Making informed consent client centred

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Making informed consent client centred

Postby malernee » Fri Nov 21, 2003 6:09 am

BMJ 2003;327:1159-1161 (15 November), doi:10.1136/bmj.327.7424.1159

Making consent patient centred



Taking the time to explore patients' objectives not only improves consent procedures but may avoid some interventions altogether



Guidance on obtaining patients' consent for treatment encourages doctors to consider their needs and priorities when disclosing information.1 However, the focus on disclosure, which has arisen from the need to tell patients about risk, has meant not enough attention is given to patients' objectives. To make consent properly patient centred, clinicians need to ask patients what they want from treatment before they discuss treatment strategies.2 We believe this approach is essential, especially in the management of chronic illness. It should also help protect reticent patients, whose objectives may differ from the assumptions made by clinicians.



Information disclosure: standard and content

For consent to be valid, patients must be competent to make the particular decision and give consent voluntarily after receiving appropriate information. The issue of what constitutes appropriate information incorporates two questions: firstly, what is the standard for determining if clinicians have properly discharged their duty to disclose information and, secondly, what categories of information should be discussed?

Two standards for disclosure have been prominent. A professional standard applies in England and Wales. This requires clinicians' practice to be "in accordance with a practice accepted as proper by a responsible body of medical men" of ordinary skill in the relevant clinical specialty.8 In Mrs Sidaway's landmark case, the House of Lords rejected her claim that a surgeon was negligent in not disclosing a risk of spinal cord damage, which she subsequently sustained.9 Four of five Law Lords found that a responsible body of neurosurgeons in that position would not have disclosed the risk. Although recently courts have been willing to assert their ultimate authority, they rarely over-rule medical opinion.10







Some other jurisdictions apply a reasonable patient standard. One influential US judgment asserted that "it is the prerogative of the patient, not the physician, to determine where his interests seem to lie." A risk should be disclosed if "a reasonable patient in what the doctor knows or should know to be the patient's position, would be likely to attach significance to the risk or cluster of risks in deciding whether or not to forgo the proposed therapy."11

Neither the professional standard nor the reasonable patient standard provides the right framework for patient centred consent. The professional standard is paternalistic, emphasising what clinicians consider appropriate to disclose rather than what patients want disclosed.12 The reasonable patient standard is inherently hypothetical, upholding the autonomy only of patients who behave like a typical patient. It asks what risks should be disclosed to a "reasonable" patient in the particular patient's position, not what risks the particular patient would regard as important. Lord Scarman applied the reasonable patient standard in the Sidaway case but still rejected her claim because a reasonable person in her position would not need to know about the risk to be able to consent.

To achieve patient centred consent we need to change our approach from disclosing information to sharing information. At present, the various guidelines all agree about what categories of information should be discussed. Clinicians should disclose what treatments and their alternatives broadly involve, their foreseeable risks and benefits, and the implications of declining treatment.13 However, clinicians are not required to ask patients what they want. Such an obligation is the natural response to the Bristol inquiry's recommendation that healthcare professionals should adopt "the notion of partnership between the healthcare professional and the patient, whereby the patient and the professional meet as equals with different expertise."5

Putting patients' objectives first

Patient centred consent must be founded on the patient's objectives. The GMC's thorough guidance encourages clinicians to "find out about patients' individual needs and priorities [as their] beliefs, culture, occupation or other factors may have a bearing on the information they need in order to reach a decision."1 However, suggesting treatment then tailoring information disclosure to patients' priorities may give only a patient centred veneer to disease centred management.

Patient centred practice requires clinicians to offer patients an opportunity to participate in a shared decision about treatment options.14 In our experience, patients who want to share decisions find it easier to do so if the process begins with an exploration of their objectives. Only then should treatment options be considered and relevant information disclosed. Discussion of risks, benefits, and alternatives has greater resonance for patients if it is put in the context of their expressed objectives.

