informed consent

Home Health Columnist / Guide · Aug 31, 2002

Google searchlink results:

http://www.google.com/search?hl=en&ie=UTF-8&oe=UTF-8&q=standards+of+practise+for+obtaining+operative+consent+and%2For+informed+consent&btnG=Google+Search

fedupnurse · Aug 31, 2002

I know in NJ nurses witness consents. We are only witnessing the signature, not that the patient understands what they were told.

shannonRN, BSN, RN · Aug 31, 2002

Originally posted by fedupnurse
We are only witnessing the signature, not that the patient understands what they were told.

that is also what i was taught here in IN.

ageless · Sep 1, 2002

Unfortunately, the URL listed did not work. I have done searches on all the major search engines, but have not found a national standard of practise. I was taught the same as the above posters, but now must defend that position. Please continue to post. I really need the help..

Nurse Ratched, RN · Sep 1, 2002

Originally posted by fedupnurse
I know in NJ nurses witness consents. We are only witnessing the signature, not that the patient understands what they were told.

Interesting. I have always wondered about the patients who come to our unit having signed a "voluntary" form for admission to a psych floor, who clearly had impaired ability or no ability to understand the form. I wonder if the nurse who witnesses the signature in the ER is doing just that - witnessing the signature. I wonder about the legality of allowing someone who is demented or with a BA of 375 to sign a legal document. This is not for surgical procedures, obviously, but once the voluntary is signed, if the person sobers up and wants to leave AMA, then he has to go through that process and the MD can keep him against his will.

Going through the hassle of a 72 hour hold is more time-consuming, but it would put us on more solid legal footing. Any thoughts?

sjoe · Sep 1, 2002

You're right, Ratched.

And when you think about it, consent for many surgical and medical procedures is anything but "informed," when the signer has never seen what this procedure looks like and often has no realistic idea about just how much it will hurt, how long they will be significantly inconvenienced, or just what the risks and after-affects REALLY are.

Not to mention the fact that many of these signatures are obtained AFTER the initial sedation, when the person is on the gurney and on the way to the OR. Or scared spitless (hardly "voluntary").

It makes the lawyers happier, though, however unrealistic ICs actually are in practice. Guess who would be blamed if the patient later protests? "What, nurse, you mean you didn't make sure the patient completely understood everything about this before you allowed him/her to sign? You didn't make sure the patient was competent and informed? You didn't refer this matter back to the MD for further patient education before the signature? And YOU witnessed it?"

ageless · Sep 1, 2002

No need to guess who is getting blamed...nurses! Its happening all over the country.

nimbex, RN · Sep 1, 2002

Per AMA guidelines... hope this helps, it IS NOT IN NURSING SCOPE... we are witnesses

Informed Consent

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Informed Consent

Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention.

In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:

The patient's diagnosis, if known;

The nature and purpose of a proposed treatment or procedure;

The risks and benefits of a proposed treatment or procedure;

Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);

The risks and benefits of the alternative treatment or procedure; and

The risks and benefits of not receiving or undergoing a treatment or procedure.

In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.

This communications process, or a variation thereof, is both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states. (For more information about ethical obligations, see the AMA's Code of Medical Ethics, contained in the AMA PolicyFinder. Providing the patient relevant information has long been a physician's ethical obligation, but the legal concept of informed consent itself is recent.

The first case defining informed consent appeared in the late 1950's. Earlier consent cases were based in the tort of battery, under which liability is imposed for unpermitted touching. Though battery claims occasionally occur when treatment is provided without consent, most consent cases generally center around whether the consent was "informed", i.e., whether the patient was given sufficient information to make a decision regarding his or her body and health care. Because informed consent claims, unlike battery claims, are based in negligence, they generally are covered by Liability Insurance.

To protect yourself in litigation, in addition to carrying adequate liability insurance, it is important that the communications process itself be documented. Good documentation can serve as evidence in a court of the law that the process indeed took place. A timely and thorough documentation in the patient's chart by the physician providing the treatment and/or performing the procedure can be a strong piece of evidence that the physician engaged the patient in an appropriate discussion. A well-designed, signed informed consent form may also be useful, but an overly broad or highly detailed form actually can work against you. Forms that serve mainly to satisfy all legal requirements (stating for example that "all material risks have been explained to me") may not preclude a patient from asserting that the actual disclosure did not include risks that the patient unfortunately discovered after treatment. At the other extreme, listing all of the risks may not be wise either. A comprehensive listing will be difficult for the patient to understand and any omission from the list will likely be presumed undisclosed. If you are using a form that contains a list, consider, with your attorney, inserting language indicating that the list is not exclusive (such as "included, but not limited to") before the list begins.

Again, this is general knowledge you can use when you ask for further information and advice from qualified attorneys and/or other professional consultants. If you need a referral to a qualified attorney, please contact the AMA Solutions ConsultingLink/Doctors Advisory Network, a national network of pre-screened health care consultants and attorneys. When you reach the AMA Solutions homepage, go to "PracticeLink", then to "ConsultingLink", and then choose "Doctors Advisory Network Attorneys."

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nimbex, RN · Sep 1, 2002

Forgot to mention... as patient advocates.... we generally assure that patients understand the basics of what they are signing and alert the MD's if the patients questions are not aleviated with nursing teaching prior to the proceedure. If the MD follows the above AMA guidelines and nursing teaching supports this... I'm at a loss as to where law suits come about...

Because law suits are initiated, does not mean nursing is at fault... It seems to be sue first, ask questions later... sad...sad Hope the AMA link helps

joannep · Sep 2, 2002

Originally posted by sjoe

Not to mention the fact that many of these signatures are obtained AFTER the initial sedation, when the person is on the gurney and on the way to the OR. Or scared spitless (hardly "voluntary").

I am disturbed about the wording of the above quote. Are you personally aware of a signature that has been obtained after a person has been sedated?

I don't know what other perioperative nurses think regarding this. In Australia the Scout & Scrub RN's in the OR (and we are fully RN staffed in the OR, no instrument techs) are required to sight the consent before allowing the procedure to commence. If a consent was not legally obtained we could be involved in a law suite. Not a nice thought.

In 16 years of working in the OR I have never seen a procedure performed where there has been no valid consent. If the patient was sedated with no consent on arrival to the OR, the checking in procedure would quickly determine the lack of consent and the procedure would not be performed until a valid consent was obtained, which would involve a period of time allowing for the effects of sedation to pass.

I am not saying it could not happen, I am just saying I have never seen it happen, and that it could, is just too horrible a thought.

Joanne

sjoe · Sep 2, 2002

joannep: One word "routinely." Usually signed in med-surg or in the ER. How do you know it is not done the same way in Australia?

And since this passes for "valid consent," who in the OR would know any different? They just see the signature, or scrawl.

"Scout and Scrub." I like that. Sounds as though surgery is taking place in the Outback, where the patient first has to be located, run down, and then have the dirt removed with a stiff brush.