PRACTICE CORNER
Informed Consent—Role of the Perianesthesia Nurse Theresa Clifford, MSN, RN, CPAN QUESTION: WHAT IS THE CURRENT STANDARD or American Society of PeriAnesthesia Nurses’ recommendation regarding nurses acquiring and witnessing a patient’s signature on a surgical consent form? Is this different from the informed consent? Response: There are actually several different types of consents that are important from a legal and regulatory standpoint. Additionally, the role of the perianesthesia nurse varies based on a number of variables.
Historical Perspective As early as 1914, the courts determined that a physician who operated on a patient without the patient’s agreement was committing an assault.1 Although the basic ethical principle ‘‘do no harm’’ remains engrained in practice, current health care culture embraces the rights of patients to have an active role as a health care partner. This includes the provision of patient autonomy, the appearance of transparency (understandable and unbiased), and collaboration in decision making between the provider and the patient.1 Patient consent for procedural or surgical interventions is no longer simply about obtaining the patient’s signature on paper. Consent is more clearly defined as a process of ongoing communication.2 The more patients know what to expect from their own treatment protocol, the better they are able to help the nurse and other health care providers deliver safe clinical care. Theresa Clifford, MSN, RN, CPAN, is a Clinical Resource Nurse, Mercy Hospital, Cape Elizabeth, ME, and a Former President of American Society of Perianesthesia Nurses from 2009 to 2010. Conflict of interest: None to report. Address correspondence to Theresa Clifford, Mercy Hospital, PACU, 54 Ocean House Road, Cape Elizabeth, ME 04107; e-mail address: [email protected]. Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.09.004
Defining Consent General Consent The perianesthesia nurse should be knowledgeable about two basic forms of patient consent. The first is the notion of general consent. Simply put, general consent is the patient’s permission to be touched. General consent is often assumed when the patient presents to a physician or health care facility for care.1-3 For example, when the patient is checking in for day surgery and is greeted by the preoperative nursing personnel, routine preoperative care is often assumed. When the nurse describes the need to obtain preoperative vital signs and the patient presents an arm for a noninvasive blood pressure, the patient’s consent for this intervention can be implied. In terms of legal implications, nurses performing routine nursing procedures have an obligation to provide at least minimal explanations to avoid providing care that may be unwanted by patients. Touching patients without consent is considered battery and/or assault, or unlawful offensive contact between the nurse and the patient.4 Failure to obtain consent can result in charges of negligence, or the failure to provide the same standard of care that a prudent health care provider would provide in a similar situation. General consent can also be explicit, expressed either in written words or orally. Whether implied or expressed explicitly, obtaining general consent is clearly necessary, and many routine or benign nursing care activities cannot be presumed without communication with the patient. Informed Consent In addition to obtaining implied or express general consent, most treatments and procedures that have associated risks require informed consent. Obtaining consent is fundamental to the practice of medicine, and patients have a right to be educated
Journal of PeriAnesthesia Nursing, Vol 28, No 6 (December), 2013: pp 413-414
413
THERESA CLIFFORD
414
before making health care decisions. In the era of patient-centered care, the process of informed consent serves to provide patients with the opportunity to make decisions about care based on their personal best interests.
Criteria for Informed Consent Informed consent has several elements. Simply providing information regarding the risks of a procedure is insufficient. In addition to the risks and benefits of the treatment, providers should discuss alternative treatments as well as the related risks and benefits, the dangers of choosing no treatment, and any consequences associated with prematurely terminating treatments. The actual content of the information provided to the patient depends on the circumstances of each case. The following data elements are minimally required for adequate informed consents5: Patient’s diagnosis, Nature of the proposed treatment or clinical procedure, Risks and benefits of the proposed treatment or clinical procedure, Rational for the proposed treatment or clinical procedure, Alternatives to the proposed treatment or clinical procedure, Risks and benefits of the alternatives, and Risks and consequences of declining the treatment/procedure. Exceptions Only a few circumstances fall under exception to the principles of informed consent.3 These exceptions include certain emergency situations where the life and/or welfare of the person is in jeopardy and consent cannot be obtained. On a rare occasion, a physician may exercise ‘‘therapeutic privi-
lege’’ on the basis of protecting the patient from information believed to be more harmful than not. Clearly, there are patients who do not want to know anything and will surrender their right to informed consents. Lastly, the patient who lacks the capacity to make decisions will have information shared through appointed guardians or surrogate decision makers.
