Sunday, 7 December 2014

Consent Directory for Common Medical Procedures

Consent is an extremely important part of medicine, particularly in the surgical specialties. When patients come seeking medical advice, they have the right to know the risks and complications of their treatments, as well as the relative frequencies.

Everyone aged 16 and older is assumed to have capacity (the ability to make informed decisions) unless proved otherwise. This includes anybody with dementia or a learning disability. If there is doubt, formal assessment for capacity needs to be carried out by a trained healthcare professional. This consists of:

1. Can the patient understand and retain information?
2. Can they weigh the pros and cons to make a decision?
3. Can they then communicate that decision?

If a patient is found to not have capacity, then healthcare professionals need to act in the patient's best interests, and in the UK we have a specific consent form for this (Consent Form 4). Some patients may have Advanced Directives or Lasting Power of Attorney, which will also impact on the consent process.

Consent for children needs to be obtained from a parent, but this is not an excuse not to involve the child in the decision.

In the UK, the GMC issue clear guidance on obtaining consent from patients (http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp).

Some of the major principles to bear in mind:

1. No-one can take consent on behalf of an adult who has capacity.

2. The healthcare professional taking consent must be suitably qualified, should have 

knowledge about the procedure/ treatment including its risks, complications, and likelihood of failure.

3. Consent can be verbal (a patient says yes to be examined), written (formal signature and documentation) or implied (a patient offering their arm when they attend for a blood test).

My hope is to make this post a one-stop directory for consent for the commoner surgical and invasive procedures. I will not list specific surgical speciality operations (e.g. nasal septoplasty), but focus on the procedures that a junior doctor in the UK might be expected to consent for (provided they meet the criteria listed above).

The complications common to ALL invasive procedures:

1. Bleeding
2. Infection
3. Pain
4. Failure of procedure
5. Anaesthetic complications (if general anaesthesia used)

The frequency of the above will depend on the procedure.

CARDIOVASCULAR

Angiography


Purpose: to visualise the internal anatomy of the coronary arteries and/or treat any blockages via stenting

Benefits: remove blockages, improve angina symptoms, obtain a diagnosis

Complications: pain, bleeding, infection + allergy to contrast, kidney damage from contrast, irregular heart rhythms (arrhythmias), damage to blood vessels, stroke

More Information: http://healthlibrary.epnet.com/GetContent.aspx?token=c5987b1e-add7-403a-b817-b3efe6109265&chunkiid=42307

RESPIRATORY

Chest drain insertion


Purpose: to drain fluid from the pleural cavity and improve breathing, obtain samples to get a diagnosis OR to remove air from the pleural cavity and treat a pneumothorax

Benefits: Remove air/ fluid, obtain a diagnosis

Complications: pain, bleeding, infection + damage to local structures including ribs, nerves, blood vessels, lung laceration, colon/ stomach injury, blockage of tube

More information: http://www.trauma.org/archive/thoracic/CHESTdrain.html

Aspiration of pleural fluid/ pleural tap


Purpose: to obtain samples of fluid in the pleural cavity

Benefits: obtain diagnosis, symptomatic relief

Complications: pain, bleeding, infection + damage to local structures including ribs, nerves, blood vessels, lung laceration

GASTRO

Upper GI endoscopy


Purpose: To directly visualise the oesophagus/ stomach/ duodenum for pathology and/or treat/ take biopsy samples for diagnosis

Benefits: obtain diagnosis, treat symptoms

Complications: pain, bleeding, infection + risk of perforation of oesophagus requiring surgical repair 

Lower GI endoscopy (colonoscopy/ flexible sigmoidoscopy)

Purpose: To directly visualise the colon for pathology and/or treat/ take biopsy samples for diagnosis

Benefits: obtain diagnosis, treat symptoms

Complications: pain, bleeding, infection + risk of perforation of bowel 

More infohttp://healthlibrary.epnet.com/GetContent.aspx?token=c5987b1e-add7-403a-b817-b3efe6109265&chunkiid=14795

ORTHOPAEDIC

Joint aspiration


Purpose: To remove joint fluid

Benefits: Symptomatic relief, obtain diagnosis

Complications: pain, bleeding, infection + reaccumulation of fluid, damage to local nerves/ blood vessels/ tendons

Joint injection

Purpose: to inject treatment directly to site

Benefits: Symptomatic relief

Complications: pain, bleeding, infection + damage to local skin/ nerves/ blood vessels, tendon damage, tendon rupture, hypopigmentation of skin at injection site

More infohttp://healthlibrary.epnet.com/GetContent.aspx?token=c5987b1e-add7-403a-b817-b3efe6109265&chunkiid=744873

OBSTETRIC/ GYNAECOLOGY

Caesarian (Cesarian) Section


Purpose: to delivery baby that cannot be delivered by normal means

Benefits: to deliver fetus

Complications: pain, bleeding, infection + blood clots, damage to bladder/ bowel requiring repair, hysterectomy, blood transfusion

More infohttp://healthlibrary.epnet.com/GetContent.aspx?token=c5987b1e-add7-403a-b817-b3efe6109265&chunkiid=14798

Surgical evacuation of retained products of conception

Purpose: to remove retained products to prevent infection/ stop life-threatening bleeding

Benefits: remove products

Complications: pain, bleeding, infection + blood transfusion, risk of perforation of uterus, incomplete removal requiring further procedure, damage to cervix/ bladder/ bowel requiring repair

More info: http://www.qegateshead.nhs.uk/sites/default/files/users/user1/leaflets/IL362%20ERPC%20%28Evacuation%20of%20the%20Retained%20Products%20of%20Conception%29.pdf

GENERAL SURGERY

Laparoscopic procedure


Purpose: variable (e.g. laparoscopic appendicetomy to remove appendix, laparoscopic oophrectomy to remove ovaries etc)

Benefits: avoid open procedure, quicker recovery, fewer complications

Complications: pain, bleeding, infection + perforation of abdominal organs, damage to local vessels/ nerves, need to convert to open procedure

Think I should add more? Please suggest what other procedures you'd like to see listed!