Informed Consent R Jane McKay Informed Consent Consent why and - - PDF document

Informed Consent

R Jane McKay

Informed Consent

Consent –why and when do we

need it ?

Patient Autonomy

All individuals have right to

determine what is done to them

Treatment is much broader than “

surgery” –involves IM

Consent Lecture

What is your role as a physician

Role is to give good sound

medical advice

Understand the procedures or

treatments being done

Be able to communicate this

information to the patient in a way they understand

Clarify and document the

understanding .

Consent Lecture

What can happen when consent

goes wrong ?

Negligence , patient harm Assault and battery legal action

against physicians occur if consent not valid

Please see CMPA site on consent

Consent Lecture

Ms Smith is a 90 yo female

referred to you by the emergency room physician for cough fever and shortness of breath . Do you need consent to do a history ?

Types of Consent

Implied and Expressed consent

Most patient care in our lives as

internists involves implied consent

The patient implies by coming to

the hospital they want help and are implying consent by asking

You don’t have to ask consent for

hx px. ( be careful pelvic , breast exams –ask )

Expressed Consent

Expressed consent is sought

whenever you plan to do anything to a patient that is painful , has risk or involves a procedure .

The patient EXPRESSES

CONSENT

It can be verbal or written

What are the requirements for valid consent ?

Ms Smith is a 95 year old

female with a MMSE of 13 was admitted with pneumonia . She is increasingly SOB with a para pneumonic effusion .Your team decides she needs a thoracentesis for diagnosis and drainage . Hoe do you plan to

• btain consent ?

Three necessary elements for valid consent ?

Voluntary Capacity Proper information

Three elements of consent

Voluntary – No Coersion of pt Capacity must be capable of making

a decision –important in elderly

Proper information- risks and

benefits explained to patient in an understandable format

What do you do in an Emergency ?

If a pt arrives needing life saving

treatment and they cannot speak for themselves and no health delegate is available you have the duty to treat the patient

Treatment refusal -

Ms Welsh is a 25 yo female with

MRSA endocarditis. The RN calls saying she wants to leave .

What is your role ?

Treatment refusal

Patients if capable have the

right to refuse treatment . Your job is to have risk benefits conversation with patient and document your discussion.

Do you know the consequences

• f not treating endocarditis ?

Documentation of Consent

To document

Treatments such as blood

transfusion require a specific consent

Do you know the risks and

benefits of transfusion ?

Common internal medicine procedures and consent

You are an R1 on call for the

ICU and you are asked to see a patient in septic shock . Her BP is 70/40 HR 110 and she is not responding to fluid .

You need a central line .

Outline your consent discussion ?

CVC Line complications

What can go wrong with a

central line insertion ?

Mechanical Infectious Thrombotic complications

Mechanical Complications of CVC Insertion

There are lots :

Arterial puncture ,

hematoma,pneumothorax

Try to avoid femoral line – lots of

mechanical complications

Pneumothorax highest w subclavian

lines

IJ – arterial puncture common

How to Decrease risk of mechanical complications

• 1. Recognise the difficult line pt
• 2. 50 lines or > : 50 % less

complication

• 3. Use and US guidance

technique

• 4. try to avoid femoral lines

Infectious Complications CVC

Catheter related infection occur

1.2/1000 subclavian 4.5/1000 femoral Antibiotic ointments at skin site

don’t help .

How to avoid infections of CVC

Subclavian site lowest infectious

rate

Sterile technique Abx impregnatned lines ?

Available

ICU Procedure References

The ICU book

Paul L Marino

NEJM Video series Try Up to date Articles NEJM March 20, 2003

348;12 – CVC

Consent

Ms Smith is a 60 yo female with

ESLD and cognitive impairment she presents with new ascites causing SOB . You decide she needs a paracentesis . Outline your consent discussion ?

Consent -capability

There are 2 features to the

consent

Capability

Is the patient to make a decision

How do you decide ?

Who do you ask for help with in

deciding capability ?

Consent – Ascites

What are the risks and benefits

• f paracetesis you will outline to

the TSDM ?

What are the complications of paracentesis

Ascitic Fluid leak

5 % usually if no Z track approach

done , large needle , large skin incision

To manage place an ostomy bag

• ver the leak

What are the complications of paracentesis

Bleeding occurs if a vessel is hit Bowel perforation

6/1000 taps

Rarely mortality – 0.16-0.32 %

Consent

Ms smith is a 27 yo female with

fever chills and a stiff neck . You need to do an LP looking for infection . The CT head is normal .

Outline your brief consent

discussion

What are the complications of LP

Post LP headache – 10-30 %

Csf leak from dura and traction

injury

Frontal ,occipital headache within

24-48 hr . May have nausea ,vomiting , dizziness tinnitis

What are the complications of LP

Backache -25% Radicular pain 15 % If on anticoagulants maybe

consider not doing LP

Hematoma and spinal injury UPTODATE –good reference

Consent

75 yr old male presents with hot

swollen red joint similar to his last gout flare . You decide to do an tap and steroid injection of the jt.

Outline your consent

discussion?

Consent

Joint Injection w Steroid

Decrease weight bearing x 48 hr Can apply ice to jt Post injection flare ( 20 % ) Flushing post steroid injection Leakage of jt fluid , infection –rare

Document of Consent

A note in the chart post

procedure is necessary outlining the consent and discussion had with the pt.

Ask staff if consent form needed