Perianesthesia Nursing Role for Informed Consent In terms of the role of the perianesthesia nurse and the informed consent process, nurses who sign as a witness to a consent form are indicating that they observed the patient’s or surrogate’s signature. It is the responsibility of the individual who will be performing the procedure or providing the intervention to provide the information necessary to meet criteria for informed consent. Nurses, however, have a duty to notify any of these providers when patients have additional questions. Nurses actively engage skills for patient assessment, education, and communication to advocate on behalf of patients who demonstrate a lack of understanding or gaps in knowledge related to the planned interventions. With an increased emphasis on patient autonomy and informed consent, patient involvement and partnership in health care require the ability to provide informed consent. Patients can freely exercise their rights by willingly consenting or refusing consent to recommended medical procedures, based on appropriate knowledge of the benefits, burdens, and risks involved. Perianesthesia nurses have a responsibility to ascertain that the patient has a clear understanding of the proposed interventions and to advocate on behalf of patients who express any ambiguity. Informed consent is not simply the attainment of a signature. Informed consent is a process that involves education, communication, and advocacy.
References 1. Childers R, Lipsett PA, Pawlik TM. Informed consent and the surgeon. J Am Coll Surg. 2009;208(4):627-634. 2. Odom-Forren J. Drain’s PeriAnesthesia Nursing—A Critical Care Approach, 6th ed. St Louis, MO: Elsevier Health; 2013. 3. Windle P, Schick L. PeriAnesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing. St Louis, MO: Elsevier, Inc.; 2010.
4. Cole CA. Implied consent and nursing practice: Ethical or convenient? Nurs Ethics. 2012;19:550-557. 5. Xue Y. Informed Consent: Hospital. The Joanna Briggs Institute. 2012. Available at: http://connect.jbiconnectplus.org/ViewPdf.aspx?058236&152. Accessed August 26, 2013.
Informed Consent—Role of the Perianesthesia Nurse Theresa Clifford, MSN, RN, CPAN QUESTION: WHAT IS THE CURRENT STANDARD or American Society of PeriAnesthesia Nurses’ recommendation regarding nurses acquiring and witnessing a patient’s signature on a surgical consent form? Is this different from the informed consent? Response: There are actually several different types of consents that are important from a legal and regulatory standpoint. Additionally, the role of the perianesthesia nurse varies based on a number of variables.
Historical Perspective As early as 1914, the courts determined that a physician who operated on a patient without the patient’s agreement was committing an assault.1 Although the basic ethical principle ‘‘do no harm’’ remains engrained in practice, current health care culture embraces the rights of patients to have an active role as a health care partner. This includes the provision of patient autonomy, the appearance of transparency (understandable and unbiased), and collaboration in decision making between the provider and the patient.1 Patient consent for procedural or surgical interventions is no longer simply about obtaining the patient’s signature on paper. Consent is more clearly defined as a process of ongoing communication.2 The more patients know what to expect from their own treatment protocol, the better they are able to help the nurse and other health care providers deliver safe clinical care. Theresa Clifford, MSN, RN, CPAN, is a Clinical Resource Nurse, Mercy Hospital, Cape Elizabeth, ME, and a Former President of American Society of Perianesthesia Nurses from 2009 to 2010. Conflict of interest: None to report. Address correspondence to Theresa Clifford, Mercy Hospital, PACU, 54 Ocean House Road, Cape Elizabeth, ME 04107; e-mail address: [email protected]. Ó 2013 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.09.004
Defining Consent General Consent The perianesthesia nurse should be knowledgeable about two basic forms of patient consent. The first is the notion of general consent. Simply put, general consent is the patient’s permission to be touched. General consent is often assumed when the patient presents to a physician or health care facility for care.1-3 For example, when the patient is checking in for day surgery and is greeted by the preoperative nursing personnel, routine preoperative care is often assumed. When the nurse describes the need to obtain preoperative vital signs and the patient presents an arm for a noninvasive blood pressure, the patient’s consent for this intervention can be implied. In terms of legal implications, nurses performing routine nursing procedures have an obligation to provide at least minimal explanations to avoid providing care that may be unwanted by patients. Touching patients without consent is considered battery and/or assault, or unlawful offensive contact between the nurse and the patient.4 Failure to obtain consent can result in charges of negligence, or the failure to provide the same standard of care that a prudent health care provider would provide in a similar situation. General consent can also be explicit, expressed either in written words or orally. Whether implied or expressed explicitly, obtaining general consent is clearly necessary, and many routine or benign nursing care activities cannot be presumed without communication with the patient. Informed Consent In addition to obtaining implied or express general consent, most treatments and procedures that have associated risks require informed consent. Obtaining consent is fundamental to the practice of medicine, and patients have a right to be educated
Journal of PeriAnesthesia Nursing, Vol 28, No 6 (December), 2013: pp 413-414
413
THERESA CLIFFORD
414
before making health care decisions. In the era of patient-centered care, the process of informed consent serves to provide patients with the opportunity to make decisions about care based on their personal best interests.
