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Informed Consent!

Discussion in 'United Kingdom' started by C Bain, May 14, 2005.

  1. C Bain

    C Bain Active Member


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    Hi All,

    I wonder which systems of 'INFORMED CONSENT' in various quarters of the Profession are being presently used? A thorny subject at the best of times! Is it,

    1. A loosely based verbal, and a full medical note-taking, incorporated into the traditional patient's notes, and the medical diary?

    2. Do you have a leaflet type advice sheet? (An INFORMATION setting out the good reasons and the pitfalls concerning the risks incurred in the patients forthcoming treatment!).

    3. Use a mixture of both of the notes One and Two above?

    Bearing in mind whatever is written and handed to the patient in the event of the wheel coming off will end up becoming the 'Holy Grail' in the event of a Judicial Enquiry, Insurance Claim, or Both!!!

    Regards,

    Colin. (Possible suicidal tendency again with this one?!?).

    P.S. This one is a marked pain to carryout in depth before treatment! It tends to get in the way of the treatment, but an absolute must I fear!
     
  2. johnmccall

    johnmccall Active Member

    Are we hiding our heads in the sand?

    Hi Colin,

    This is a real thorny issue which I feel none of us really want to address.

    Currently I get:
    1. Signed informed (also back up leaflet) consent for nail surgery and for taking digtial images
    2. Verbal (assumed*) informed consent with back up leaflet for most everything else.

    * Assumed Consent = me explaining the condition, outlining the options and carrying on with an agreed course of action. Unfortunately I don't always record the exact details of the conversation but an edited version with brief details. It's not enough I say, not enough!

    For my sins I've attended two talks on litigation recently. One by a London Barrister at the Diabetes UK conference in Glasgow and one by our very own Maureen O'Donnel (from GSOC) at a private practice forum in Stirling.
    Reach for the Immodium.

    I thought my record keeping was quite good however I wonder if it would stand up in a court room.

    If nothing else these two main things stuck in the heid:

    1. Communicate well with the patient to ensure that they know what the condition is, what the treatment options are and what the risks are (you need your evidence base for this one).

    2. Record absolutely everything, yes everything. Write it down carefully and legibly. Miss nothing out.

    Short of having a digital video/audio recording (with signed, informed consent of course!) of every patient consultation I really don't know how to keep a bomb-proof record that doesn't take longer to write than for the treatment to be done. Doctors ain't stupid, they use a dictaphone. I wonder if they keep the tape recordings after the paper/computer record is written.

    Cheers
    John
     
  3. C Bain

    C Bain Active Member

    Evidence!

    Hi John,

    Thank you for that! It has spurred me onto write this which I hope may be of use to someone? After retiring a good few years back now, and after the surgeon had stitched the two ends of the colon back together again, I decided to finish my degree and later train as a chiropodist, (No more police records or hourly filling in of Police Pocket Books etc.). One has these lapses of insanity from time to time you know?

    But now what do I find when I read this months article on record keeping in the Institute's Chiropody Review, (A good article I hasten to add!), a return to insanity in record keeping approaches! With your forbearance I would like to take you through what this could mean to the average podiatrist having his written work examined by a Judge and possible Jury?

    For example I am examine an Onychocriptosis on a patient's Left Hallux! I have to decide,

    1. Whether I can recover the corner of the nail and stem the infection safely?

    2. Send the patient to his G.P. for antibiotics and possible nail removal?

    3. Advice him to goto a Podiatrist locally who will be able to treat the nail if he/she can afford it?

    What are the implications of safe written procedures with regards to the production of forensic evidence which will end up in court later, expect the worst at all times?

    1. RECORDING:-

    1). Do I continue to write as I speak in the patient's personal records? Bearing in mind Judges do not like loose bits of paper!

    2). Should I adopt police procedure and write straight into my Medical Diary, (In my case a pocket book carried at all times and available, and up to date in my pocket whilst visiting.)?. This then becomes the original note which would be presented to the court rather than the Patient's record, sometimes with a loosely attached piece of paper or card?

    3). And as you have said John you would have everything in the Medical Record that had happened including the Kitchen Sink!!!

