Surgical procedures and giving your consent

Thanks to the bravery of women coming forward to tell their stories about harassment and abuse across the spectrum of society, many more people are now familiar with the concept of consent compared to a decade ago. Consent can sometimes sound like a complicated legal process, but the basics are very simple: Consent simply means giving permission. Without your consent, anything done to you – a surgical procedure, an examination or even a touch – could be considered assault, and whoever does it could be charged with a criminal offence.

However, because social interactions can be complicated, the bar set for proving that permission was given in a healthcare setting is relatively low and varies according to the seriousness of the procedure performed. Hospitals would grind to a halt if they required their doctors to get written permission every time they needed to touch their patients or perform a relatively minor procedure like taking blood. In such cases, a quick check such as saying, “I’m going to press on your belly now if that’s OK” or “Can I take your blood now?” is seen as adequate, and if you don’t object, lifting your top for an abdominal examination or stretching out your arm is taken to mean consent was given. This is called implied consent.

Implied consent wouldn’t be acceptable for bigger procedures with more risks, such as surgery. Here, the process of gaining your permission needs to be more formal and often confirmed with your signature.

But how can you agree to a procedure if you don’t know what it involves or what the risks might be?

This is where the principle of informed consent comes into play. This means it isn’t enough for your doctor to just ask you whether you agree to a procedure; they have to explain what it involves, what results can be expected and what the main possible complications are, together with how often we expect to see such complications occur.

If this process doesn’t happen, the doctor is unlikely to be found guilty of assault providing you did give permission to go ahead. However, they may be found negligent in their duties to properly inform you.

The consent form explained…

For bigger procedures like caesareans and certain instrumental deliveries (anything that needs to be performed in an operating theatre), the hospital requires a consent form to be completed. Seeing this form can be daunting to any patient and, without careful explanation, it can feel like you’re being asked to “sign your life away” or agree to all sorts of things buried in the small print. Some people feel like they’re being asked to sign a disclaimer, but this really isn’t the case. There’s one key thing to remember about the consent form:

It’s a record of a conversation that has taken place. It’s true that, sadly and rarely, consent forms are sometimes revisited in a legal case. However, the form itself is worth nothing if it wasn’t accompanied by an equally good conversation. Just because you signed a form doesn’t mean you necessarily received adequate information about the procedure. You should sign the consent form only if you feel you have enough information about the risks and benefits to make an informed decision.

Unfortunately, labour and delivery can be unpredictable, and sometimes time is of the essence. Any procedure planned out in advance (an elective procedure) should involve having time to think about it, asking questions and perhaps reading an information leaflet before going ahead. But sometimes on the labour ward, minutes matter, and it’s likely that in these situations you’ll get a sense of urgency very strongly from your doctor or midwife.

It’s easy to feel like healthcare professionals are either not giving you the whole story or are overwhelming you with lists of risks and statistics. The process of giving your consent should be a two-way conversation, with your doctor checking that you understand and making sure you have the opportunity to ask questions.

Each time something is done to you, the doctor or midwife needs to judge the risks of the procedure, the urgency of the situation and, therefore, how detailed and formal the consent process needs to be. It isn’t an easy thing to get right! You can help the encounter go smoothly by making it clear if you feel what is being said is too much and scaring you, or if it is not enough and you want more information.

In rare emergency scenarios, the consent process will necessarily be very short. If you or your baby are at risk of immediate harm and seconds count, giving consent for even a caesarean section could be as quick as “We need to do an emergency caesarean! Is that alright? Do you have any questions?” This is very uncommon and is particularly unlikely if everything else was going well. If you’ve had many complications arise and the doctors feel you’re at high risk of needing a major procedure, they may suggest discussing the risks and benefits before the situation arises, so all that is required in the moment is a quick agreement to go ahead.

In these situations, where a procedure has happened very quickly and after only a very brief discussion, your doctor should offer an opportunity to debrief afterwards, talking through the situation in more detail when things are calmer and answering any questions you might have. Sometimes, this needs to happen days or weeks after the delivery during a dedicated appointment. If you feel this would be helpful or should have happened but has not been offered, please do speak to your doctor or midwife.

