Tag Archives: ethics

Things I Wish I’d Known From the Beginning: Informed Consent

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“Can you go get the consent?”

New interns and their more seasoned senior residents are asked this almost every day. So let’s talk about this for a minute and what that question really means…

What you are being asked to do.

The hospital requires a signature on a consent form (always printed with very small font and several pages long). This part of the consent process that has a long history guided primarily by legal counsel for hospitals and, yes, you need to get the signature. But…

The signed form isn’t the consent.

Maybe I should say that again….

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So what is?

Photo credit – from a great article on disclosing the presence of learners in the OR

There are five things that must be present for informed consent. If any of them is missing, it’s not informed consent.

The patient must have the capacity and ability to understand. (No intoxication, translation when needed, etc).

The patient must actually understand. (This means you have to confirm they understood with a conversation – Can they explain it to another family member? Do they have questions?)

The person performing the procedure (or their designee) must describe the procedure and must discuss alternatives, risks (and how likely they are) and the expected benefits (and how likely they are).

The patient has to agree without coercion. (If you aren’t sure about this, don’t proceed)

The consent has to be documented.

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There are questions that every intern would like to ask about this process but can’t/won’t. Here are a few that come to mind…

What if you’ve never performed (or even seen) the procedure yourself? It’s hard to get truly informed consent if you aren’t competent in doing the procedure. But – you know (intellectually) the alternatives, the potential risks and benefits, and the “big picture” of the procedure. Particularly for complicated procedures, you can assume that the attending has discussed these (and therefore is the person who actually got the consent!). Here’s a way to make this easy… “Hello, I’m Dr [xxx}. I know that Dr. Attending has already talked to you about your surgery. I’m here to go over the alternatives, risks and benefits again – to make sure you don’t have any questions I can take back to Dr. Attending for you.”

p.s. If you are “Dr. Attending” in this scenario, you are the one who is ultimately responsible for the informed consent (and liable if it’s not done properly).

Is it important to get the consent just before the procedure? No, in fact it makes it legally more sound and much more efficient to document informed consent when you first see the patient. For elective or semi-elective surgery, it takes no time at all for “Dr. Attending” to put this phrase (or one like it) in their clinic (or ED) note: The procedure including alternatives, risks, and benefits was discussed with the patient, all questions were answered, and informed consent was obtained. This documentation often holds more water than the signed form (at least according to most attorneys I’ve talked to). Best yet – do both. Get the consent form signed at the same time! It’s easy to scan into the medical record to be there for the day of surgery, which is a win-win for almost everyone involved.  

What if It feels like you are scaring the patient/family when you review the list of the possible complications? First of all, that’s a normal feeling. But we have to learn to handle the anxiety that is always part of this process. In addition to trying to be really calm and supportive, here’s how I handle that: “When we decide about doing surgery, we always ask which is riskier… to do it or not do it. For you, we’ve decided together that it’s risker not to do the surgery… which is why you are here. But because there are risks, I want to make sure you understand them and we can talk about them before the operation.”

What if they don’t speak English but the family says they can translate for you? It’s not informed consent unless it’s translated into their language by a professional medical translator. Imagine the shoe on the other foot. What if your best friend the artist was travelling in a country where none of the doctors or nurses spoke English and they needed surgery? They would be terrified and so would any family member who was with them (even – or maybe especially – if they were being asked to translate). Don’t cut this corner. Please.

Isn’t this blog post oversimplified?

Yes!

Informed consent is a fascinating and rapidly changing area of medical ethics. I hope I’ve hit the critical highpoints and addressed a few unspoken questions many trainees have, but it’s unquestionably a “30,000-foot view”.

p.s. If you have more questions, even ones that seem naïve, please comment on this post or email me (if you don’t want them to be public).

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Here are some other great resources to learn more:

American College of Surgeons educational pdf on informed consent

ACS and Association of Surgical Education student curriculum on informed consent

Informed Consent for Academic Surgeons: A Curriculum-Based Update (with links to all the slides for the course!)

Whose Decision Is It? Teaching Students and Physicians About Informed Consent

Informed Consent and Shared Decision Making in Obstetrics and Gynecology

Fantastic You Tube video on obtaining informed consent

Treating Patients as Partners, by Way of Informed Consent – column by Pauline W. Chen in the New York Times

 

 

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Should I Go or Should I Stay?

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I am sick and tired of COVID!

We are all sick and tired of COVID!

And we are all sick and tired of not seeing our friends….

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So how do we decide if we should go to that big dinner or an out-of-town meeting in this complicated world of COVID-19? This is a classic ethical dilemma…and there is a tool kit* you can use to come up with an answer. 

Step 1: Assess the information. What do you know and what do you need to know?

The first question to ask is “Who are the parties involved?” If you are deciding whether to go to an event, It clearly affects you and the other people who might be going to the event, but who else will be affected by the final decision? 

The next two questions in this step are straightforward: What do you know? What else do you need to know?

Step 2: Think out of the box.