Criteria for Informed Consent Informed consent has several elements. Simply providing information regarding the risks of a procedure is insufficient. In addition to the risks and benefits of the treatment, providers should discuss alternative treatments as well as the related risks and benefits, the dangers of choosing no treatment, and any consequences associated with prematurely terminating treatments. The actual content of the information provided to the patient depends on the circumstances of each case. The following data elements are minimally required for adequate informed consents5: Patient’s diagnosis, Nature of the proposed treatment or clinical procedure, Risks and benefits of the proposed treatment or clinical procedure, Rational for the proposed treatment or clinical procedure, Alternatives to the proposed treatment or clinical procedure, Risks and benefits of the alternatives, and Risks and consequences of declining the treatment/procedure. Exceptions Only a few circumstances fall under exception to the principles of informed consent.3 These exceptions include certain emergency situations where the life and/or welfare of the person is in jeopardy and consent cannot be obtained. On a rare occasion, a physician may exercise ‘‘therapeutic privi-
lege’’ on the basis of protecting the patient from information believed to be more harmful than not. Clearly, there are patients who do not want to know anything and will surrender their right to informed consents. Lastly, the patient who lacks the capacity to make decisions will have information shared through appointed guardians or surrogate decision makers.
Perianesthesia Nursing Role for Informed Consent In terms of the role of the perianesthesia nurse and the informed consent process, nurses who sign as a witness to a consent form are indicating that they observed the patient’s or surrogate’s signature. It is the responsibility of the individual who will be performing the procedure or providing the intervention to provide the information necessary to meet criteria for informed consent. Nurses, however, have a duty to notify any of these providers when patients have additional questions. Nurses actively engage skills for patient assessment, education, and communication to advocate on behalf of patients who demonstrate a lack of understanding or gaps in knowledge related to the planned interventions. With an increased emphasis on patient autonomy and informed consent, patient involvement and partnership in health care require the ability to provide informed consent. Patients can freely exercise their rights by willingly consenting or refusing consent to recommended medical procedures, based on appropriate knowledge of the benefits, burdens, and risks involved. Perianesthesia nurses have a responsibility to ascertain that the patient has a clear understanding of the proposed interventions and to advocate on behalf of patients who express any ambiguity. Informed consent is not simply the attainment of a signature. Informed consent is a process that involves education, communication, and advocacy.
References 1. Childers R, Lipsett PA, Pawlik TM. Informed consent and the surgeon. J Am Coll Surg. 2009;208(4):627-634. 2. Odom-Forren J. Drain’s PeriAnesthesia Nursing—A Critical Care Approach, 6th ed. St Louis, MO: Elsevier Health; 2013. 3. Windle P, Schick L. PeriAnesthesia Nursing Core Curriculum: Preoperative, Phase I and Phase II PACU Nursing. St Louis, MO: Elsevier, Inc.; 2010.
4. Cole CA. Implied consent and nursing practice: Ethical or convenient? Nurs Ethics. 2012;19:550-557. 5. Xue Y. Informed Consent: Hospital. The Joanna Briggs Institute. 2012. Available at: http://connect.jbiconnectplus.org/ViewPdf.aspx?058236&152. Accessed August 26, 2013.
