Terry O’Kelly is a Consultant General Surgeon in Aberdeen and a part-time Senior Medical Officer with the Scottish Government.
He is also a member of the Consent review task and finish group who have helped redraft the GMC’s guidance for doctors on consent ahead of consultation in 2018.
This is my first blog and writing it coincided with me giving a lecture to our medical students on the principles of surgery, which covers key issues including consent. My lecture and this blog is a pretty honest account of my practice. It also reflects a personal wish to never hear a patient express regret about their treatment and the choices they’ve made. Patients can be disappointed by a less than perfect outcome but they should never be regretful.
The changing doctor-patient relationship
During the lecture, which I have given for almost 20 years, I show a still from a popular 1950s film, Doctor in the House, to illustrate an era when patients accepted that ‘doctor knows best’. The second image, of a mother and her child, Nadine Montgomery and son, emphasises that society has changed and patient expectations are now very different.
The Montgomery judgement brought case law into line with existing GMC consent guidance and, importantly, made it clear that discussing risk with a patient is not about bombarding them with information covering every conceivable risk. It is about having a meaningful, clear conversation and coming to a shared decision.
Both a personalised approach and shared decision making are crucial in gaining consent for treatment. But what does this mean in my clinical practice?
Empowering patients to make informed choices
Acquiring consent must be viewed as an inclusive and evolving process that requires discussion with patients about the treatment options available to them (including no treatment) as well as relevant risks and benefits.
I find that asking these two questions is very helpful: what is important to you? and what do you want?
I think these are empowering for patients and give them permission to voice their own opinions and concerns. The answers can be surprising and may require further questioning, but if a patient has appropriate information and understanding, then their opinions and decision must be respected.
I am currently caring for two patients who have declined surgery for treatable bowel cancer. In both cases, understanding has been checked using a technique called teach-back – asking the patient to recount information in their own words and discussions have been carefully recorded. I have also encouraged patients or a family member to record conversations on mobile devices; and one patient also wrote down their thoughts using a modified version of ‘request for treatment’ (treatment in this case being ‘watchful waiting’). Their decision and subsequent course might not be the one I would choose but I am very respectful of their wishes.
Clearly, these discussions take time and can require more than one consultation to allow for reflection. Assistance from other clinicians, such as specialist nurses, can also be very helpful and providing appropriate information is crucial. Fundamentally though, time must be made available and we have a responsibility to ensure it is. Would we expect any less if we or a family member was the patient?
Adapting conversations to the situation
Having a meaningful, clear conversation and coming to a shared decision also applies to patients who present as emergencies. Here, the style and nature of the conversation might be different but it is important that it occurs.
In my practice very few emergency patients are whisked straight to theatre and few decisions are made without me being involved. One example I described to the students was that of a relatively young woman who recently presented with established large bowel obstruction.
Breaking the news to the patient was understandably difficult but we quickly engaged in a conversation about what to do. It was clear she wanted her cancer to be resected but wished to avoid formation of a stoma if at all possible. We discussed possible harms and agreed that I would assess ‘risk of harm’ at the time of surgery and would restore intestinal continuity provided I thought this was acceptable. Our conversation and use of key questions allowed her care to move forward in the way she wished and we both understood the permission she had given me.
Supporting those with specific needs
In my practice I do not come across many patients who do not speak English as a first language. However, when language is an issue I find discussions about consent challenging. Again, time must be put aside and thought given to the best source of language support. I ask for assistance with this. Relatives can be helpful but caution is needed to ensure accuracy of translation and that the patient’s real wishes are reported.
Impaired capacity presents further challenges and highlights the importance of the clinical team. Interaction with the patient by members of the team identifies a potential issue and tests of cognition can help but my test is can I have a meaningful discussion or communicate purposefully with the person in front of me?
If not, then involving relatives and carers is crucial and enlisting the help of colleagues from relevant disciplines, is very important. I view management of a patient who lacks capacity in the same way that I view management of a patient with organ dysfunction such as renal failure. If there is a problem that cannot be easily resolved then I need help from a colleague with the right expertise.
Working in partnership with patients
Much has changed in the time that I have practised medicine but the fundamental relationship I try to establish with my patients remains the same. This is a partnership based on openness, trust and communication. Gaining a better understanding of the needs of patients as well as the factors necessary to help them make decisions strengthens that partnership.
The GMC is currently reviewing its guidance for doctors on consent. You can give your views on the redrafted document during the public consultation, which is due to launch in spring 2018. Find out more here.
Improving medical education and practice across the UK 
What if the patient insists on choosing a treatment for a condition against professional recommendations in situations when risks of treatment is far far higher than risks from the condition? Especially when treatment is to prevent a serious event in future but the likelihood of the serious event is 100 fold less than the risks of treatment.
Surgical consent is still disempowering patients. My personal experience with surgical consent is that it left me feeling stressed and worried about what was going to happen. Especially as I would be unconscious during the operation – both unaware of what was happening, and unable to make my wishes known.
(1) At the time consent is taken, there is not enough time to read the 2-page document carefully and digest what it means and think through what should be in it. You hesitate to ask about the consent again if you’ve had second thoughts. I spoke to a patient who knew she’d made the wrong decision the moment she’d signed the consent form, but thought she could not reverse the decision. Patients are not invited to come back on the decision, or as Ikea says ‘It’s OK to change your mind’.
(2) Few patients actually get asked what is most important for them around the operation, or what they worry about most. Putting these issues on the consent form would be very helpful to patients.
(3) The form states that there is no guarantee that a particular surgeon will perform the operation. This makes the patient worry, * Could anyone just walk in and do the operation? * Would I even know someone else had done the operation? * What is their level of experience and supervision? * Can I ask that the consultant with whom I have discussed this operation does it themselves? * If I question this, will that be perceived as an expression of distrust against the surgeon?
(4) The form states the type of operation, but often not other things that are important to the patient – e.g. what to avoid if possible (such as stoma formation, blood transfusion, power morcellation, certain access options). The patient worries whether these wishes will be taken into account, especially if the consent discussion happens a few days before the operation.
There is a lot that can be improved about consent. Perhaps the GMC should commission research asking surgical patients what is most important around consent, what might be missing, and how it could be improved.
Couldn’t agree with you more! I say to all patients, that a. The consultation is for exchange of information. Recommendation is professional but decision is solely patients. B. A cooling off period of 2 weeks c. Our availability to answer any other questions by patients till the moment they are anaesthetised.
Our duty is to tell the patient accurate and up-to-date information and it is for the patient to make the decision (as long as patient is compos mentis). document clearly in the notes and let the patient decide. If I strongly feel it is against patient’s best interest, I would decide not to give the treatment and refer the patient back to his/her GP and/or to a consultant of patient’s choice.