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 obtain 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 of 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 of 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 over 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
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