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informed consent?

post #1 of 7
2/12/04 at 11:11am
Thread Starter 
can someone please explain informed consent to me?

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post #2 of 7
2/12/04 at 12:26pm
As I see it, the movement toward informed consent in the medical setting reflects ethical values that dictate that not only should a patient be able to give consent to a procedure, but that the patient should understand the major benefits and risks of that procedure before giving consent. We are by no means anywhere close to achieving full informed consent before every procedure in the medical arena.

Some examples from the obstetric field, since that is where I work.

A year ago, medical school alumni lobbied to stop what was at that time a standard part of their education -- practicing vaginal exams on unconscious pregnant women. Essentially, women who had been put under general anesthesia for surgery (like c-sections) were positioned so that the med students could repeatedly perform ve's on them for practice. This was not done with the women's permission. Because the women had not given their consent, this process was unethical.

I was at a very slow birth the other day where the mom was very calm and able to carry on a detailed conversation with the nurse anesthesitist who came in to educate her about pain options. When they were talking about epidurals, the nurse explained in detail about what getting an epidural was like, how it would affect her movement, how it would affect the baby, possible rare side effects in case of poor placement, what kind of pain relief she could expect, and the possibility of spinal headaches. That mom never did get an epidural, but if she had, I feel like she would have given true informed consent. In other situations at the same hospital, I feel like most of the time they manage to convey the most important information about anesthesia drugs, hitting the highlights about risks and benefits. In a hurried situation, sometimes this is the best you can do, but except in the most rare emergencies, I think it is necessary to convey some information about the risks and benefits of medications/procedures.

In contrast, I was at another birth a few months ago where the nurses kept on asking if the mom wanted a "little medicine in her iv" to help with the pain. There was no mention of any negative side effects, or even of the name of the drug given. In the nursing classes I am in, my professors tell me that it was routine in hospitals 10-20 years ago to refuse to tell patients what their medications were or why they were being given certain doses; patients were told to ask their doctors, who might only visit once per day. There is now more of a movement to educate patients about the drugs they are given, but my experience is that medical folk will often oversimplify or omit information if they want you to take a drug.

Informed consent can be very politicized in obstetrics. I have worked with VBAC moms who have been given multi-page documents to sign which outline the multiple risks of vaginal birth after a cesarean, but who are not given any information at all about the risks of a repeat cesarean.

Having informed consent as an ideal has helped there to be a lot of positive changes in the medical field, from the way that medical studies are conducted, to helping to virtually eliminate such things as forced or unwilling sterilization, to providing some kind of legal space for patients to refuse recommended treatment and seek alternative care. Overall, I think that its implication is a positive force and that we should move as close to universal informed consent as we can.

Hope this helps.
post #3 of 7
2/12/04 at 2:48pm
def, that was a great post! thanks for your thoughtful and experienced views on this.

as a doula, i've been pretty amazed at how wide the interpretations can be for informed consent... i've seen anesthesiologists waltz in and begin a procedure with very minimal information to the client, and i've seen doctors who will give clients all the time they need to ask their questions (but not necessarily offer information without the questions), and i've seen nurses who will go out of their way to track down answers.

i saw a doc perform AROM on a second twin, about ten minutes after the first twin was born (quickly and without incident, and twin B was monitoring well... there was no rush here!). he didn't say peep to the mom, just started the procedure. i asked what the baby's station was, and he just glared at me and asked me if i wanted to stay in the room or not! watching him, i could tell he was rooting around pretty high. this kid was nowhere near 0 station! and of course, *I* knew that AROM with a high baby, with a mom on her back, is just asking for a prolapsed cord. if he had spoken to the mom about it at all, i would have told her this. but she never had a chance to consider it, he just did it. and of course, we had a cord wash down, next contraction we had nasty decels, and he called for a crash cesarean! but a nurse, bless her, leaned over and said, "if you can, push your baby out in the next contraction and he'll be OK." and that mom DID IT! from less than 0 station to birth in one push! it was like watching someone pick up a car or something. baby was fine, but it was a scary situation that was COMPLETELY unwarranted. it really made me mad, and when the mom figured it all out later, she was pretty peeved too. (she went on to have a beautiful home birth four years later).

i guess i was naiive when i thought this was a legal definition that all practitioners had to follow! but it's a lot fuzzier than i ever knew. one good thing is that it has taught me how to be a better advocate for my clients... how to form good questions to get the most information as possible (ie, not a yes-or-no question!), and how to negotiate for time so clients can truly think about the implications of their decisions (if time is not an issue).

i'd like to think i would have the balls to say to that doc now, "please tell the mom what you are doing, so she can give you her informed consent on the procedure." i wish i'd spoken out then!

katje

(AROM=artificial rupture of membranes; station is the position of the baby's head in relation to the cervix... 0 is at the cervix, -3 is above, +3 is below)
post #4 of 7
2/12/04 at 5:39pm
Can true informed consent come from a doctor, who has a financial interest in giving drugs and performing other procedures?

In other countries, they have a flat fee for births regardless of how many interventions are used. This is not so in the U.S. I got a copy of my OB records and there was a xeroxed post-it note saying "If you manually scrape out the uterus, you can bill an extra $75."

Informed consent should ideally be explained by a truly unbiased patient advocate who is not an employee of the hospital. Maybe a doula would be able to help there.

Some hospitals still do things without telling the patients, such as injecting pitocin in an IV bag to augment labor, or breaking waters. (If your water ever broke during a vaginal exam, it probably was no accident!)

Some medical centers have a form of "implied consent," where by being a patient you have by default consented to certain medical or procedures or lab tests. HIV testing is an example, as are urine drug screens.
post #5 of 7
2/12/04 at 5:42pm
Defenstrator and SamuraiEarthMama's posts were very informative! Thank you both!

So I think I will give the shorty version: using the BRAN method
**asking**
**what are the Benefits
**what are the Risks
**what are the Alternatives
**what if we do Nothing at all)

This is great for a current situation and also great as a learning tool when thinking about interventions, nutrition, diagnostic testing, etc.

warmly,
claudia
post #6 of 7
2/12/04 at 6:08pm
Defenestrator : OMG! Med students "practicing" VE on unconscious women... that makes me ill. Tears for those poor women. I would say that is getting very close to sexual battery. I am horified, thought I had really heard it all about what is done in hospitals, but ugh. Unethical, more like illegal!
post #7 of 7
2/12/04 at 6:27pm
I forgot to respond to the med students "practicing" vaginal exams on women... this smacks of the Tuskegee syphilis research in the middle of last century. *grumble grumble* medical ethics *grumble grumble*

--claudia
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