Discussing objectives may seem superfluous in simple cases when the benefits of intervention seem obvious but the risks are not. For example, a clinician might assume a patient with hay fever understands the benefits of an antihistamine but acknowledge the basic duty to disclose its sedative side effect. However, our experience at the National Refractory Angina Centre suggests clinicians make similar assumptions about what patients expect from invasive procedures. Many patients are uncomfortable questioning clinicians and may not declare their objectives unless asked.3 The onus, therefore, is on clinicians to explore patients' aims rather than merely discussing risks and benefits associated with procedures.15 Clinicians can then be led by what patients want, rather than by professional assumptions about management of a disease.

Challenges for doctors and patients

Ultimately, it is for patients and their carers to decide if a treatment is appropriate. To do so, patients must be competent and decide voluntarily on the basis of appropriate information. This must include a realistic assessment of likely benefits as well as a discussion of the risks and alternatives. To give this information clinicians need to ask patients what they count as a benefit. The question may be challenging for patients, and some may prefer not to share in the decision making process.16 Chronically ill patients will often have to compromise because what can be achieved by treatment falls short of their ideal health state. Some, though competent to consent, will not be able to state an objective. Patients may express objectives in terms of life goals—for example, the patient in our case history wanted to avoid his son going into care (box 2)—rather than in disease centred terms, and clinicians will need to be creative to respond with appropriate strategies. Nevertheless, these challenges must be overcome as involvement of patients in setting goals is fundamental to the concept of patient centredness.17 Clarifying patients' objectives is not a substitute for the GMC's guidance on good consent practice. Rather, it provides the ideal reference point for tailoring treatment and information to individual patients' needs. Conversely, if patients' objectives are not established, offers of treatment with even full disclosure of risks, benefits, and alternatives, may yet fail to be patient centred if made in ignorance of what a compliant patient truly wants.





Summary points



Clinicians have been encouraged to make consent procedures patient centred

Guidance implies this is achieved by tailoring disclosure of information to individual patients' needs

Consideration of patients' objectives has been neglected

Failure to agree objectives can lead to inappropriate treatment

The disclosure based model needs to be replaced by shared decision making, with objectives agreed before treatment is discussed









References


General Medical Council. Seeking patients' consent: the ethical considerations. London: GMC, 1998.
Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med 1996;125: 763-9.[Abstract/Free Full Text]
British Medical Association. Report of the consent working party: incorporating consent toolkit. London: BMA, 2001.
Department of Health. The NHS plan. London: DoH, 2000.
Bristol Royal Infirmary Inquiry. Learning from Bristol: the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 1984-1995. www.bristol-inquiry.org.uk/final_report (accessed 15 Sep 2003).
Chester MR. Chronic refractory angina. www.angina.org (accessed 15 Sep 2003).
RITA-2 Trial Participants. Coronary angioplasty versus medical therapy for angina: the second randomised intervention treatment of angina (RITA-2) trial. Lancet 1997;350: 461-8.[CrossRef][ISI][Medline]
Bolam v Friern Hospital Management Committee [ 1957] 2 All ER 118.
Sidaway v Board of Governors of the Bethlem Royal Hospital [ 1985] AC 871.
Smith v Tunbridge Wells HA [ 1994] 5 Med LR 334.
Canterbury v Spence. 464 F 2d 772 (DC, 1972).
Brazier M. Medicine, patients and the law. 2nd ed. London: Penguin, 1992.
Department of Health. Reference guide to consent for examination or treatment. London: DoH, 2001.
Towle A, Godolphin W. Framework for teaching and learning informed shared decision making. BMJ 1999;319: 766-9.[Free Full Text]
Charles C, Whelan T, Gafni A, What do we mean by partnership in making decisions about treatment? BMJ 1999;319: 780-2.[Free Full Text]
Elwyn G, Edwards A, Kinnersley P. Shared decision-making in primary care: the neglected second half of the consultation. Br J Gen Pract 1999;49: 477-82.[ISI][Medline]
Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med 2000;51: 1087-111.[CrossRef][ISI][Medline] (Accepted August 28, 2003)
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