    2. EVIDENCE :- What is evidence?

    Briefly evidence as far as we are concerned fits into three parts,

    1). PRIMARY EVIDENCE. The Patient's Left Hallux. He may not want to give you it? (Mind you I have walked out of the Mortuary before four O'Clock in the morning with eight fingers and two thumbs, of course this one was dead at the time,(HPC. might not be happy at our recovering of this bit of Primary Evidence, however?).

    2). SECONDARY EVIDENCE. A full and accurate account of what has happened during the examination and treatment. Should it go directly on to loose Medical Record Card or more safely into your Medical Record Diary? Which ever first will become the ORIGINAL NOTE! All others are immediately demoted to copies, (Tertiary Evidence, Written Hearsay perhaps? Frown on by the courts!).

    I am considering going up a peg or two in my recording, (Part of the reason for starting this Thread against my better judgment?). I must have a separate computer never in touch with the Internet and secured from prying eyes. Disk only transfer one way if it becomes necessary! Then I can store photographic evidence safely. It is worth remembering the pitfalls of photographic images,

    (1). Printing must be as accurate as possible to the Original Primary Evidence for it to be good Secondary Evidence. The toe and nail must have colour and contrast as near as it makes no difference on the photograph! An accurate photographic copy, if the Judge tells the complainant to take his shoe and sock off what will the court find?

    (2). You must take a second photograph called a 'Situ.' This shows the toe and nail in situation on the patient!

    (3). You may need a Intermediate Situ. Shot if you cannot get the Patient's face beside the toe. (A joke, I wonder?).

    NB:- Don't forget the 2.54cm. measure label next to the toe? It, the photograph should be presented Actual Size.

    3. OPINION:- (Expert Evidence, Hearsay, Copies).

    This evidence happened not in the presence of the accused (Podiatrist!) - Expert evidence sits on the fringes of this one,

    1). What the Patient may think. (Primary if it relates to a scalpel slipping into the toe for example observed by the Patient!).

    2). When is a corn a verruca etc.?

    3). After treatment the toe falls off! The toe is primary evidence like the body at a murder scene, (Murdered toe - Might it be Toe-manslaughter if the Podiatrist did it without intent?).

    I have tried to put some humour into this Post. It's hard going when you think how serious this subject is! I haven't hardly mentioned chiropody from one end to the other in this.

    Regards,

    Colin.

    P.S. A few years ago I sat and listened to a Chiropodist speaking on the time he was suede for causing hurt and discomfort to a patient at his surgery. He now has a spy camera mounted above his surgery clock and the surgery I believe is wired for sound!!! (It turned out that the patient if that's what he was had suede his doctor, dentist etc. before starting on the chiropodist (He was exonerated, but you see what I mean!).

    P.P.S. I do not presume to have exhausted and produced a fireproof system here but I hope I have directed your attention to pitfalls in note taking here. I hope it will be of some use to somebody as this looms higher on the horizon as time goes by.
     
  4. DAVOhorn

    DAVOhorn Well-Known Member

    re informed consent

    Dear Colin,

    In my pCT we use informed consent when we use Local Analgesia and Nail Surgery. We are considering it for Gait Analysis and provision of orthotics.

    We use a specially printed form which provides a high quality Carbon copy.

    The original is given to the pt and we keep the copy.

    The form identifies the presenting pathology for which the identified treatment plan is indicated. the treatment plan is detailed.

    The benefits of the tt plan are itemised
    eg removal of offending nail , reductiion of incidence of OC Infection pain etcetc. Basically all the reasons why you have offered the tt plan to the pt.

    The risks of the tt plan are itemised which inclued:

    Anaphylaxis, fainting, pain from the LA, post op pain ,post op infection, post op regrowth. WE also add DEATH as a potential risk.

    We also give the pt the information leaflets on the procedure, post op dressing regime with which they must comply.

    They sign a receipt for these.

    If the pt does not appear to fully comprehend all of the above we chuck em out. If the pt umss and aaahs about signing the consent we chuck em out.

    So when the pt is able to prove to us they understand the presenting pathology the reason that they have been offered the procedure under stand the benefits and risks they are then offered the paperwork to sign.

