February 1st, 2012
By Jennifer Olin, BSN, RN
Across the blogosphere, this past week or so, terms like patient advocacy, patient education, and informed consent have appeared more times than I can count. On Twitter and Facebook nurses are talking, decrying, in fact, that a nurse in Arizona was seemingly fired for furthering the client’s education on a surgical procedure they were about to undergo.
According to reports, the patient had already agreed to the surgery. However, when the nurse assessed the patient’s understanding of the procedure and the post-surgical recovery she found the client didn’t really understand all their options. The nurse proceeded to provide teaching materials and request a case management consult. One of the biggest issues in this case, one that should concern patients and everyone on healthcare teams everywhere, is informed consent. What is it, what should it encompass, and who is responsible?
Informed consent is a person’s agreement to allow something to happen, such as surgery or an invasive diagnostic procedure, based on a full disclosure of risks, benefits, alternatives and consequences of refusal. Informed consent creates a legal duty for the physician and/or healthcare provider to disclose material facts in terms the client can reasonably understand to make an informed choice. Ok, that’s pretty much a textbook definition.
We have said it is a legal duty between the doctor or healthcare provider and the patient. All legal duties come with legal paperwork, so once that consent form is signed it’s full steam ahead for whatever the patient has agreed to, right?
It is not that easy. To quote the American Medical Association (AMA) “Informed consent is more than simply getting a patient to sign a written consent form.” This process should be a specific communication between the patient and physician about what the doctor wants to do, possible complications, and likely outcomes. In other words, they need to sit down and talk and there should be documentation that echo’s what is discussed. The following factors are required for informed consent:
Now, what the physician describes and what the form says may not be exact, but as stated earlier, it should echo it.
Nursing’s Role in Informed Consent
Because nurses do not perform surgery or direct medical procedures, in most situations, obtaining clients’ informed consent does not fall within the nursing duty. Even though the nurse often assumes the responsibility for witnessing the client’s signature on the consent forms, the nurse is not legally responsible for obtaining the informed consent.
What that means is you, as the RN, are merely collecting the signature, not responsible for the information included on the form or provided by the physician. You are like a notary when you sign it yourself. You are simply verifying that the patient signed the consent voluntarily.
That’s the legal standard, but the ethical standard, the moral standard is a little more complicated. When you hand the patient that form you should ask, “Do you understand the procedure you are agreeing to?” If they say no, or provide a description that is fuzzy, or if, as the nurse, you suspect they don’t really get it, you must notify someone. Call the physician, talk to your nursing supervisor, let someone else know that there is a lack of understanding on the patient’s part and don’t let them sign until that has been clarified.
The reality is lots of people, healthcare workers included, get lost in the explanations. As they teach us all in nursing and medical school, the worst time to talk to a patient is right after they have been given a diagnosis. They often just don’t hear you because their minds are wrapping around the fact they have kidney disease, or cancer or whatever else. They nod, they agree to things, but they don’t really hear.
Also, many people hesitate to question their physicians. Either it is generational, or cultural or they don’t want to appear stupid, but patients often just say ok without asking further questions of the doctor. It is often reported that nurses are easier to approach, plus we are the caregivers at the bedside 24/7. We are the familiar faces, the hand holders, and the teachers. According to JCAHO (Joint Commission on the Accreditation of Healthcare Organizations), in their Accreditation Manual for Hospitals under patient rights and responsibilities:
Informed consent is NOT the form. It is the explanation leading to understanding of the proposed procedure or treatment by the patient. What defines “reasonable” and what steps a nurse may take to “ensure” patient comprehension differs from place to place. It is defined by individual states’ nursing scopes of practice and by each facility’s scope of practice and standard protocols for nurses.
Who May Give Informed Consent?
While the nurse is not technically, or even legally, responsible for providing the information necessary for informed consent there is an ethical responsibility to look out for the patient’s best interest. The nurse’s role is both as a witness and as the patient’s advocate. As patient advocate, it is our responsibility to ask questions of the patient to determine whether he or she has received sufficient information to make an informed decision. That is a significant role and one we should never take lightly.