Friday, December 11, 2009

Informed Consent

Unknown to me, the medical center apparently had some big inservice that only the clip board toting administrative non-patient caring for nurses had a chance to go to about proper informed consent. This including the use of attorney developed forms and proper statements to document that consent was obtained for a procedure and that all realistic risks, benefits and alternatives were discussed. These forms of course make sure that all outcomes are the responsibility of the physician and in no way should the medical center be held responsible for the patients misinterpetation of what was about to happen.

So here I am in the middle of the night with a patient that comes into the ED from an accident bleeding out. We are rushing into the OR and the adminoRN stops us and says that we have to have informed consent before we can procede! I look at the patient and said, "there's something bad wrong in there, we gotta open you up", he looked at me and said, "Fix me doc!" and scribbled a line of the paper. Consent obtained. As we rolled in to the OR, the patient looked at me and then looked at the consent Nazi and muttered "what a b****"!, cant she see Im dying here!"


SeaSpray said...

Hmmm...I've been that consent Nazi B**** (But compassionately) many, many times because of working in emergency registration. It's an *awful* position to be in... but you have to do what you have to do.

I've been out of the loop a few years.. but if you thought those seconds mattered ..couldn't you have just whisked him away? There are situations that the paperwork just has to wait.

I've been yelled at, scowled at and refused by patients... or family. Fortunately ..most people complied ..but then maybe they expressed their disgust to the staff with them.

I would just always be as sensitive to their concerns and supportive as possible..yet get the consent...but I did it on my terms. That is because the one time I went against my instincts really backfired.

The ER supervisor..a tough cookie,,by the book and good at her profession told me I HAD to get the signatures no matter what is going on.

So when still a night a father came rushing in with his very young child who had 3 toes cut off by a riding lawnmower. A few minutes later I was back in the trauma room with both parents (mother crying), the screaming child, Doc and nurse. I had to get her name, etc..but by the time I got to insurance..the mother lost it, desperately looked at her husband and he YELLED at me so loud that I am sure through closed doors was heard at the other end of the hospital..never mind the entire ER/OP area. (I felt like a snake. I didn't want to do it, but was told I HAD too.)

I sincerely apologized, quickly exited, did the chart, brought it back and did not ask for signatures. Then went across the hall to briefly collect myself and back to work. The father came to me later and apologized and I apologized to him and glad I had the opportunity. I knew when he yelled at me like that it was really all his emotion about the accident coming out.It was all so sad and upsetting. Then another relative came in with the toes in a container said he was trying to find them in the grass with a flash lite. Not a good night and it was also very busy.

I told the supervisor what had happened and again questioned timing and she was adamant that we HAVE to get the signatures. But from that night on.. I did NOT always do that. I left chart with staff, but ALWAYS followed up. There are just times you should not. Maybe I was wrong..but you have to be discerning.

Getting signatures from family members who arrive after the pt who is a CPR in progress is also not easy. You know they're dead but have to pretend you don't know because family is still holding out hope and even worse..if they know the person is dead. Same supervisor said they won't want to do it later either so do it.

I know you're talking about OR and they have their own set of forms.

Isn't there something for implied consent? He's alert and oriented on his way to the OR? Or I guess it is so all responsibility falls on you.

She obviously didn't discuss risks and patient obviously didn't read the form. Couldn't bleeding out be considered as signing under duress?

I hope all went well with your patient.

"Consent Nazi B****" could be a blog title. ;)

SeaSpray said...

P.S. Depending on who you worked with..the nurse would also help get the signatures during the difficult situations. They are legal documents..every detail counts and has to be accurate..but the patients/families have to be considered too in certain situations and you know what to do when you're in the mode of the moment.

I realize you were annoyed at the pencil pushing nurse stopping you ..the irony of it all - pt could die and you just want to get him into the OR so you can *save his life* ..but wait ..nurse needs his signature!

But perhaps as a physician'd disagree with my "being discerning" if I was acting on your behalf and would be afraid if it wasn't done immediately then it might not get done.

Btw I didn't show it, but a pet registration peeve is when a patient sitting in front of me says " Gee ..I could be having a heart attack! or What would you do if I was bleeding to death?" when asked to sign, etc,

:) I know..they just don't get it.