Informed consent: What should I discuss? Part 1

If I could pick the one aspect of anesthesia that has the most variability amongst practicing anesthesiologists, it would definitely be the informed consent discussion. When I was in residency, I noticed every attending had their own approach. Some had just one line, like "we'll take good care of you" (really, isn't that the best catch-all phrase in pre-op?). Other attendings listed a laundry list of possible anesthetic complications, talking so fast in a noisy pre-op area that there's no way the president of Mensa could have remembered all the details. 

So, what's the right answer? What do I need to discuss during the informed consent discussion? 

Well, this blog post is going to provide some clarity. But, there's a twist: I'm going to make clear how ambiguous the answer is. 

Let's start with some basics. We saw in my earlier post ("Informed Consent: The Legal Angle") that there's no law or statute that mandates the content of an informed consent discussion (as far as I'm aware). Similarly, I've never seen a hospital policy that does the same. 

In the world of medicolegal affairs, it's very common to hear about the "reasonable person standard". What does this mean? It means that the physician should discuss with the patient the relevant risks that a similar, reasonable person in the same situation would want to be informed of--risks that a "reasonable" person would "attach significance to" (also discussed in the aforementioned previous blog post). Notice that this has parallels with the standard of care definition, which is generally defined as the actions of a similarly-trained, reasonable, prudent physician practicing in that community. So, dumbing it down a little bit: you should discuss with the patient the things that most other reasonable patients would want to know. 

But let's face it. That's all neat and tidy when it's words on paper. In real life, we know things are much messier. Patients span an enormous spectrum with respect to level of education, health literacy, English comprehension, interest in their own medical care, and ability to process information. Picture two patients: the first is a 23-year-old healthy patient who's scheduled for a breast augmentation, and the second is an 85-year-old patient with mild cognitive impairment who's in acute pain from a hip fracture. Are those two patients going to process your informed consent discussion the same way? Of course not. 

As if this weren't complicated enough, let's add another wrinkle: in California, many patients don't speak English as their first language. Even with a professional translator, are you certain that you're getting your points across? It's important to note that many immigrants come from cultures that have a  paternalistic style of medicine, i.e. "this is what the doctor recommends, so that's what I'm gonna do" and patients may be much less engaged in the pre-op discussion because they're culturally accustomed to trust physicians.  

So, you're faced with a challenge: you want to have a meaningful informed consent discussion, but all your patients differ so much that you find it difficult to have a standard template for the discussion. 

In the second part of this blog post, I'll discuss some practical steps that will help you deal with these patient variables and have a meaningful informed consent discussion. Keep reading!