Informed consent

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The landscape of health care in the United States provides an influential backdrop for consumers of both human and veterinary medical care. Consumers need only to turn on the television, read the newspaper, or search the Internet to find headline stories that reflect an increasingly litigious climate, problems with health care access and affordability for many Americans, high consumer dissatisfaction, and heartbreaking outcomes due to preventable medical errors. While these problems require reform on a macro and systems level through legislation and policy changes, an important element underlying these problems is the relationship between health care practitioners and consumers, aimed specifically at minimising expectation conflict[1].

In veterinary medicine, the importance placed on the quality of communication between veterinarians and clients has been underscored in several studies within the past 5 years[2]. The following excerpt from a letter sent to a veterinary practice by a client about a fee dispute underscores the significance of this relationship. As you read this excerpt, consider the high stakes that are contingent on the quality of and communication within the client-veterinarian relationship.

Dr. [name withheld] asked me several times, "How aggressive do I want to get?" "I don't," was my answer. "I want to go slow and easy with him." She knew this about me and did not like it. I wanted [name of dog] dealt with on as minimal [a basis] as possible and [left] alone. Seven blood transfusions tells me they didn't leave him alone for a second. It was a critical point, and we did not connect. I knew the second I left, she would do what she wanted, disregarding how I wanted to deal with my overly sensitive bulldog. Maybe [it was done out of] pride that she was the doctor and I wasn't

While there are indeed at least two sides to every story, consider that perhaps the veterinarian did his or her best to communicate effectively with this client. For instance, the veterinarian in this case may have spent an inordinate amount of time explaining a recommended course of care. The veterinarian may have had good intentions but may have made a very common communication error: neglecting to ensure that the client was interested in pursuing this course of care or, at the very minimum, that the client understood the proposed treatment. We might ask, "Was the client fully informed?" I am reminded of a recent quote[3]:

I judge myself by my intentions. Others judge me by my actions. My intentions and the actions that others see may be miles apart. Unless I know that, I am unlikely to change.

In the health care field, consumer perception is often considered the gold standard for evaluating how effectively we have communicated. It is surely no surprise to learn that studies have confirmed that consumer perceptions of medical care depend highly on the quality of consumer interactions with health care providers[4].

Client-vet relationship

Abundant research evidence in human medicine has informed us that the manner in which a clinician interacts with patients has a significant effect on a number of health care outcomes, including malpractice risk, satisfaction, adherence to treatment recommendations, and diagnostic accuracy[5]. Unfortunately, some health care professionals may minimize the importance of learning and practicing more effective ways to communicate with patients and clients. In fact, the critical task of communication training in clinical care has traditionally been overlooked or defined as a "soft skill" in medical education. Evidence has demonstrated otherwise. The impact of communication in the medical care setting is anything but soft. For instance, it has been estimated that 75% to 95% of the information needed by physicians to make a correct diagnosis comes from the patient-reported medical history, which is elicited through astute and thorough interviewing and communication skills. Reliance on the client-reported history in veterinary medicine is equally important[6].

Of particular interest to clinicians, malpractice carriers, and risk managers is the research evidence linking poor communication with liability risk. For example, the often-cited research by Beckman et al (1994) indicates that the major reason behind a patient's decision to pursue litigation against a physician is a perceived lack of caring by the physician[7]. This re­search included close examination of plaintiff depositions and found that 71% of malpractice claims were initiated as a result of a physician-patient relationship problem, with a common theme being the patient's perception that the physician was uncaring. Furthermore, 25% of plaintiffs in these cases reported poor delivery of medical information and poor listening by the physician.

Other researchers have sought to pinpoint which behaviors, if any, set apart physicians who are sued from those who are not[8]. The researchers found that patients who were seen by physicians with prior malpractice suits were more likely to report physicians who appeared rushed, showed a lack of concern, and provided inadequate medical information than were patients who were seen by physicians who had not been sued. Malpractice claims are often initiated by consumers who feel deserted or ignored. Furthermore, for practitioners, being the target of a malpractice suit can lead to significant emotional distress, which has been shown to color the future practice on a personal and professional level. For in­stance, experiences after malpractice suits include emo­tional burnout, defensive-medicine practices, and aban­donment of practice[9].

