Witnessing Consent

[Apples&Oranges]

I thought I had a handle on what witnessing consent meant - that I had been present for a conversation in which the provider (MD, PA, NP, etc) had outlined the invasive procedure to be performed, explained the risks, offered (or at least mentioned that) alternative treatments (existed) and answered questions from the patient or family.

In my orientation to this new hospital system (about a year ago) the educator was adamant that my perception was WRONG. That as a nurse, I was only witnessing a signature, nothing else. No conversation, understanding, clarification, NOTHING but a literal signature. Since the policy for this hospital system is floating somewhere in the Nothing (don't even get me started) I have always used my own ethics to conclude that this is a bunch of crap.

I have always refused to sign a surgical or blood consent for which I did not witness the conversation - I'm not a jerk about it, I just take the paper, walk back into the room, ask, "Is this your signature? So your having a left lobectomy? Do you feel like you understand the risks? Do you have any questions about alternatives?" 99% of the time the answer is "No, I get it, I'm good." Cool.

This week, a doc freaked the **** out on me, in the hallway, because I refused to sign a consent for a urology/nephrology procedure on a patient who was:

1. Not consentable, in my personal opinion (she was ether MR or close to it)

2. Told me point blank she didn't understand why they had decided to do one procedure rather than the other

3. Wanted her son and husband to be part of the decision (and no family members are ever around to consent at 6am...)

So when I paged, called the OR, paged again, called the OR again to say that I would not witness the consent (Oh, BTW, the surgeon tossed the paper at me after speaking to the patient and said "sign this,") I apparently was breaking an unwritten rule.

The Very Important Surgeon then had to waste his precious time coming back up to the unit and have the conversation again (in which he again, did not include me, the witness) and then freaked out when I again, wouldn't sign the consent.

Dude! How did you not get this the first time?? Get the freaking nurse in the room if you want her to sign the consent! Honestly!

Suffice it to say, we had words...

There is obviously more to this story, but for the sake of brevity, I'll leave it here. What do you guys think of this? While we are told in nursing school that you are witnessing the X, Y and Z that I outlined, is that really what we are SUPPOSED to be witnessing? Or was my educator right? Are we really only supposed to be signing that we saw the patient sign and nothing else?

Any evidence - federal, state or even facility policies would be appreciated, I can't seem to find a good source. As always, anecdotal experience is really what I'm after.

[~Mi Vida Loca~RN, ASN, RN]

I have never heard that we are "Witnessing the signature" I have always worked in the ER and mostly in teaching hospitals, so the residents come down and sometimes are quick to leave. So I have normally done what you have done and went and made sure the patient understood what was going on, if they had any questions, did they know alternatives and that they consented. Never once was a problem and I would sign.

However there was a time I bumped heads with a resident on the consents and it was regarding the blood consents. I knew the patient pretty well and her husband. They spoke decent English but their primary language was Spanish, I can speak a little Spanish. Anyway this was a young woman having her gall bladder removed. The resident brings me the consents and asks me to witness them and place them on the board. I notice she marked that the pt refused a blood transfusion and I found this odd. They were not Jehovah's witness which is usually the main time you see this so I asked the resident if she knew why the patient refused the transfusion. She was like "I dunno, they just said they don't want someones blood. I told them it's not a big deal because it's a very common procedure that usually goes smoothly and there isn't going to be a reason to need blood anyway"

I mean I couldn't let that fly. I had no doubt the patient and her husband did not fully understand the ins and outs of possibly needing blood and what it meant to refuse it. So I told the resident that she needed to get the translator and make sure the patient fully understands. After that the patient no longer refused the transfusion and before she left the resident mumbled under her breath when she handed me the new consent "this is absurd, nothing would have happened" she was a first year resident. I told her "You're most likely right, the procedure will go smoothly without a hiccup. But do you know when that 1% chance will come that you have a bad outcome??? That time that you take a young healthy patient to surgery and didn't think the blood consent was a big deal. That will be the day that something happens and the patient needs blood and you can't give it. That will be the day that you have to go explain to that patients husband how his young healthy wife is dead because it was assumed nothing would happen and no one wanted to take the time to make sure they understood what it was they were refusing"

Her attending who was one of my favorite surgeons (we had an awesome rapport and football rivalry) was sitting at the nurses station and heard all this and backed me.

[blondy2061h, MSN, RN]

Legally anyone can be a witness to a signature on a form. They can have a housekeeper do it and as long as the housekeeper saw the patient sign the form, they can witness that it was the patient that signed the form.

From a nursing perspective, part of your duty as a nurse is to be an advocate for your patients. They have a right for INFORMED consent. If you don't feel that was achieved, go to the provider. If the provider isn't amenable to fixing it, go to their superior. Take it to the ethics committee if you need to. Involve your superiors early on, too, if it looks like it's going to get sticky.

[MunoRN, RN]

The expectation of every BON I've been licensed by is that a nurse's professional responsibility when "witnessing" consent is to confirm that consent has actually occurred (that the patient understands the procedure and agrees to the procedure without further questions). This same scenario came up at one place I worked; the facility policy was that the witness was only witness the actual signature, this was put to the state's BON who replied that no facility policy can reduce a nurse's professional responsibility, and they considered failing to confirm actual consent to be a violation of their license.

