Informed Consent – let’s ask the right persoN!

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Contributor: Dr. Henry Siu

Summary:

An undergraduate medical student first meets the concept of informed consent and substitute decision-making as part of the medical ethics teaching in undergraduate medical school curriculum. The medical student interacts more firsthand with these concepts again as a clerk on rotations where they may be asked by supervising physicians or residents to get “consent” from a patient prior to a procedure. These firsthand experiences are further reinforced as the student progresses through residency, and ultimately informs this student’s eventual clinical practice as a full-fledged practicing physician. For older adults, often the instruction around seeking consent to learners is: “Speak to the family” along with a clarifying instruction of “What does the family want?”.  This InfoMorsel will identify where these instructions are falling short of appropriate informed consent and identify ways that we can start practicing and teaching our learners differently.

The Ontario Healthcare Consent Act (HCCA) was created in 19961. The ultimate purpose of the HCCA is to provide a set of rules for treatment consent that is consistent across all clinical settings; with an underlying goal of enhancing personal autonomy in any healthcare treatment decision. In plain language, the HCCA seeks to protect a person’s right to make their own healthcare decisions. When they are not able to do so, the HCCA lays out who should be approached next for this decision (i.e., Substitute decision-maker, SDM). 

Accessed from: https://advancecareplanningontario.ca/substitue-decision-makers/who-is-my-sdm

As a result, as educators, we need to be careful when we ask learners to “Speak to the family” to obtain consent. We need to model for learners that reason we are speaking with the family is because we have assessed and deemed an older adult to be incapable of making a healthcare decision. The HCCA provides clear criteria for clinicians on how to assess healthcare decision-making capacity; age is not a criterion!  We also need to model that we are approaching the correct SDM for consent on a treatment proposal. This is especially true when an Attorney for Personal Care is not a Spouse/Partner or Parents/Children.

The second question, “What does the family want?” is often used to demonstrate patient-centred care in the context of an incapable person. While clarifying what the family wants could gauge their understanding of the current clinical situation, this question inadvertently places the onus on proposing treatment on the SDM. This often leads to consent for more aggressive treatment that does not align with what the older adult would want or could benefit from. For clinicians, we need to recognize our role in the informed consent process is to identify capacity, assess the clinical situation, and propose a clear treatment plan based on our assessment and understanding of the person in front of us. The SDM’s role is to provide consent (or not) to our proposal. Therefore, as educators, it is our job to teach our learners to propose a treatment plan when speaking with SDMs. Doing so can help reduce the stress and decisional conflict SDMs may face when making a significant healthcare decision2-4. By making a change in our statement: “What does the family want?” to “This is what I am proposing, [insert treatment proposal here], is this what the patient would want”, we do our part in supporting informed consent, and remind SDMs that their decision is to advocate for what the patient would have wanted.

Each situation is different, and each situation will have unique contextual factors. However, if we make a small shift in how we teach our current learners to engage with and participate in the HCCA, we can ensure that their future interactions with older adults will respect their autonomy and right to choose.

Take-Away Tidbits:

Learners are often taught to seek informed consent from a substitute decision-maker when caring for older adults. While, this might be appropriate in clinical settings of incapacity, seeking consent from the wrong individual could lead to an older adult receiving care they do not actually want and/or benefit from. Ensuring we speak and convey a treatment proposal to the correct decision-maker for healthcare treatment decisions is one step towards promoting better patient-centred care. TALKING TIP: “This is what I am proposing, [insert treatment proposal here], is this what the patient would want?”.

References:

  1. https://www.canlii.org/en/on/laws/stat/so-1996-c-2-sch-a/latest/so-1996-c-2-sch-a.html
  2. Hickman R, Daly B, Lee E (2012) Decisional conflict and regret: Consequences of surrogate decision making for the chronically critically ill, Applied Nursing Research, 25(4): 271-275. https://doi.org/10.1016/j.apnr.2011.03.003.
  3. Iverson E, Celious A, Kennedy C, Shehane E, Eastman A, Warren V, Freeman B (2014) Factors affecting stress experienced by surrogate decision makers for critically ill patients: Implications for nursing practice, Intensive and Critical Care Nursing, 30(2):77-85. https://doi.org/10.1016/j.iccn.2013.08.008
  4. Heyland DK, Heyland R, Dodek P for the ACCEPT Study Team and the Canadian Researchers at the End of Life Network (CARENET), et al (2017) Discordance between patients’ stated values and treatment preferences for end-of-life care: results of a multicentre survey, BMJ Supportive & Palliative Care, 7:292-299.