the medical notes are used for this purpose. It is important to understand that the written form simply documents that the patient has given their consent. It does not necessarily provide any information about the quality of that consent. Written consent is no more ‘valid’ than verbal consent but the documentation may provide some evidence of the process in the event of problems.
At present, anaesthetists use a combination of all these types of consent in their daily practice: the patient implies consent to blood pressure monitoring by holding his or her arm in position; he or she may have agreed verbally to general anaesthesia and its attendant risks and benefits with the anaesthetist; he or she will almost certainly have signed a consent form for the proposed surgical procedure. Currently, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) is of the view that a formal signed consent form is not necessary for anaesthesia and anaesthesia-related procedures, since it is the process of consent itself that is important, and a signed form does not increase the validity of the consent. However, it is recommended, particularly for procedures which are invasive or which carry significant risks, that both a patient’s agreement to the intervention and the discussions which led up to that agreement are documented. This can be done on a standard consent form, on the anaesthetic record or separately in the patient’s notes.
Gaining consent should be considered a process, not an event. For most patients, the process starts long before they meet the anaesthetist when they are seen by their family doctor and then the surgeon. At each step in this process, they are being given information and consenting, however informally, to the next stage in the process. Healthcare professionals, family, friends and other sources will all be providing information which will help them to come to a decision. The anaesthetist adds to this process with information about planned anaesthetic techniques, risks and benefits. The final consent from the patient should reflect this whole process – and documentation should support this.
A fundamental principle of valid consent is that it should be voluntary. Consent is always given or withheld by the patient. It is not something done to a patient. Anaesthetists, along with other healthcare professionals, should avoid references to ‘consenting the patient.’ The anaesthetist should take appropriate steps to satisfy him/herself that the patient is not being coerced by other people, however well meaning, or by the situation. In normal practice, this involves nothing more than straightforward discussion with the patient. Anaesthetists should be aware that the context of consent must be considered, not just whether there is undue pressure from family or friends. An elective patient who is in the anaesthetic room and given new, significant information about the anaesthetic technique may be viewed as being in a coercive context because it would be difficult to refuse the interventions offered.
The anaesthetist has a professional duty to offer his or her opinion about what he or she believes the best course of action might be, but this should not cross the line into coercion. Patients have the right to refuse offered treatments. However, this does not mean that anaesthetists have to provide a treatment which they feel is unsafe just because a patient requests it. In the unusual event that this problem arises, clear documentation and discussion with senior colleagues are vital.
In broad terms, the anaesthetist should provide the individual patient with sufficient information to make a reasonable decision. The patient should have some understanding of what he or she is consenting to. The anaesthetist must consider the individual patient – as suggested by the AAGBI: ‘What would this patient regard as relevant when coming to a decision about which, if any, of the available options to accept?’. Conversely, information should not be withheld solely because the anaesthetist feels it may deter a patient from undergoing a particular intervention or therapy.
There is no statute which clearly defines what information should be given to patients about anaesthesia, and different countries’ legal systems have taken slightly divergent views. The AAGBI guidance is shown in Table 19.1. It must be emphasized that the anaesthetist should adapt this to the individual patient and surgery. For instance, visual loss after prone surgery is a rare but significant procedure-related complication which is relevant to specific patients.
Generally what may be expected as part of the proposed anaesthetic technique. For example, fasting, the administration and effects of premedication, transfer from the ward to the anaesthetic room, cannula insertion, noninvasive monitoring, induction of general and/or local anaesthesia, monitoring throughout surgery by the anaesthetist, transfer to a recovery area, and return to the ward. Intraoperative and postoperative analgesia, fluids and antiemetic therapy should also be described.