    When they sign it is off to work we go.

    Hard to believe that all of the above is required to perform a very safe and low risk procedue.

    BUT THAT IS HOW IT IS.

    It has been this way in my area for a no of years now.

    We still have the occassional minor incident despite all of the above.

    The usual one is nausea due to fear and the occassional **** LOST HIS LUNCH.

    Best incident i have had is a gorilla off the rigs.

    Walked into clinic was greeted by myself and colleague. Pt asked do i have to have an injection?
    we replied yes and WALLOPPPPPP keeled over all 6ft 6in and 18 st of this guy.

    One must remember that this procedure is elective surgery, so consent is a big issue and must be fully explained to and understood by the pt.

    regards David
     
  5. C Bain

    C Bain Active Member

    Hi David,

    Yes, I like it! Especially the one about the gorilla!

    Regards.

    Colin.

    P.S. Helps to put things into focus, (Talking about these things, and judging where to draw the line, if there is a line to draw of course)!!!

    P.P.S Not trying to out do you David but last year I was sitting in one of my patients front-room cutting her nails when she gets an irate phone call from her G.P.'s Nurse. Seemly her 35yr. old son was about to get an injection at the surgery when she turns round in time to see the patient's son doing thirty mile an hour up the road, (We think it was the needle that did it!!!).
     
    Last edited: May 17, 2005
  6. DTT

    DTT Well-Known Member

    Hi John

    If what you say is so (and I have no reason to believe otherwise) then it has happened the world has gone totally and utterly mad !!!

    It is a practical impossibility to record give leaflets etc on EVERY eventuality .

    How about this way round :-

    Patient rings for appointment = (their choice)
    Arrive at surgery = Patient consent
    Primary examination carried out .
    Examination findings and explanations given to the patient verbally .
    proposed drug administration and patient notes recorded as usual

    THE PATIENT HAS THE OPTION TO LEAVE AT ANY STAGE IN THE PROCEEDINGS. THEY DO = PATIENT CHOICE , THEY DON'T = CONSENT TO TREATMENT

    Treatments and procedures are carried out in the best interests of the patients condition with safe effective practice .

    NO ONE HAS FORCED THE PATIENT TO STAY IF THEY DON'T WANT TO IF THEY ARE UNHAPPY WITH ANYTHING AT ANY STAGE THEY ARE FREE TO LEAVE = PATIENT CHOICE

    We can all dream ourselves into law courts and listen to the American horror stories from the Ambulance chasing lawyers and the ridiculous litigation situation there ,but I hope and believe we have not reached that stage here.
    Common sense must prevail or where do you stop ??

    Do we have CCTV installed in all our surgeries ?? sound recording ?? What happens to patient privacy and confidentiality not to mention photographing children ???? In your surgery or not , there IS a can of worms !!

    Unless you do that ,the "he said I said you said" will still prevail and as I was once told by a barrister , "justice has nothing to do with it , it is who can tell the biggest believable lie in court that will win" .

    Professional claimers are unfortunately becoming part of the life of everyone and are very well practiced in their "art"and know the levels that they can claim to make it cheaper to settle out of court .
    The only way that will stop this lying and cheating is when the courts stop awarding excessive payments for minimal injury and reform the legal profession to make it more accesible for the defendant in these cases .

    In the meantime my indemnity insurance is paid up like everyones I hope

    Be lucky

    Derek ;)
     
  7. DTT

    DTT Well-Known Member

    Hi David

    Surly a one liner as above covers all the risks and would save so much time and paperwork ?? :D

    Cheers

    Derek ;)
     
  8. C Bain

    C Bain Active Member

    One more for the Pot!

    Hi Derek,

    I knew you would not be able to keep out of this one after what you told me privately!!!

    Yes and I still wish I hadn't!

    Regards.

    Colin.
     