Informed consent

As in human medicine, there is evidence in veterinary medicine that client complaints to licensing agencies and veterinary boards are related to communication breakdowns between the client and veter­inarian[10]. In addition, increasing sophistication in modalities in veterinary care has enhanced the ability to provide high-quality care, resulting in increased client expectations. Furthermore, noneconomic damages are coming under increasing con­sideration in litigation involving companion animals[11]. Many communication breakdowns linked to malpractice risk in equine practice point to the necessity of obtaining informed consent from clients. What are the elements of informed consent? According to Braddock et al (1999), true informed consent involves the following elements[12]:

  • Discussion of clinical issues
  • Discussion of options, including pros and cons
  • Discussion of uncertainties of the decision, such as side effects and aftercare
  • Assessment of client understanding
  • Exploration of client preferences

While most clinical encounters require at least one patient (client) decision, studies of physician-client interactions indicated that approximately 15% of visits did not adhere to any of these elements of informed consent. Furthermore, more than 50% of visits included only one element, 24% included two elements, 6% included three, and 2% included four.

Informed consent implies an agreement by the client to a course of diagnostic procedures or treatment after receiving enough information to make an intelligent decision[13]. Information about the risk involved is especially important in this process. Informed consent is considered authorization for the care provider to act. Signed consent provides written authorization. In­formed consent addresses the ethical need to fully inform clients about the risks and benefits of treatments and to ensure that clients' values and preferences play a prominent role in the final decision. Informed consent is rooted in the concept of client autonomy. Why, then, are the elements of informed consent so frequently overlooked? What are some of the communication challenges to successfully obtaining informed consent in practice?

There may be several reasons veterinarians are reluctant to use written informed consent in practice[14]. For example, written informed consent may be viewed as time-consuming because of the perception that it requires lengthy discussions and explanations as well as additional paperwork and storage. Furthermore, veterinarians may fear that explaining complex procedures may overwhelm clients. Although these may be valid concerns, signing consent is a normal procedure in human medicine (although not without problems, of course), and clients have accepted this as essential to their receipt of medical care. While implementing written informed consent in veterinary practice may seem daunting, over time, it can become routine and facilitate the delivery of professional services.

Although written informed consent may be perceived as important by many people, there is less agreement about how to implement it. What specific behaviors facilitate the informed consent process? Most people agree that veterinarians must do more than just give their clients a consent form to sign. A signature on a document is insufficient — it does not complete the process. Informed consent requires a two-way conversation i.e. a dialogue.

References

  1. Murphy J, Chang H, Montgomery JE, et al (2001) The quality of physician-patient relationships. J Fam Pract 50(2):123-129
  2. Shaw JR (2009) Four core communication skills of highly effective practitioners. Vet Clin North Am Small Anim Pract 36:385-396
  3. Clemmer J (2006) Practical leadership: From inspiration to application. www.clemmer.net/excerpts/feedback.shtml
  4. Clark PA (2003) Medical practices' sensitivity to patients' needs: Opportunities and practices for improvement. J Ambulatory Care Manage 26(2):110-123
  5. Stewart M, Brown JB, Donner A, et al (2000) The impact of patient-centered care on outcomes. J Fam Pract 49(9):796-804
  6. Peterson MC, Holbrook J, Von Hales D, et al (1992) Contributions of the history, physical examination and laboratory investigation in making medical diagnoses. West J Med 156:163-165
  7. Beckman HB, Markakis KM, Suchman AL, Frankel RM (1994) The doctor-patient relationship and malpractice: Lessons from plaintiff depositions. Arch Intern Med 154(12):1365-1370
  8. Hickson GB, Clayton EW, Entman SS, et al (1994) Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA 272(20): 1583-1587
  9. Couch CE, Thiebald S (2002) Who supports physicians in malpractice cases? Am Coll Phys Executives 28(2):30-33
  10. Takash T (2005) Veterinary license complaints from an attorney's perspective. Prof Liability 24(3):1-2
  11. Nunalee MMM, Weedon GR (2004) Modern trends in veterinary malpractice: How our evolving attitudes toward non-human animals will change veterinary medicine. Anim Law 10:125-161
  12. Braddock CH, Edwards KA, Hasenberg NM, et al (1999) Informed decision making in outpatient practice: Time to get back to basics. JAMA 282(24):2313-2320
  13. Hannah HW (1997) Communicating with clients: Informed consent. JAVMA 211(11):1385-1386
  14. Fettman MJ, Rollin BE (2002) Modern elements of informed consent for general veterinary practitioners. JAVMA 221(10):1386-1393