(Truly) Informed Consent

Andrea Perreault BSN RN

He arrived the way they always do, flat on his back behind the bars of the bedrails, one leg tied to a ten-pound sandbag that dangled over the end of his bed like a fishing buoy. Not surprisingly, Mr. H's first words were about the frigid temperature in the Operating Room. I tucked heated blankets around him and my colleagues and I began our routine.

When patients arrive in the OR I jokingly ask them if they feel like they're at the center of a pit crew, but in many ways they are. OR time is expensive, often thousands of dollars per minute. OR time is for surgery, and non-surgical minutes are to be minimized.

The clock starts when the patient rolls through the door. The patient is moved to the OR table, and monitors are quickly applied. Induction of anesthesia begins while the surgeon hovers with a level of impatience that varies by the doctor and the day. The moment the anesthesia provider gives the OK the team begins positioning the patient for surgery. Heated blankets are whisked off, body parts are shuffled into the correct configuration, pressure points padded, alignment checked, safety straps applied, plastic warming blanket slid into place, surgical area prepped, surgical drapes placed, and the incision is made. Throughout it all, we are aware of the minutes we are spending.

When inpatients come for surgery, such as Mr. H. with his fractured hip, I don't have an opportunity to meet them in advance. That means I use OR time to determine whether the patient has provided informed consent. I need to make sure the patient knows what kind of surgery they are about to have, why they're having it, and what could go wrong. It sounds straightforward, but it's not.

Many hip fracture patients are elderly and possibly medically fragile but live independently until they fall and break their hip. In the hospital, the mix of pain medication and sleep deprivation can cause confusion. They arrive in the OR not knowing why they're there, with a surgical consent signed by a relative to whom the patient never gave permission for decision-making. Here's where it gets tricky. A hip fracture is not a life-threatening injury, so an appropriately signed consent is required. Additionally, not having surgery for certain hip fractures increases the risk of life-threatening complications, especially if the patient has other health problems. It can be easy for the surgical team to accept the signed consent form at face value and do what seems best for the patient, without giving too much worry to who signed it.

So when I asked Mr. H. about his understanding of his imminent operation and he replied that he wasn't really sure what was going on, nobody missed a beat. EKG electrodes were affixed to his chest and a blood pressure cord was unwound. I was not surprised by his answer, but stood still and pressed him for a little more. Had he hurt his hip? Yes, Mr. H. knew that he had broken his hip, but he wasn't sure that he wanted surgery. He wanted to know what his options were. There was a soft tearing of Velcro and a blood pressure cuff was plunked on the bed in front of me, but I stood still. This man was not confused. He was capable of making an informed decision, and he needed to be more informed.

His surgeon was in the corner of the room. I asked him to come speak with Mr. H. as buttons were jabbed on the anesthesia monitor and a pulse oximeter was placed on Mr. H.’s opposite hand. I raised the head of Mr. H.’s bed a little so that he could better converse with his surgeon. The empty blood pressure cuff began inflating on the bed and I continued to ignore it as Mr. H. started his story.

He was from the Baltic states, but had lived in the US for the past twenty-five years. His wife had dementia and he could no longer care for her alone, so they had moved back home where he had family who could help. His house in America had sold, and he was in town for a few days to handle paperwork when he fell and broke his hip. His wife would not do well without him. He needed to get back immediately. Was surgery really necessary? How long would he be in the hospital postoperatively? Would he require rehab? How long until he could walk? What if he flew back to Europe and had surgery there?

It took a while for the gears of forward motion to cease around us. At first, his surgeon answered him cryptically, convinced that surgery was the only reasonable choice. All I did was stand still, my immobility an anchor that eventually brought everyone to stillness. The anesthesiologist reeled the blood pressure cuff back in and sat down. The surgeon realized that this man wasn't looking for an answer, but for options and the time to make a choice. They talked, and Mr. H. decided to have the operation. He said it aloud, and everyone stayed still while he sat with his statement. His face relaxed the slightest bit. When he woke up, he would still find himself in a trying situation, but he had the comfort of knowing that he had made the best choice for himself under the circumstances. Even though he had signed his paperwork with that same surgeon the night before, it was in my OR that he actually gave informed consent.

(Truly) Informed Consent

About Andrea Perreault BSN RN

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