Every ethical dilemma has a “yes-no” answer, in this case to go or not to go to the event. But what other actions might be possible? Limit the number of people? Require testing and/or masks? Is there an option to participate virtually? This step should be a serious brainstorming exercise to explore ANY possible option (if you do it right, there will be some things on the list that sound almost crazy). 

Step 3: Consider the Appeals

This is a fancy way of saying how do the possible choices fit with your values and what we, as a society, think are virtues?  

Considering the appeals starts with a simple question – “Is there a rule?”  For example, does your employer have a rule limiting travel during the pandemic?  Are you traveling to a state that has a law prohibiting mask mandates? 

The second question in this process is “What could go wrong?” What are the possible consequences of each option? If one option is to pay a little extra to be able to get a refund on your plane ticket, it’s probably not going to be important in making your final decision. But if it turns out that your decision might lead you to inadvertently infect your 70-year-old mentor with COVID, that’s more serious. Once you get a list of all the possible consequences try to put them in order of significance by asking if they are serious, irreversible, and/or likely. 

The third question is “Which choices have more virtue?”. Which ones are more likely to reflect what we, as a society, think are behaviors and motivations that good human beings demonstrate? Most of us will agree that compassion, courage, self-sacrifice, legitimately protecting ourselves, integrity, and honesty are virtues, but there may be others that are important to you. Here is a link to see a long list of virtues to consider. 

Step 4: Decide

It’s time to decide. Look at all the objective data (step 1), the list of possible actions (step 2), and which of the actions has the most virtue (step 3). Some of them will have more weight for you than others. That’s not only ok, it’s important. We may come to different conclusions, but using this process, we will both know why.

Step 5: What could have been done to avoid this in the first place? 

This step won’t change your current dilemma, but it will help you and others with future decisions. 

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Let’s assume you’ve been invited to speak to a group next month. It’s an honor, and it’s a talk you love to give! But we are in the middle of a pandemic… should you say yes? 

Step 1: Assess the information

Who are the parties involved?

You, the organizers, the people who will (or won’t) hear your talk, the people in your life you might infect if you get COVID, your work partners, the organization you work for.

What do you know? 

It’s an honor to be asked, so this is good for your career. You love this topic and you really want to give this talk. The number of people who will be at the meeting (based on past meetings) will be between 700 and 800. Given the demographics, it’s likely that >95% of the people at the meeting will be vaccinated. You are vaccinated and boosted. The state they are holding the meeting in has a law prohibiting mask mandates and the organization has not put out any directives about masking or testing. The state they are holding the meeting in has an unvaccinated rate of … % and a COVID prevalence of … %. (Here’s where to look up these data.) There are people in your professional and personal life who are at high risk if you were to inadvertently bring COVID back to them. 

What do you need to know?

Have the organizers addressed the issue of the mask mandate?  Are the organizers going to require masks? Testing?  Does your employer have rules or recommendations about travelling?

Step 2: Options

The obvious

  • Go to the meeting
  • Don’t go to the meeting

The not so obvious

  • Go to the meeting
    • But just for the day you are presenting and don’t attend any other sessions
    • Go but avoid social gatherings and wear a N95 all the time
  • Don’t go to the meeting
    • Ask if they would consider a hybrid meeting so you can present virtually 
    • Record your presentation so they can show it during your session

Step 3: Appeals

  • Rules/laws: The law in the state to not mandate masks should be addressed by the organizers of the meeting, but you can choose to wear a mask regardless. There aren’t any other obvious rules or laws that apply (unless your employer has restrictions on travel).
  • Consequences. If you go to the meeting you might contract COVID (possibly serious, only remotely irreversible, possible but not likely). You could bring it home to others (possibly serious, only remotely irreversible, unlikely). If you are sick there will be a burden placed on your work partners (could be serious, not that likely)  If you don’t go to the meeting you might lose your status in the organization (possibly serious, only remotely irreversible)
  • What is the most virtuous thing to do? It may make the most sense to ask if the organizers will allow a hybrid approach so you can present virtually – or if they would let you record your presentation. But if those aren’t possible, you’ll need to decide if you are going or not. If you go to the meeting you are showing integrity (You said you would do it, so you are following through) and self-sacrifice (The organizers thought you had something important to say, so you are willing to take the risk). If you don’t go to the meeting you are showing legitimate self-interest (protecting yourself), compassion (for the family and friends you might inadvertently infect).You are also showing care and respect for your work partners, who would be burdened if you were to become ill. 

So… do you go or do you stay? 

*To give credit where credit is due: The process described above is a slightly modified version of the “Ethics Workup” originally developed by the faculty of the Center for Medical Ethics and Health Policy at Baylor College of Medicine. 

Does the Fetus Feel Pain?

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I teach embryology to wonderful first year medical, nurse anesthetist and PA students.  Last week, one of my students asked me, humbly and thoughtfully, if (and when) a fetus feels pain. Because of recent publicity concerning late term abortions, I knew this was a question about more than fetal physiology.

Let’s talk embryology.