[Rose_Queen, BSN, MSN, RN]

Our consents can be witnessed by anyone- the MA in the surgeon's office is the one who witnesses for patients being admitted from home. Do I need to be there when the surgeon obtains consent? I don't think that's necessary, plus this is all done in an office setting where I don't work or on one of the hospital floors, also not where I work. I've also been told that all we are witnessing is the signature; however, when I do my preop interview, I am checking to see how the patient describes the surgery (taking care of those blocked arteries in my heart or replacing my valve through the artery in my groin) compared to the consent. If a nurse had to sit with a patient and a surgeon when the discussion is being had, that nurse would never be able to get the work done. Going off of Muno's comment, the BON expects the nurse to confirm that consent occurred, not to be present during the discussion.

[Here.I.Stand, BSN, RN]

the only time I am asked to witness is when the MD needs to get a telephone consent. I am present for the conversation. After the family member states yes, the MD says "I'm going to pass the phone to the RN to confirm." Before signing anything I always ask the pt if they had any questions about the procedure, or any other concerns they still need to discuss with the MD? If no, then I confirm that the family member is consenting to the procedure.

In your case, you absolutely did the right thing -- the pt has the right to informed consent. That surgery cannot proceed until the surgeon has answered all questions

[LovingLife123]

I think the only time I have to witness is if consent is obtained from a family member over the phone. We used to have to witness, but not anymore. When I did witness, I didn't have to be in the room, I simply made sure the procedure was explained to the patient and that they didn't have any questions.

I think the first time you did the absolute right thing, the patient did not understand the procedure. I think you pushed it the second time feeling like you were proving a point that you needed to witness the whole thing.

I would clarify with my facility what the policy and procedure is.

[brillohead, ADN, RN]

I work nights, so this is rarely an issue for me. But we did have an episode once where a day nurse gave the off-going night nurse a hard time for not getting the patient to sign their consent for a surgery/procedure scheduled for that day.

The daytime nurses have been FILLING OUT THE FORM for the physician, plus getting the patient to sign it!!!

I backed up the night nurse 100% on this matter. I would have NO way of knowing what procedure the physician discussed (if any) and what risks/benefits (if any) were discussed, etc., if I wasn't in the room at the time of the discussion AND the physician wasn't the one to fill out the consent form that lists the procedure and the risks/benefits of that procedure!

If the physician has filled out the form and listed the procedure and the risks/benefits in the space provided, I have no problem verifying with the patient that they understand the procedure / risks / benefits, they don't have any additional questions, and they are agreeing to the procedure -- I'm fine with witnessing to that. But I'm not going to fill out a form and just ASSUME that the physician has done all the teaching associated with it. Nope.

[NurseSpeedy, ADN, LPN, RN]

Our system is electronic so we get an electronic order for witness consent. The order includes the doctor and the procedure. The doctors notes (hopefully) include notation about the conversation with the patient. We fill out the form word for word from the order and witness the consent signature.

Now, here's my take on it. I will witness after 1) assessing that the patient is alert and oriented (and hasn't recently taken something to impair them. No here's your dilaudid ivp and can you now sign on the line below). 2) the patient confirms that their doctor has explained the procedure to them and they have no other questions and 3) they want to get the procedure done.

Surprisingly this was something covered in depth in school and had an NCLEX question related to it. We NEVER explain the procedure or risks/benefits. This is the doctors responsibility. If a patient states, "no one explained anything to me" a phone call is being made stating the patient would like to speak to you about their procedure before signing the consent. This is more common when the patient is not able to sign for themselves and there is a POA involved. The doctor needs to speak with this person first.

[RNOTODAY, BSN, RN]

I work in the Operating Room. Obviously I deal with consents every case. My only responsibility is to ensure it it PRESENT, and signed by patient and MD

[RNOTODAY, BSN, RN]

I work nights, so this is rarely an issue for me. But we did have an episode once where a day nurse gave the off-going night nurse a hard time for not getting the patient to sign their consent for a surgery/procedure scheduled for that day.

The daytime nurses have been FILLING OUT THE FORM for the physician, plus getting the patient to sign it!!!

I backed up the night nurse 100% on this matter. I would have NO way of knowing what procedure the physician discussed (if any) and what risks/benefits (if any) were discussed, etc., if I wasn't in the room at the time of the discussion AND the physician wasn't the one to fill out the consent form that lists the procedure and the risks/benefits of that procedure!

If the physician has filled out the form and listed the procedure and the risks/benefits in the space provided, I have no problem verifying with the patient that they understand the procedure / risks / benefits, they don't have any additional questions, and they are agreeing to the procedure -- I'm fine with witnessing to that. But I'm not going to fill out a form and just ASSUME that the physician has done all the teaching associated with it. Nope.

Nope, it's against the law, nurses do NOT obtain consent, they are only allowed to witness it. You ate correct.

[RNOTODAY, BSN, RN]

The expectation of every BON I've been licensed by is that a nurse's professional responsibility when "witnessing" consent is to confirm that consent has actually occurred (that the patient understands the procedure and agrees to the procedure without further questions). This same scenario came up at one place I worked; the facility policy was that the witness was only witness the actual signature, this was put to the state's BON who replied that no facility policy can reduce a nurse's professional responsibility, and they considered failing to confirm actual consent to be a violation of their license.

You are misunderstanding. Half the surgical consents are signed in the surgeons office @ the time of booking the case-// by a MA usually.... as an RN our responsibility is to ensure the document ( consent) EXISTS, and has been signed by PT and md...