Communication

In any profession, some people are naturally good at communication and some have to work a little harder at it.  Health and maternity care are no different, but every doctor and midwife will be aiming to communicate with you clearly and compassionately, and you have every right to expect this from them.

There are guidelines that staff should be aware of when discussing procedures and conditions with you. They should:

• Quantify terms like “very rare” or “common”, as these mean different things to different people. For instance, did you know that if you have a 1 in 100 chance of something happening, that’s classed as “common”?
• Help you to appreciate the size of risk using natural frequency, which means group sizes you might be familiar with. For instance, “One person in a family” or “One person in a village”.
• Use the same denominator to discuss different risks, which means making the same comparison. It’s clearer to say “there’s an 11 in 100 risk of bleeding and a 6 in 100 risk of infection” than “there’s a 1 in 9 risk of bleeding and a 1 in 17 risk of infection”.
• Frame the risk in different ways, positively and negatively. For instance, “This treatment will cure 89 out of 100 people. Which means it won’t work for 11 out of 100.”
• Consider your individual situation. There’s no point in quoting national figures for the chance of needing a caesarean if, for example, they know that your risk is much greater due to a medical condition.

Describe changes in absolute risk, not relative risk. For example, “double the risk” sounds dramatic, but double a 1 in 1000 risk is still only 2 in 1000! However, doubling a 15 in 100 risk to 30 in 100 is a significant increase. You should be told the absolute numbers – how many people does this actually happen to?

In an ideal world, the guidelines would be followed every time risk is discussed. Unfortunately, humans make mistakes, and work pressures distract and sometimes win over good communication. To help you get the information you need in such situations, there are 4 easy points to remember to ask:
B – What are the Benefits of the suggested intervention?
R – What are the Risks?
A – What are the Alternatives – do I have any other options?
N – What happens if we do Nothing for now?

Main Points

• Consent means giving your permission, and it’s necessary to give consent before doctors or midwives do anything to you, be it an examination or a surgical procedure.
• In a healthcare setting, minor procedures and examinations usually only require “implied consent”, which does not involve any consent form, just your verbal permission to have the procedure/examination carried out. Consent can also be implied by your actions. Implied consent is not acceptable for bigger procedures where the risks are higher.
• For more serious procedures, such as surgery, informed consent needs to be given. Before you can give informed consent, your doctor will need to explain what the procedure involves, the expected result, and the potential risks. You will need to sign a consent form.
• Failure to adequately inform you of the procedure may result in your doctor being found guilty of negligence.
• A consent form will always be used for procedures such as caesareans and instrumental deliveries.
• A consent form is a record of a conversation that has taken place. You should sign the form only if you feel you have received enough information about the procedure to make an informed decision.
• Because childbirth is unpredictable, and unforeseen complications can arise that require emergency procedures, consent may need to be obtained quickly. In these situations the process of your doctor or midwife informing you of the risks may seem rushed.
• As healthcare professionals will not have a lot of time to explain in urgent situations, they may suggest discussing the details of any major procedures with you earlier in your pregnancy, particularly if you’ve had a complicated pregnancy and the risk of you needing such a procedure is high.
• In cases where a procedure has happened very quickly after a short discussion, your doctor should offer you a “debrief”, in which what just occurred is discussed in more detail and you’ll have the opportunity to ask any questions. If a debrief was not offered and you feel it should have, speak to your doctor or midwife.
• There are guidelines that medical staff should follow when discussing procedures and conditions with you to ensure what they’re saying is clear and easy to understand so that you can make an informed decision.
• To help ensure you get the all the information you need in a particular situation, you can use the mnemonic BRAN to help you remember which questions to ask.

References

McILwain, JC. Consent: Practical principles for clinicians. Bentham Books, 2015

National Institute of Health and Care Excellence (2012) Patient experience in adult NHS services: improving the experience of care for people using adult NHS services (Clinical Guideline 138), available at: https://www.nice.org.uk/guidance/cg138/chapter/1-Guidance#tailoring-healthcare-services-for-each-patient

Royal College of Obstetricians and Gynaecologists (2008) Presenting information on risk (Clinical Governance Advice No. 7), available at: https://www.rcog.org.uk/globalassets/documents/guidelines/clinical-governance-advice/cga7-15072010.pdf