I am very, very confident that the blastocyst doesn’t feel pain. I am equally confident that babies at the time of birth do feel pain. So, there must be a moment during development when nerves to sense the pain, nerves to transmit the pain, and a brain to perceive the pain come together to make it possible to perceive noxious stimuli. I’m not a developmental neurologist, so I can’t claim to be an expert, but based on published research, those three things are present somewhere around 22-24 weeks gestation. For those that are concerned about abortions that happen after 22-24 weeks, It’s important to realize that only 1.3% of abortions occur after 21 weeks gestation and 80% of these for serious birth defects.

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 Let’s talk suffering.

As healers, we seek to relieve suffering. Let’s be clear – that’s not the same thing as the “pain” I mentioned above. Let me give you a couple of (real life) examples.

A developmentally delayed 15 year old is raped by her cousin who threatens her if she tells anyone. Over the next two months, the girl becomes progressively withdrawn, depressed and even suicidal. Her mother takes her to her pediatrician who is able to convince the girl to tell her what happened. She sends the appropriate labs, including a pregnancy test, which is positive. Her pediatrician recommends termination of the pregnancy, and refers her to a gynecologist and a pediatric psychiatrist. Because of her depression and suicidality, both of these physicians also recommend termination of the now 14 week pregnancy.

A young couple comes to their gynecologist for a routine screening ultrasound.  Something isn’t quite right, so they are sent to the maternal-fetal medicine clinic for a more detailed ultrasound. They are at 18 weeks gestation, which means 22 more weeks until term. They receive horrible news. The fetus they are carrying has a fatal disorder and will not survive after birth. After a few weeks, they return to their doctor in tears. The emotional burden of carrying the pregnancy to term is causing them immense suffering.

Let’s talk ethics.

We teach our medical students to take complex situations like deciding to terminate a pregnancy and use an “ethics workup” to help guide decision making. The ethics workup starts with defining everyone who might be affected by the decision. For example, in the first case I mentioned above, that would be the 15 year old patient, the fetus, the patient’s mother, and the doctors. Then, based on the possible outcomes (to terminate or not to terminate the pregnancy), we consider the outcomes with appeals to consequences, professional obligations, ethical rights and virtues. What this process does is allow us to understand the complexity of the situation and the choices being made, rather than just going with our “gut reaction”.

Let’s talk about listening.

When I was Dean of Student Affairs, the “Pro-Life” group on campus invited a speaker that the “Pro-Choice” group felt strongly should not be allowed to speak. I asked the leaders of both groups to meet with me. They were pre-clinical students who had not yet experienced dealing with patients and families facing complex and heartbreaking decisions. I recognized that their conflict was a great learning opportunity, a chance to learn to work through a situation where colleagues disagreed. I asked them to develop a plan together on how speakers should be invited, a plan that I insisted reflect the culture of tolerance at our medical school. They did not disappoint. Their plan was amazing and included attending each other’s meetings and reviewing speakers for each other before invitations were issued. They also wrote a beautiful statement to be read at the beginning of each meeting explaining that they were there to learn from each other and to listen. They went even further and added that disrespectful comments or intolerance would result in being asked to leave the meeting. What a great example for us all – to listen to learn, and to do so with kindness and tolerance.

As physicians we are absolutely allowed – even encouraged – to include our personal views when making a thoughtful, ethical decision about caring for a specific patient.  Although it’s not a common event, physicians are allowed to choose not to care for a specific patient as long as they refer them to a different doctor. What physicians are not allowed to do is to impose our views on our patients, or our colleagues.

Facebook and Other Social Media

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Social media, like Facebook, is an important way to keep in touch with friends and not feel so isolated when you are in medical school and your residency.   It’s a wonderful tool, but it can backfire if you don’t realize some of the pitfalls.

Unlike high school and college, once you are in medical school, you are part of a profession.  (Yup, from the moment you start).  So there are a few important rules you need to know about using Facebook or any social media network.

1.  Never friend patients or their families.  This is an important rule to follow.  Even if they are the nicest people in the world just make up your mind now that the answer is “never.”   Once you are in practice, you may choose to use social media by developing a page for people to “like”… but don’t do it while you are in training!

2.  Beware changing privacy rules.  Facebook in particular is notorious for changing who can see what.  You need to check – often.   Everything on your Facebook page should be “friend only” .

3. Make sure you know what other people can find out about you on the Web.  Residency programs routinely use search engines to screen for “red flags” in applicants.  This is even more true once you finish residency and are looking for a job.   So, periodically, do a search on yourself.  You’ll need to make sure there is no misinformation out there and do whatever it takes to get it corrected.

4.  Never post unprofessional photos or comments. You are not in college anymore.  Think about what you have on Facebook now (and what you will put on in the future).  Is there anything you wouldn’t want the Dean of Students or your Program Director to see?  Do you really want people to see the disparaging comment you made about a professor or attending?  Take it off.  It’s not professional.

5.  Never put ANY patient information on Facebook.  Part of being a professional is knowing the rules.  Patient confidentiality is protected by law… and by the ethics of medicine.  Never, never, never  (in case it wasn’t clear – that means NEVER) put ANY information about a patient on Facebook or any social media…

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