  9. Tuckersm

    Tuckersm Well-Known Member

    Hi All,

    we provide all new patients with an information sheet send out with their first appiontment letter. This includes all the info about where the clinic is and the importance of being on time and of wearing suitable clothing and usual footwear, we also include info on the risk of general podiatry care, ie we use sharp instruments and you may get cut etc. For the usual administration of an LA verbal consent is obtained and documented. I feel this follows the medical and dental model, as I have never signed a consent when recieving a local from a Dentist or a Doctor, nor when recieving a prescription for any medicine that is potentially harmful. For photos that are used clinically, eg; wound photos we don't require written consent, as this is similar to an X-ray, but we obatin consent if the pictures are to be used in presentations etc.

    If patients were to undergo a GA, written consent is important as the patient is unable to withdraw that consent.

    One are I do have some problem with is with patients who are not competent eg; following a CVA, who require podiatric nail care sometimes for safety reasons, to prevent skin tears etc. but are reauctant to have their feet touched. Is it OK to "force" nail cutting on such people?
     
  10. DTT

    DTT Well-Known Member

    Hi Stephen
    Nice to see the common sense approach on this consent issue is alive and well in Aus :)

    It is my understanding here in the UK , that unless the patient has been MEDICALLY CERTIFIED as mentally incompetent or incapable ,forced anything constitutes assault.

    Outside of this and in the situation of the type of group to which you refer eg; post cva , confused elderly ,Alzheimer's etc , I think the "carer/ relative would then have to give a written consent on the patients behalf for treatment to protect the patients safety and well being.

    My understanding of it

    Cheers

    Derek ;)
     
  11. DAVOhorn

    DAVOhorn Well-Known Member

    re consent

    Dear All,

    In the hospital i work in there a few very frail very elderly confused pts.

    The wards are one PCT and my dept is a different PCT.

    So when one of these souls comes down to see us we insist upon the named nurse who is able to act as the Guardian for that pt.

    If the pt is brought down without that person we refuse t/t as pt is not able to give their informed consent.

    It does cause friction with the wards even after 15 years of working in that hospital.

    Today a pt is brought from the ward.

    No referral form completed by the Senior Nurse on the ward.

    I insist that the referral form is correctly filled in and completed.

    Staff Nurse on ward phones my office to complain that i refused to tt the pt.

    I leg it down to the ward to ask WHAT IS GOING ON>

    They then reluctantly complete the referral form but then do not want to sign it. So i say fine no sign no touch pt.

    So they then grudgingly sign the referral form.

    I then ask the person who signed the form to accompany me to my clininc to oversee the tt. This again pleases the Nurse.

    So i win, the nurse attends and the pt is seen.

    The pt is not able to consent due to mental frailty and confusion so is not able to give informed consent.

    All i was aking for was that the pts named nurse who is their advocate to accompany their pt to my clinic in order to tt the pt of the ward.

    Joy.

    regards David
     
  12. DTT

    DTT Well-Known Member

    Hi David

    After some 24 years in the NHS (in a different discipline) I have seen the CARING , TLC and professionalism with many nurses depart in many cases to be replaced with self aggrandisement , self importance and quite frankly an uncaring hard attitude :mad:

    They are all up front with their pay scales ( my opinion is many are OVERPAID for what they do) and frequently tell visitors how hard done by they are , RUBBISH !!! :mad: .

    I think from what you have said , in your situation there is an abundance of these people !!

    Geriatric care is hard , heavy and thankless in many cases and there are some excellent nurses who care deeply for their charges. There are I believe many more who find everything too much trouble to help anyone that are rude uncaring and heavy handed on some of the most vulnerable sections of our society.

    David I genuinely sympathise with your position and admire your tenacity in getting the correct consent , but the question has to be asked , WHERE WERE THE ADMINISTRATORS / SENIOR MANAGERS whilst all this was going on ???? Are we not about patient CARE ??

    I left my previous discipline through injury and re trained and yes I am grandparented , but I have a total of 39 years in "hands on" patient care (including the elderly) and even now get a mixture of joy and sadness at outcomes and events and always try to give my best however old and confused.

    Your situation as you describe (and from that your frustration is evident) is at best sad at worst disgraceful .

    Have you thought about how much easier your job would be if we could all unite and support you as a profession ?? How much improvement to patient care would that bring ??

