Informed Consent

The Age of <>Consent
by Charlotte Huff September 18, 1998

Three-fourths of surgical consent forms require at least a high school education if patients are going to scribble an informed signature on the dotted line. And given patients’ state of mind before surgery, that level of complexity can be too much. That’s according to a computer analysis of consent forms published in May in the journal Surgery.

The study highlighted a process that’s as complex as it is commonplace for healthcare providers on the front lines. Obtaining informed consent is the legal obligation of the treating practitioner—generally a physician. But the rapid-fire pace of health care, combined with a sicker and more ethnically diverse population, means that questions and gaps in understanding may emerge soon after the physician leaves the room, say several clinicians. "Some physicians think it’s just getting a piece of paper signed, and they absolve themselves of involvement in the educational process," said Susan Murphy, JD, RN, a San Antonio-based medical malpractice attorney and author of the Legal Handbook for Texas Nurses.

And patients don’t necessarily understand the paperwork, said the study’s author, Kenneth Hopper, MD, and his colleagues, who requested forms for surgical or invasive procedures from 10 percent of U.S. hospitals. Thirty-one percent responded, but not all provided forms, leaving 616 to analyze in detail. Twenty-four percent required at least an eighth-grade reading level, 75 percent a high school education, and 9 percent at least a college degree, according to a computerized test of reading difficulty. One demanded 30 years of book learning.

Just another paper
From the patient’s side of the bedrail, the consent form looks like just one more piece in a stack of paperwork, said Mary Lynne Weemering, MSN, RN, director of surgical services at Pomona Valley Hospital Medical Center in Pomona,Calif. "By the time they get through the whereases and the therebys, it’s difficult for a patient to grasp," she said. "I think a lot of people sign the consent because they know all the legalese has to be done."

Gauging understanding can sometimes be difficult since patients don’t tend to admit confusion, said Vicki Fox, NP, RN, an acute care nurse practitioner based in Tyler. "You have to take their word for it. Do you know they understand it?"
By the time the consent form is presented, the physician and patient should have already discussed the risks and benefits of the procedure, Murphy said. The nurse’s role is considered administrative, witnessing the actual signature. Murphy said nurses are generally expected to consider three items—the identity of the patient, the voluntary nature of the signature, and the patient’s ability to understand what he or she is signing.

The trouble with comprehension
It’s that last item that most troubles nurses, said Murphy, especially when they aren’t nearby for the vital physician-patient conversation. "Every patient already has some misgivings about procedures," she said. "If a patient has a question, does that mean the patient can’t sign a consent form? I don’t think so."

The potentially life-threatening situations at stake can encourage clinicians to construct a verbal wall, said Cindy Hylton Rushton, DNSc, RN, FAAN, assistant professor and clinical nurse specialist in ethics at Johns Hopkins University School of Nursing in Baltimore. "It’s more comfortable to get behind our jargon and reduce the encounter to the giving of information and getting permission rather than engaging in a really meaningful dialogue."

Fill in the blank
Hopper prefers consent forms with blanks that the physician fills in, listing risks and other information appropriate for the patient’s surgery. But understandable language is still crucial, Fox warns. "Most surgical procedures are seven-syllable words. Basically what patients want to know is that their gallbladder is being taken out and what does that mean."
Tag teaming helps the process run, said Fox, who worked with a general surgeon for nearly a decade. She remained nearby while the physician explained the procedure. "After the surgeon left, I would translate it," Fox said. "That was to reinforce and supplement the information the surgeon gave."

??? When in Doubt ???
If you have any doubts about the patient’s consent, start asking questions, "From a legal perspective, the nurse’s role is pretty limited. From an ethical perspective, the nurse’s obligations go beyond merely verifying the person’s signature on the consent form," said Cindy Hylton Rushton, DNSc, RN, FAAN, assistant professor and clinical nurse specialist in ethics at Johns Hopkins University School of Nursing in Baltimore.

+ Nurses who weren’t nearby during the physician-patient conference may be uneasy about probing, but Rushton suggested they toss out open-ended questions. Ask patients to recap what the physician said. Delve into whether any specific information would help the patient feel more comfortable about the procedure.

+ The shift toward more outpatient surgery means the consent process can be split, with the physician explaining the procedure several days before in his or her office. That can be too far ahead for the form to be legally signed, said Richard Pessagno, MSN, RN, a senior policy analyst at the American Nurses Association department of nursing practice. By surgery day, significant questions can arise.