Informed Consent? Input needed...

[MereSanity]

OK...I just need input here. We did an Anterior Hip Replacement and the consent only said Total Hip Replacement (no indication of anterior approach). I ticked off the Dr when I asked that "Anterior" be added to the consent. His argument was either way it's a total hip replacement. Was I wrong? Is this a grey area? Did it matter? I'm pretty good at navigating consents but he had all the pre-op nurses mocking me by the end of the day. Input appreciated! Thanks!

[Rose_Queen, BSN, MSN, RN]

I very rarely see any kind of an approach listed on our consents. Lap chole vs open chole? Nope, consent reads "removal of gallbladder". Partial sternal split aortic valve replacement vs full sternotomy aortic valve replacement? Nope, just "aortic valve replacement". However, I would address your concerns with your manager as each facility's policies may vary.

[Double-Helix, BSN, RN]

The anterior approach has a smaller incision, quicker recovery, and lower risk of dislocation. It is a technique, not a procedure.

I see no reason for the approach or technique to be listed on the consent if it doesn't change the outcome. Often, the surgeon needs flexibility to choose the best plan of care intraoperatively. Even in laparoscopic procedures, there is potential to convert to an open procedure if complications arise. If the surgical technique was part of the consent and the plan changed, the surgeon would have to abort the procedure, wake up the patient, and reschedule the case after the anesthesia has worn off and new consent could be obtained.

[MereSanity]

Anterior however is supine and on a specialty table whereas a traditional hip replacement is lateral. Completely different positioning and couldn't be changed mid procedure like a chole or valve. And like it or not anterior is a laterality.

[MereSanity]

Ours always say laparoscopic possible open, never just gallbladder removal because laparoscopic and open are such different procedures (same outcome) but definitely different.

[rn&run]

Check out the CMS guidelines for informed consent: http://www.dialogmedical.com/wp-content/uploads/2016/04/CMS-Requirements-for-Consent-Webinar.pdf. It's a gray area. Short answer, check with your OR manager/director to determine whether your hospital's policy requires a distinction. Longer answer, a well-designed consent will specify the nature of the procedure specific to the patient, which would include approach, as well as any other potentially indicated procedures and any PA/SA/Resident assistance that will occur. But how often do we see that? Answer: rarely. The CMS pdf that I linked indicates 26% of the forms reviewed had all the basic components of an informed consent present. The surgeon was dumb to get ticked at you, because you were safeguarding the integrity and repute of his practice. If the patient woke up surprised by the location of the incision, or any other aspect about the procedure directly related to differences in approach, they would potentially have a leg to stand on (pun intended) in a malpractice suit.

[Double-Helix, BSN, RN]

Anterior however is supine and on a specialty table whereas a traditional hip replacement is lateral. Completely different positioning and couldn't be changed mid procedure like a chole or valve. And like it or not anterior is a laterality.

No, anterior is not a laterality. The surgeon is not not replacing the anterior hip.” The surgeon is replacing the right/left hip via an anterior approach.

[PositiveVibesRN]

Hi, I'm curious about this because I do many Ortho and Spine cases which include different approaches and see varying consent forms.

First off, KUDOS to you! You're being a vigilant patient advocate and Nurse! Similar to what was stated above, you're protecting the integrity of that surgeon's practice, as well as your license, and most importantly patient safety and advocacy. I believe it is a valid question.

Second, The "approach" of a procedure, like you said, can be a difference in patient positioning but also can have significant differences within the procedure, even if the final procedure / outcome is the same.

For example:

Ortho - Anterior Hip Replacement approach (Supine and use of Specialty Hana Table) Surgeon separates muscles to access site INSTEAD of cutting the muscle to access site like in a Posterior (Traditional, Lateral positioning) approach. That is why Anterior Approach is minimally invasive but both have the same final procedure / outcome

Consent: I have always seen it as "Right or Left Hip Replacement" I rarely see the approach on the consent. Maybe once with a "Newer Surgeon"

BUT in Spine cases: ALIF vs. DLIF / XLIF

Surgeons DO specify approach "Anterior" Lumbar Interbody Fusion vs. "Direct Lateral" IF / "Xtreme Lateral" IF on the consent form

Anterior-LIF : Risker due to the approach, especially L4-L5. Going through muscle and major vessels (Bifurcation of the great vessels) versus DLIF / XLIF (going through the side) less invasive due to cutting muscle to access site but both have the same final procedure / outcome

I would think it's comparable to Laparoscopic vs. Open. Essentially it's the same procedure / outcome, example: removing a gallbladder but how the surgeon does it, Robotic vs. Laparoscopic vs. Open is significant.

I believe everything that rn&run said is correct. Consent form should be specific and individualize but how often do we see that? As far as legal matters, direct it to your administration.

From my humble experience, I've seen very detailed consent forms vs. vague consent forms (just depends on the Surgeon) but as an OR Nurse and Patient Advocate I feel like my main priority is, is that patient well informed.

Though my consent reads "Right Hip Replacement" I will still ask the patient if everything been explain to them? I'll mention the anterior approach to see how well informed they are about the procedure. I also do Robotic Assisted (Mako) Hip Replacements and will also mention the Robot as well. I assess how informed they are and if they have any questions before proceeding. I don't answer any questions, because of course it's out of my scope of practice, but will get the Surgeon to do so. I also chart this in my charting.

This was a good blog and reminder on inform consents

Do You Understand “Informed Consent?” | Notes from the Nurses' Station

This is a great question because I am curious too. I believe everyone in the OR has a different perspective due to each individual priority. I will ask my Surgical Director, Clinical Educator, Ortho and Spine Surgeons and get back to this thread.

Also, Anterior Hip Approach vs. Posterior Hip Approach (traditional), is just that, an approach to how to do the HIP REPLACEMENT (both have final outcomes). There is no laterality other than RIGHT OR LEFT HIP. (agreeing with double-helix on that)

[RNOTODAY, BSN, RN]

The consent was correct