    Hah hum got all lyrical there for a mo :eek:

    Good luck to you & never give up :)

    Cheers

    Derek
     
  13. DAVOhorn

    DAVOhorn Well-Known Member

    re consent

    Dear Derek,

    There are many reasons why the quality of nursing care , and i would add care provided by others, is lacking self importance is only one.

    In many instances it comes down to the Management ensuring that they have the correct amount of staff for the needs of that ward.

    Also that there is an appropriate skill mix.

    ie not just one trained nurse and lots of anciliaries.

    There is an increasing reliance in the NHS on the use of and probably inappropriate use of untrained nurses.

    When you have insufficient staff the staff become prison warders as they have to ensure that everybody is safely tucked up in bed or safely strapped to a wheelchair.

    I heard of an incident recently where there was a fall of one pt and it required the 4 nurses on duty in that ward to deal with the incident.

    That left no other staff to attend to the several other pts on the ward.

    This is when the mobile go walk about, and the non mobile try to become mobile by joining the other fallen pt on the floor.

    Crazy but true.

    I will not pretend to know the answer.

    But here is an eye opener.

    Under Agenda For Change one East Anglian PCT has assimilated 35-40 care assistants on to AFC.

    No problem you would think.
    They go through the matching process are matched .

    Everybody is happy including the employer.

    Then finance go!!!!!!!!!!!!!!!!!

    35-40 staff with an average pay rise of £700.00, this equates to an employers cost of £1000.00 per emplyee due to NI holiday etc etc.

    So an immediate increase of salaries of 35-40 K.

    Now let me see we have a deficit of £7million in the PCT where the hell will we find this additional money.

    So now add on the other 1200 employees who will all get a pay rise under AFC in this PCT.

    1200 x 1k =£1,2000.000.00 additional salaries per annum.

    Well done Mr Blair.

    You have come up with a system which is non viable unless you the Govt put in the extra resources to fund AFC.

    So lets see to balance books reduce no of staff and increase the no of untrained anciliary staff to keep bums on seats to keep workforce no up.

    Then wonder why people are not going into the health care professions in the NHS.

    In my hospital 2 Catering staff have walked out this week.

    Admittedly one was due to the new NHS smoking policy , the other was due to AFC.

    This is a fun game.

    My depts advert for a Sen 2 post will be out soon. I wonder if anybody will apply?

    Hopefully a new Graduate will wish to join us.

    Enthusiastic and keen to get going.

    We will have to wait and see.

    regards David
     
  14. DTT

    DTT Well-Known Member

    Hi David

    You are preaching to the converted HONEST .

    I have not worked in the NHS for 18 years now but still come into contact with NHS situation and I still have many friends who still toil on in their particular disciplines , Nurses ,consultant surgeons,physicians , anaesthetists and see them talk to them learn from them .

    One point I would make is that you state it took FOUR nurses to deal with ONE patient fall which left a ward unattended :confused: I obviously don't know the details and there may well be a logical reason for it but FOUR nurses. ??? Could it be to quote a personal example :-

    I recently had an elderly relative die suddenly at home. An ambulance was called and a paramedic 3 staff in all. The police were called a police surgeon was called and after 4 hours the undertakers removed the body to the local hospital mortuary. In that 4 hours the ambulance crew and paramedic were in attendance throughout :confused: WHY ?? I don't know that answer to that one either

    The one thing they all have in common is the frustration of "the system" much of which you have described. and yes we have another 4 years ( at least) of the same thing ( shame as the other side actually won in England!!)

    I don't profess to know the answer either ,but even I get really angry when I try to integrate a " genuine need" patient into the NHS system because their financial position will not allow continued private treatment , and I am met with a wall of bureaucracy and administrative bovine excrement and despite my best efforts the patient is denied NHS care .

    I could cite several recent incidents but I won't bore you with the details as I'm sure you are aware of what I am referring to.

    Low staff morale ,staff shortages are always front runners in a benchmark for declining standards but yes we all know the system is at breaking point as far as funding goes :(

    Until clinicians are given back control of funding /patient care standards and yes the "bums on seats " brigade is disbanded I personally don't see any improvement in the foreseeable future .

    I wish you well

    cheers

    Derek
     
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