Wednesday, February 07, 2007
Age of Consent
"Whatever you say, doc." "Just tell me what you're going to do, and forget about all the rest." Once in a while, you still hear that sort of thing. There are times when "informed consent" isn't all it's cracked up to be.
Don't get me wrong (not that no one ever would, or could, or has!): I believe in full disclosure, think an informed patient is a good patient, and in fact I always took pride in my ability (and willingness!) to take plenty of time to explain things clearly. And yet... I also think instilling confidence and a positive attitude facilitates smooth recovery. Nurses regularly told me that my patients always seemed calm and confident when they were admitted, and I considered that a very good thing, and high praise indeed. So I hated, at the end of a conference with a patient and family wherein I explained the plan and tried to alleviate fear, to whip out a consent form and ask them to put their name on a shopping list of horrors. It made me feel like Snidely Whiplash. Which is why I generally didn't.
What I liked to do, rather than list all the things that can go wrong, is to enumerate the steps I planned to take to make it go right. It's better, to my way of thinking, to say "putting you on a liquid diet and giving a dose of antibiotic lowers the chance of infection or leakage to less than one percent" than to intone "the suture line could leak and give you a serious infection or kill you." That there is danger is implicit; yet the emphasis is on safety. "To protect your lungs and prevent clots, we'll get you up right after surgery and walk you around, and we'll give you a mild blood-thinner" sounds better and is more positive than "you could get pneumonia or drop dead from a blood clot."
With regularity, I was regaled with the latest consent form generated by lawyers and insurance execs, each more detailed, cold, and frightening than the last; always with the admonition to use that form or suffer unspeakable consequences. Cover your ass above all, they'd say: forget about the patients' peace of mind. I never did. My office notes included what I'd said and how I'd said it. For most operations, I gave handouts or booklets that I'd written myself, and I referred to that in my notes as well. I solicited questions, asked if there were things they were worried about, and I noted that, too. But I wanted my patients to leave my office feeling OK about what they were facing, and I worked hard at it. Foisting a frightening form full in the face after all that is sort of a spell-breaker. So I left the consent signing to the hospital, when they got there. No one ever called me on it, and I never had a reason to regret it. I'm not sure I could get away with it today.