We will start this series by exploring the consent process in medical treatment processes—a process that is relatively new to the doctor-patient relationship in India. In the United States, the informed consent is nothing less than an extreme medico-legal document–not an ideal situation either.
Well, what is the essence of an informed consent? Informed consent is a patient’s acceptance of the procedure and/or the treatment to be performed by a given doctor or a team of healthcare professionals, after being fully informed about the pros and cons of the treatment by the doctors. There is no longer room for the paternalistic doctor-patient relationship that used to exist – “Doc, we trust you, just go ahead,” is good for neither the patient nor the doctor. A patient has the right to, and should, know the salient features of any procedure or treatment.
What does a patient need to know?
I would want all my patients to ask the doctors the following questions:
1. What is the underlying problem?
2. What are my treatment options?
3. What are the risks of the treatment versus benefits?
4. What are the debilitating and/or life-threatening consequences of this treatment?
5. Is doing something better than doing nothing? Is this evidence-based? Is this the best standard of care?
6. Are you (the doctor) the appropriate person to provide this treatment?
For example, a patient undergoing an operation for colon cancer should know that a small percentage of patients will develop a ‘leak’ if the bowel edges do not heal. This could lead to severe infections and complications that could jeopardise the patient’s life. However, surgery offers the best chance of cure for colon cancer that has not spread outside the colon.
There is a lot to ask and talk about regarding all these, and certainly as a surgeon I know that time is limited. So how do we get the appropriate information across in a limited span of time? This takes effort, understanding the patient’s level of knowledge and good insight into his/her ailment. A team of nurses, doctors and allied healthcare professionals is essential to ensure the patient is counselled appropriately. As a doctor, it is sometimes impossible to go through every single possibility. I tend to focus on common risks and consequences that could lead to severe repercussions or can be a threat to life.
Unfortunately, medicine is not predictable. The possibilities for a given patient are innumerable. “Doctor everything will be ok, right?” is a question that is human to ask, but very counter-productive to the doctor-patient relationship. Every doctor wants to answer “Yes”, and knows everyone would want to hear “yes”, but also knows that the answer is not always “Yes”. The doctor’s job is to instil confidence in the patient while maintaining realistic expectations—this is not a simple task in today’s health care and medico-legal climate.
Taking informed decision is your responsibility
What system can a hospital create, to ensure that informed consent is obtained? For a patient headed to the operating room for example, the informed consent will need to be completed by the surgical team. Usually this is the job of a nurse. A patient has to be counselled before being taken into the operating room, inform of the consequences and benefits and has to agree to be operated. You will be surprised how often it is not followed. In case there are any issues, it becomes a nightmare for all to deal with it.
Add to this elderly patients, multiple languages and busy schedules, getting an informed consent is no longer a simple part of the process. But there are some institutions that follow the procedure. At my current institution, the nurses do not let a patient into the operating room without a verified written and verbally confirmed informed consent. This is a hard stop, but is important.
In fact, one of my colleagues suggested the term “informed decision” rather than “informed consent”. The informed decision is central to a safe health care system as it sets the appropriate expectations.
So the next time you or your family members seek health care, do not be shy to ask the doctors. Focus and prioritise your questions. We may know more about science, but it is your body and it is you who choose what to do, based on the expert’s recommendation. Understand what can and cannot happen from the procedure, and take wise steps.
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All good, but you haven’t mentioned something that matters dearly to patients — the cost! India has the most privatised medical care in the world and hospitals have a opaque “package charges” for all procedures. Before you commit to a procedure, it makes sense to shop around to arrive at a price-value equation that works for you. For example, I recently paid nearly Rs 4000 for a simple sebaceous cyst removal at a private hospital in Koramangala. The CGHS rate for the same is Rs 1200. While this may not be a price available to private citizens, I couldn’t access any other benchmark easily short of calling up individual hospitals.