The Last Word: Improving methods of consent

By Dr Natalie Blakely and Mr Adrian Richards / 01 Feb 2015

Consultant plastic and cosmetic surgeon Mr Adrian Richards and aesthetic doctor Dr Natalie Blakely argue for better standards and streamlining of consent within the speciality of aesthetics

Mr Adrian Richards

Unlike other countries, the UK has traditionally had what is generally perceived as low levels of medical litigation. This, however, is changing, and many of us are seeing this change reflected in a rise in our indemnity costs. Many medical litigation cases hinge on the process of consent. They seek to address the following questions: Were the risks of the procedure fully explained to and understood by the patient? Is the risk and the patient’s understanding of the risk recorded accurately in the patient’s notes? During my plastic surgery fellowship in Australia in 2000, I was struck by the detailed nature of the Australian consent forms. In the UK, I had been used to a printed sheet with one line for the surgeon to write the potential complications of the procedure. In Australia, there were specific consent forms for each procedure and five to six pages detailing the pros and cons, as well as the potential risks associated with the specific procedures patients were undergoing. Patients were given the forms two weeks prior to surgery and, after having time to study the forms, were asked to sign their consent on the day of surgery, at the same time as the clinician. In some medical centres they were required to sign after each paragraph to demonstrate that they had read and understood all aspects of the form. Today, Australian surgeons still follow similar stringent consent guidelines. Acquiring consent for photographs is also essential. Under standard medical practice guidelines, practitioners should not show before and after pictures to other patients or publish them on or offline without specific written consent from the patient. We can all learn from this thorough approach. For the patient, a better understanding of the benefits versus risks of any procedure helps them to make a more informed decision on whether to undergo treatment. For the clinician, accurate, detailed and legible consent reduces the risk of litigation. At my clinic I have worked with our team to improve and standardise our consent process. This involves adhering to the following steps:

  • Prior to the first consultation the patient is sent an information pack detailing the surgical process, likely recover period and a description of possible post-operative complications, as well as contact details for a 24 hour hotline should they have any concerns.
  • During the first consultation the pros, cons and potential risks of the procedure are discussed and documented in the patient’s notes.
  • If photographs are taken, the patient signs the specific consent form.
  • The patient is given a procedure-specific consent form and a CD in which the pros and cons of the operation are discussed. Realising the demand for a simpler way for patients to understand the different aspects of the procedure, I created CDs, typically lasting 40-60 minutes, which provide the relevant information. I would recommend practitioners record their own CDs, as technique, treatment and outcome can vary.
  • During the second consultation the patient and clinician both sign the consent form, and the patient is asked to confirm in writing that they have listened to all of the information on the CD.
The completion of each stage is recorded in the patient’s notes. At present the consent forms are printed, signed and scanned onto our patient management system. In the future we hope to have a completely digital consent process with patients signing on screen.

In the 12 years I have been practicing, I’ve been fortunate to have a very low rate of litigation
– I believe this is partly due to our robust consent process. 

Dr Natalie Blakely

As our society becomes ever more litigious, it is vital that we as clinicians improve our consent process. Litigation rates in private practice and the NHS are reported to be rising at 20% per annum.1 In aesthetics, most doctors use consent forms that are normally provided by the manufacturer of the product. As they are product specific, most practitioners I have spoken to agree that they are more convenient to use. However, I found that I was constantly running out of these consent forms. During my personal research to find out how other practitioners dealt with the critical matter of consent, I came to the following realisations:

  • Some practitioners had only ever consented their patients once (sometimes as long as five years ago).
  • Some doctors did not consent at all, assuming implied consent. 
  • Most consultation notes did not reflect the detailed discussion that took place before a procedure. 
  • Consent is often not properly taken, with patients being asked to sign the form whilst the doctor is standing over them. A signature does not necessarily mean consent. The patient must fully understand every part of the consent form before that consent is valid.
We as a speciality need to ensure that we spend sufficient time educating patients about the risks and benefits of treatment before proceeding. New technology has allowed us to streamline this process. I founded a patient management app in order to aid this process, and I would love to create an interactive consent form to be used on an iPad. At the moment however, some aesthetic doctors still rely on pen and paper and rushed and incomplete consultation notes that leave us wide open to litigation (warranted or not). Isn’t it time we changed? 
References

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