Consenting and decision making in management of patients

S. Chockalingam

Senior Consultant in Orthopaedics, Kauvery Hospitals, Cantonment, Trichy

Background

The most important and sometimes difficult part of medicine is perhaps explaining the diagnosis, planning management. It may be surprising that the importance is given more than the management of the patient itself. We would discuss the reasons for the same in the paragraphs to follow. We would also discuss the issues in consenting and decision making and the strategies that one can follow as a health care professional for smoother transfer of information to help the patient.

As the information about a particular condition or disease is more easily accessible for the patient and relatives through other sources, the communication should become easier for a health care professional, one would imagine. However, the reality is often different as most health care professionals would vouch for.

With the information over the cloud more readily accessible, the patient has some understanding of the disease which is affecting her. Hence the doctor who is treating has to come with the terms that the patient may already have a good level of knowledge. The doctor then has to start the discussion at a different level although he/she would not have any idea of what the patient or the relatives already know.

A good way to start is to listen to the patients and relatives first prior to explaining the plan of management. How can we do this effectively, is a question which springs to our minds. The patient and the relatives may have some idea of the diagnosis and treatment options available to them. Some of them may not be appropriate to their situation, though. They also may have concerns about what is going to happen to themselves with or without treatment. Obviously we should understand that their expectations about the management. We can abbreviate this as

ICE, I.e Ideas, Concerns, Expectations. (Ref)

When the information the patients and relatives acquire from cloud resources, they may get clarity of the diagnosis and treatment, however they rarely look into the complications. When the information they get from other members such as friends and well wishers, the complications may be stressed more than necessary. Hence the consenting becomes difficult for the doctor and there is often a fear factor in the patient minds even if he or she consents in the end.

A way to go forward is to unearth from the patient and relatives of what is there in their minds with the information feed from multiple resources. We can then understand what the ICE of the patient. The doctor has to carefully go through one by one with an understanding as if he or she “is in their shoes”. One has to come to agreement of what is correct and what is misunderstood by the patient and relatives.

Here comes the difficult part of going though complications after the agreement of the diagnosis and treatment planned. Let us go through a scenario outlined below to get a clearer understanding of the same. A particular patient is admitted for a major surgical procedure, and with major anxiety about the outcome of the procedure in relieving her symptoms and cure of the disease itself. As the surgeon who is going to perform the procedure starts explaining of the surgery and possible complications, the patient understandably becomes more anxious.

It is a common and correct practice for a doctor to highlight the complications of an intervention which may be medication or intervention such as surgery. However here is a patient wants to get rid of a disease which is affecting her, but she starts getting information of what can go wrong in the process. Who would not, even if the patient is a doctor herself.

Hence a patient when explained that there is a 5% chance of developing a complication, his or her mind focuses on the complication itself. The corollary is that there is 95% chance of not developing the same complication and getting a good outcome. Even if there is 10% chance of a complications, there is 90% chance of not developing one!

Wouldn’t a patient want to know of the chances of not having a complication if he or she agrees for intervention, more than chances of developing one?. It is time to rethink the lines of communication we often follow due to the traditional learning as a doctor or health care professional.

Summary

To summarise, the consenting and decision making for an intervention would become easier and empathetic if we the health care professionals start

  1. imbibing ICE in our discussions which will help in appropriate understanding of the diagnosis and treatment of the ailment affecting the patient
  2. Explanation of the chances of not developing a complication or an untoward event would be more appropriate and avoid unduly increasing the concerns which the patient may already have.

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