Time to discuss a clinical topic Section

The consent for surgery – more candour?

I consider consent, alternative treatments and impact associated with risks. The world of consent is changing.

Whenever we have surgery it is usual that a form called a consent is signed. This has been called informed consent which carries with it the implication that you actually understand what you are signing. I have been on the patient side myself and maybe there is a presumption we all understand what we are signing, but do we? I understood my consultant because it was my own field. In fact I doubt I would have done as well had I not been a health professional. How much time do we need with patients? Sometimes like today for instance a 20 minutes consultation took me 45 minutes as my patient had trouble getting to grips with the risks and effect.

As the law is changing in Scotland the consent has even less sense of confirmation that suggests we understand what has been said. I confess that I am a lousy writer so even if you understand me perhaps my writing is not that good.

“Doctors ( and other healthcare professionals – my words in brackets) must now ensure that patients are aware of any “material risks” involved in a proposed treatment, and of reasonable alternatives, following the judgment in the case Montgomery v Lanarkshire Health Board.”



So what have I been doing to bring my practise up to a better standard? Well I introduced my <strong>fact sheet 40</strong> sometime ago. You won’t get to theatre without it. The fact sheet on my webpage is the original and I have not updated this as I use quality leaflets instead now and update these at each reprint. If you want more information on published results on risk, you can go to the website for podiatrists (PASCOM-10.com) Fact sheet 40 covers up for my scribbled writing because it is legible and presented (I hope) in a way that is less jargonese. We healthcare people do like our complicated words!

So how have things changed? Well I use the consent as a part process; a receipt that says we have met and I stamp the information sheets by number that you need to read where is says ‘information’. Those facts sheets listed on the consent form give specific risks. What I feel we should now concentrate on is informing you about the impact of surgery. What does it mean to you and what could arise if a problem should occur, and how would it affect you? We look at alternatives and you should not feel pressurised to have surgery. Doing nothing is still a decision which might be best for you. The decision to proceed still must fall to you the patient by weighing up all the factors such as recovery, and what if you had a complication, could you cope? Check out the new wound sheet (49) what if a wound fails to heal how will that affect you? Some wounds can take many months to heal.

Low risk does not mean Low Impact. You may have a low risk of infection but what if you experienced a bug that ate away your flesh. This is necrotising fasciitis and it can lead to both loss of limb and death. It is low in risk thankfully but high in impact, if not to you but your kin. There is a condition called Complex pain syndrome (CRPS). It does not mean usual pain after surgery but burning pain. The risk is low, the impact is high, purely because the worst kind may not be treatable. High impact mean high cost, loss of function, inability to work again and the impact affects friends and families. High risk of course does not mean high impact. On the contrary swelling is high risk because it is frequent, but then we expect it and it may affect 20% of patients lasting for 4 -12 months before it subsides. Wounds might open up in 5-10% of cases. A modest risk and modest impact if healing takes 2 more weeks than expected.

So, when it comes to consent be sure you understand me when I say it is a low risk but high impact. If I suggest conservative treatment before surgery please listen. If I am not keen on surgery for your foot then you should not been more keen to go ahead. These new changes will affect England sooner or later. If that happens some will refuse performing surgery as it empowers the lawyers more than ever. The net effect will be fewer surgeons eventually willing to take on work with even small risks. Let’s hope that never happens.



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