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Informed consent: what, when, who--2/8 Ed Memo
The patient is in the middle of a Persantine thallium stress test. The doctor asks him to sign a consent form. The patient reads it, sees "death" as a possible result, and freaks out. Only after much heated, frantic discussion does the test proceed.
Impossible? Not at all; I know the patient in this case. When he complained that he should have been told of the risks before the test began, the doctor apologized and said that the nurse in the nuclear medicine department should have had him sign the paper before the test started. "No," the patient said, "you should have explained it to me in the office before we even scheduled the test."
The patient was right, of course. And the doctor almost admitted as much when he called his office and told his assistant to lay in a supply of the consent forms for a Persantine stress test.
That's great if the doctor will take the time to thoroughly review the procedure with the patient when he's in the office. But I'm willing to bet he won't.
How often do you provide a thorough explanation of every test you order for your patients? Or every procedure you're going to perform?
I mean a really thorough explanation, even down to acknowledging that death could be a consequence?
Patients need to know what to expect when they go in for a test or procedureincluding even such minor details as whether the room will be cold or what kind of sounds an MRI scanner makes. It gives them a certain level of comfort, a certain feeling of control.
You may worry about scaring them, running the risk that they won't have the test or procedure at all. I think that risk is slim. In fact, I think that many patients will be more scared if they don't know what to expect.
I had a phone call just yesterday from a man who used to work in our building. He, too, as it happens, is scheduled for a stress thallium (plain, no Persantine). He couldn't quite remember the name of the test, but knew it involved a radioisotope and was worried. "What do they mean 'radioisotope'; isn't that dangerous? Nuclear radiation and all. Won't I get sick from it?"
I explained what the test is and how it works and the sequence in which things happen. This was all news to him. He says his doctor "doesn't explain stuff." Happy that he now knows what to expect, and that the test is, in fact, quite safe, he'll show up for a study that could save his life. And he'll show up confident and unafraid.
In the informed consent process, it may help to think of your patients as athletes getting ready for a competition. Athletes typically prepare mentally as well as physically. They get their head in the right place; some even visualize the entire race or game, plotting strategies or reactions to different circumstances.
Many patients face medical tests and procedures the same way. And they see you, their doctor, as the coach. Training them, preparing them for what they need to get through successfully. They want you giving them the pre-game talk telling them what to expect out there and how to get through it. You, not the ball boy or the trainer or even the assistant coach.
Getting informed consent is your legal responsibility, true. But it's also your best way of building patients' confidence and trust. If they know they'll get the facts, from you, and spelled out completely and realistically, they'll be ready for the news that comes at the end of the test or procedure and more willing to proceed with the next steps in their medical care.
Informed consent: What, when, who? As much as possible, in the office at the time you make the referral for the test or procedure, YOU.
Marianne Mattera. Memo from the Editor: Informed consent: What, when, who. Medical Economics 2002;3:7.