I turned up panic-stricken with my six year old son in A and E a little while ago. He was having proper breathing difficulties. I drove him through the busy town centre promising him anything from trips to the fair to “crisps later” to try to keep him happy and calm as he periodically struggled for air. It sounded like croup, but I thought it could be an asthma attack. I was frightened. A bossy nurse took in his state in a moment; “He’s got croup” she said. “We had eight of these in yesterday.” A few minutes later she turned up in the waiting room and squeezed a syringeful of steroids into his mouth. I don’t recall consent being asked or given. No risks or benefits were explained. No alternative treatment options were considered, or if they were, they weren’t mentioned. Did she confirm that I was his natural mother, not his stepmother (because in case you didn’t know, step-parents can’t give valid consent unless they are the legal guardian)? I don’t think so. I don’t even think she told me she was giving him steroids without me asking what was in the syringe. My meek, desperate state probably indicated that I trusted her and was happy for her to do anything she liked just to help him. And forget patient confidentiality. She had a voice like a foghorn. Ten minutes later we saw the doctor , who said she thought it wasn’t croup (this consultation still being conducted in the waiting room within earshot of everyone). The doctor looked pretty young, it was the week after junior doctors took up their posts, I’m guessing she’d googled croup and been thrown by the fact that the internet said he was older than the usual age. Well, there was a brief period of doubt, until a doctor a bit higher up the food chain apparently overrode google to confirm that yes, you could get croup at age 6. After a few hours the emergency had passed, and I gratefully took my son home to fulfil a string of rashly-given promises. Of course I didn’t mind at all that I hadn’t been asked for consent. I didn’t even notice, because I wanted them to do anything to help, and they did help. Thank you NHS. But what if something had gone wrong? What if my son had had a reaction to the medication? I would have sworn in court that I hadn’t given consent, but had I? It’s all a bit of a blur. I certainly implied by my manner that they could do what they liked, just please don’t let him die! And let’s face it, if all the nurse had to do was record in her notes that the patient’s mother had given consent, well it would have been my word against hers. That’s the thing with consent I’ve never quite understood, considering such weight is placed on it. Written consent carries no more weight than verbal consent. This provides an enormous loophole. The nurse could have diligently recorded it, even if she hadn’t actually done it. But this would count as proof in court? I’m as bemused by this as by the notion that crossed fingers can really ward off a vampire.
The CROaM Study – practitioners think patients are giving consent, when patients don’t think they are giving consent
From this experience, I realised that doctors and nurses have the same difficulties fulfilling the requirement to obtain consent as we do. And I am still learning, refining what I know, and still forgetting to do it sometimes. On an e-learning low back pain course , produced by Jerry Draper-Rodi (highly recommended, contact him on firstname.lastname@example.org if you want to sign up for it), I learnt a bit more about consent, courtesy of Steve Vogel. He is a bit of an expert, having been one of the authors of the CROaM study which was published in March 2014. No, I haven’t read it, (not even the shorter Summary version I’ve linked to), but I do plan to one day, honest. He had a few tips and points of interest which he explained on tape to Jerry Draper-Rodi. One of the interesting things they found was that osteopaths reported gaining consent quite a bit more than patients reported giving consent, which they only thought they had done 50% of the time. These were patients asked on the same day of treatment, not 6 months later. (Slightly reminiscent of the recent finding that principals of practices report giving a lot more support to their associates than associates report receiving – this giving and receiving strangely doesn’t seem quite in synch). To a patient, (and I’m thinking of myself clutching a pale and poorly child in the waiting room), giving consent probably should involve something a bit formal and explained. However from the other side of the therapeutic relationship, I would probably consider the patient had consented if they seemed to understand what I was saying, and didn’t disagree with my treatment plan, and murmured a vague assent to “is that all right, stop me at any time if something feels uncomfortable?”. So Steve Vogel’s solution is in the way you frame it. Instead of a breezy, collective “We’re going to do this….OK?”, you say something more like “I propose we do this, what do you think?”. I am guessing you want them to be aware they are actively deciding on their treatment, together with you.
The days of the paternalistic approach are over. It’s all about partnership now.
Some patients just love an authority figure. They even explicitly say “I trust you, do whatever you think will help”. And maybe a paternalistic relationship can form part of a therapeutic dynamic which really works well for the patient. (See Trisha Greenhalgh’s paper on measuring quality in the therapeutic relationship ) Well, that’s fine, unless something goes wrong. If my child had had some serious complication as a result of being given steroids, without me being warned, and despite an unsure diagnosis, I would have quickly forgotten my willingness to hand over all that responsibility. I would have fought my way through any court to get some sort of justice for him.
Warning about risks
Fortunately the risk of major adverse events is much lower with osteopathic than medical treatment. The only really prevalent risk is soreness, which is experienced by 20 – 25% people. So you really must warn patients about this, and warn them BEFORE the treatment. It’s quite common, (and I do this all the time), to tell people at the end of the session that they might experience soreness. Too late! This is no good if the person consented to the treatment unaware of these potential adverse effects. What if your patient is a lawyer, a lawyer who is going on a week’s holiday the following day, a lawyer who is not intimidated by legal processes and is quite happy to sue you because a third of their holiday was ruined by post-treatment physical discomfort? Well, you might be in trouble. (Yes, hypothetical scenario based on a true story). Consent isn’t even valid unless you have explained the benefits and risks before the treatment, so get used to needing assurance from the patient that they want you to go ahead even though they might be a bit sore afterwards.
It’s not just about HVT
It has become easy to think that HVT is the only thing we do that carries the risk of a serious adverse event, and apparently we tend to record and note consent specifically for HVTs. I know I do. It is a more evidently stand-alone technique, unlike soft tissue, advice and indirect work which all tend to run into each other. And it’s one technique that everyone knows has occasionally caused a stroke. But it’s not just HVT. Only recently there was a story in a Kent paper about a woman who had a stroke following a facial which included a neck massage. Yes, it might be incredibly rare, but worth bearing in mind, that techniques other than HVT need to be treated with similar care and respect.
Don’t do what I did
Yes I hope you realise I am on a learning curve myself. In a previous post I happily recounted that I frame the consent-obtaining-discussion in a kind of “sorry but we have to do this by law” way to soften the formality of the procedure. No, no, no, no, no. Apparently rolling your eyes whilst muttering “health and safety gone mad” is not the way to do it! Who’d have guessed? All that does is devalue the process, as if it is not an essential part of the consultation. Anything to help patients to feel that the locus of control for their treatment and condition is within themselves is a very helpful aspect of treatment, let alone a protection for the practitioner. It’s empowering, it ensures shared responsibility, it lessens the likelihood that you will be blamed for imposing something on someone, and it’s just a bit more respectful and grown up all round. Yes, to wildly paraphrase Steve Vogel, let’s be like Pollyanna who saw the good in everything, and try to see consent as a “helpful, useful engaging process” of the consultation, a rapport-building and information sharing feel-good time for you and your patient, not a boring, bureacratic burden.