View from the other side: What is informed consent?

Being a patient helped me learn and understand a lot about the ethics of our medical system.

One of these things is the concept of informed consent.

First, let me tell you what happened: 

Time: 2AM
Place: Hospital

Me:  (sleeping restfully for the first time in 24 hrs in mild respiratory distress)
Night Nurse: (knock, knock) I have to do a fingerstick.
Me: (wakes up groggily thinks, "Why fingerstick?", but is too sleepy and sticks out finger.) 
Night Nurse: (Takes blood and tests it.)  It's good.  Oh, by the way, I forgot to ask if you wanted to pneumonia shot.
Me: (still groggy)  What?  Which one?  Can I tell you when I'm awake?

When I woke up I was like "What the heck? Did that really happen?  That would never happen at St. Chris."   Who wakes up a patient in the middle of the night and then asks them to give a vaccine?!?!?!  (So not a night time issue!!!)

But, that was not a dream, because another nurse came in the morning, and asked me again if I had thought about getting the vaccine.   (No, I just happened to be sleeping for the first time in days.)   I held my tongue and told her would think about it, even though I knew I needed to get it.

 As a pediatrician, I am the ultimate proponent of vaccines.  Better to prevent than to treat damage done.  Plus, I have seen first hand the devastation effects that S. pneumococcal disease can cause, especially in patients who don't have normal lungs--like asthmatics.  Plus, working in healthcare with kids puts me in extremely high infectious exposure risk.

(For non-medical peeps: Streptococcus pneumoniae is a bacteria that can cause pneumonia and other diseases including meningitis.  We vaccinate our children for this, as well.  Shameless plug: Pneumoccoccal vaccination been extremely effective in decreasing the incidence of meningitis in children, and protects against some strains that cause pneumonia, as well.)

 So what exactly is the definition of informed consent?

From Wikipedia: 

"Informed consent is a phrase often used in law to indicate that the consent a person gives meets certain minimum standards.  An informed consent can be said to have been given based upon a clear appreciation and understanding of the facts, implications, and future consequences of an action. In order to give informed consent, the individual concerned must have adequate reasoning faculties and be in possession of all relevant facts at the time consent is given. Impairments to reasoning and judgment which may make it impossible for someone to give informed consent include such factors as basic intellectual or emotional immaturity, high levels of stress such as PTSD or as severe mental retardation, severe mental illness, intoxication, severe sleep deprivation."

Being half asleep definitely qualifies for impairment to reasoning, especially for me, whose function as a human being is directly proportional to the amount of sleep I get.

So what is informed consent supposed to look like?
From: Joint Commission on the Accreditation of Healthcare Organizations Comprehensive Accreditation Manual for Hospitals – Patient Rights and Responsibilities
“Nursing staff and other professionals who routinely obtain signatures on consent forms shall take reasonable steps to ensure that the benefits, risks and alternatives of any procedure to be performed on a patient has been explained to the patient or patient representative or surrogate by the physician before obtaining signatures.”


When the time came to administer the vaccine, the benefits were not explained to me,  neither the risks, or the alternatives of the vaccines.  Perhaps the staff made an assumption since they knew I was a doctor that I would know these things.  The nurse just said, "Here's your shot and the information paper!  Sign here."  Of course, informed assent was obtained.   Consent has yet to be obtained, even though I signed the paper.   At the time, I didn't want to feel like a nuisance on the nurses, so I didn't make a big fuss.  Now that I reflect about it, this encounter definitely fell short of the healthcare professions' ethical standards.

I take away lessons learned as both doctor and patient through this experience.
1.  As a patient, you have to advocate for yourself.  Don't be afraid to ask questions.  There is no such thing as a stupid question, because the doctors and nurses are medical experts.  Their job is to educate you and help you to understand what their thought process is, why they are treating you, and how they are treating you.  This is your body, your health and you absolutely have the right to understand exactly what they are doing and why.  Never sign anything unless you are satisfied with your level of understanding for the procedure and treatment. 

2.  As a doctor, you have to advocate for your patients while protecting yourself.
a) Always remember the reasoning capability of the patient or surrogate signing consent.  The lawyers will have a field day if you consent a patient who had impaired reasoning or judgment.  This tends to be more applicable in adult medicine, but it does happen in pediatrics.  Last year, the parents of a NICU baby were high when the surgeon came down to consent their daughter for surgery.  The surgical fellow very correctly said, "These parents are under the influence of drugs, so I can't get their informed consent."  Needless to say, Department of Human Services got involved. 

b) Never rush a consent process.  Never will I groan again and say, "Oh man, I have to go through this whole schpiel with a  'difficult mom' who asks a ton of questions.  It's going to take forever."  I hope to approach each consent encounter as an opportunity to educate, advocate, and document an important piece of medical communication.

Thanks for reading such a long entry.  Please leave comments.