Procedural Consent Problems

[bubblern90]

Hi all- I'm new to the hospital I'm currently working at in CA and I've had an issue with the way this place does next of kin consents. A lot of the doctors will call a family member on their own time, then put in an order for RN to get consent, at which point it is then the nurse's job to call the NOK and ask them that the MD spoke to them about surgery and if they have any questions and then have a second RN there to verify. I got in some trouble because I didn't feel like this was adequate consenting as I wouldn't know the appropriate questions to ask or answers to expect to ensure NOK knows the risks/ benefits/ other options and it feels wrong to put my name on a legally binding document saying I was witness to something I wasn't present for. I got a lot of heat from the House Sup and Charge Nurse telling me I couldn't refuse to do it and them going to other nurses and asking them how they do it to "prove" it's okay. I just want to know am I out of line or saving my license? Thanks!

[klone, MSN, RN]

I'm confused. If it's all being done over the phone, and the NOK isn't actually signing anything, what exactly are YOU signing, and why can't the physician do it at the time they speak to the family member?

Also, what exactly is this consent FOR?

[bubblern90]

Nurses are supposed to sign as a witness to the informed consent. I've come across this issue twice now one for OR for an ex lap and one for an EGD. I have no idea why the doc can't do it, as the House Sup told me: "that's how we do things here".

[chare]

bubblern90 said:

Nurses are supposed to sign as a witness to the informed consent. ...

During the consent process the physician should discuss the following:

1. The nature of the procedure.
2. The risks and benefits and the procedure.
3. Reasonable alternatives
4. Risks and benefits of alternatives, and.
5. Assessment of the patient's understanding of elements 1 through 4.

When the nurse witnesses the consent it is her or his responsibility to verify that the provider discussed items 1 - 4, then ask if they understood or have any questions. 

 Informed Consent

[Nurse Beth, MSN]

Technically witnessing a consent simply means witnessing a signature. Follow your facility's policy regarding obtaining consent.

[bubblern90]

The problem is that I'm not witnessing a signature because it's interactions done over the phone. The nurse signature on the consent paperwork is essentially a stand in for the patient or NOK signature. The charge nurse told me I'm supposed to call family ask them if the procedure was explained and if they say yes then I'm supposed to sign saying informed consent was provided despite myself not being present for the conversation between NOK and the MD 

[JKL33]

bubblern90 said:

The problem is that I'm not witnessing a signature because it's interactions done over the phone. The nurse signature on the consent paperwork is essentially a stand in for the patient or NOK signature.

Sorry to split hairs, but it matters:

Are you saying:

1. Simply that you didn't witness the conversation between the physician and NOK, but that the NOK is there to sign the form?

OR

2. That neither the physician nor the NOK is present and you are simply informed that a conversation has taken place and you are to basically fill out the consent form in a way that accounts for BOTH the NOK signature and your "witness" signature?

 

If #1 >> I always handled this by asking whether the conversation happened and included the items mentioned by @chare above, if so >> NOK signs form and I sign on the witness line and (personally I chose to write next to my signature) "witness to signature only"

If #2 >> There is zero reason that the physician who obtained the consent can't do PRECISELY the steps that you are being asked to do. They can have the form their and write "phone consent obtained" on the NOK signature line and sign it. The end. Having a nurse fill out the form as a "witness" who witnessed absolutely nothing about this is NOT buying that facility any additional legal protections, no matter what so-and-so administrator might like to pretend.  This is probably a simple matter of them not being willing to make the physician deal with a piece of paper.

[JKL33]

bubblern90 said:

A lot of the doctors will call a family member on their own time, then put in an order for RN to get consent

Also as a side note, we (nurses) generally need to tighten up the verbiage we use about all of this.  We are NOT "getting consent."

The one who wants to perform the procedure is the one who legally needs to get/obtain the consent. They do this through the informed consent conversation. This is only done by the proceduralist/surgeon, NOT the nurse.

We should describe our part in it as "making sure the consent forms are signed," not as "getting consent."

??

[LibraSunCNM, BSN, MSN, CNM]

bubblern90 said:

The problem is that I'm not witnessing a signature because it's interactions done over the phone. The nurse signature on the consent paperwork is essentially a stand in for the patient or NOK signature. The charge nurse told me I'm supposed to call family ask them if the procedure was explained and if they say yes then I'm supposed to sign saying informed consent was provided despite myself not being present for the conversation between NOK and the MD 

In today's episode of "weird s*** that happens in health care"...Jeez.  That is not OK.

[JKL33]

chare said:

When the nurse witnesses the consent it is her or his responsibility to verify that the provider discussed items 1 - 4, then ask if they understood or have any questions. 

My only issue with that concept was always that I couldn't really "verify" any of that, either, or the general content/appropriateness of the conversation. Classic example - worked in small place where THE (one and only) general surgeon did everything as open procedures. Do you know how many consent forms I've been asked to have people sign where I know full well that they were not told of the "alternative" that everywhere but right here this would be a laparoscopic surgery? Since you're not dying you might want to know that 40 miles down the road no one is going to cut you open for this?

Easy to get into the weeds with nurses' role in the consent process. I feel like my concerns (above) were a bit in the weeds...and eventually I just felt better by saying "I understand the physician has spoken with you about the proposed procedure?" >>> make sure their basic description of what is going to happen generally matches what is on the procedure line, ask if their questions were answered to their satisfaction, and have them sign the form, with me witnessing their signature.

Otherwise, if my signature was meant to ensure anything more than that, I really would've had to be there for the conversation itself. In which case....how about the person who had the conversation just sign the form.

ETA: I do admit that bringing the nurse (or any second person who is not the proceduralist)  into the scenario does somewhat prevent a situation where the physician didn't have any conversation at all. It does at least "verify" that something was said about this and the person understands that surgery is recommended and agrees to undergo surgery...

[bubblern90]

JKL33 said:

Sorry to split hairs, but it matters:

Are you saying:

1. Simply that you didn't witness the conversation between the physician and NOK, but that the NOK is there to sign the form?

OR

2. That neither the physician nor the NOK is present and you are simply informed that a conversation has taken place and you are to basically fill out the consent form in a way that accounts for BOTH the NOK signature and your "witness" signature?

 

If #1 >> I always handled this by asking whether the conversation happened and included the items mentioned by @chare above, if so >> NOK signs form and I sign on the witness line and (personally I chose to write next to my signature) "witness to signature only"

If #2 >> There is zero reason that the physician who obtained the consent can't do PRECISELY the steps that you are being asked to do. They can have the form their and write "phone consent obtained" on the NOK signature line and sign it. The end. Having a nurse fill out the form as a "witness" who witnessed absolutely nothing about this is NOT buying that facility any additional legal protections, no matter what so-and-so administrator might like to pretend.  This is probably a simple matter of them not being willing to make the physician deal with a piece of paper.

The second option you laid out most accurately describes. Neither the MD or the NOK are in person at the time of when nursing is supposed to call and ask if they have been consented by the MD. 

[klone, MSN, RN]

Nurse Beth said:

Technically witnessing a consent simply means witnessing a signature. Follow your facility's policy regarding obtaining consent.

But there is no signature. They're doing it over the phone.