Informed Consent: Dan Schmidt--July 13, 2008
Opening Words:
Hippocrates, Decorum
Advice to physicians:
"Perform these duties calmly and adroitly, concealing most things from the patient while you are attending to him. Give necessary orders with cheerfulness and serenity, turning his attention away from what is being done to him; sometime reprove sharply and emphatically, and sometimes comfort with solicitude and attention, revealing nothing of the patient's future or present condition."
**********************************************************************
Word for meditation:
Proverbs 1:10 (Advice from King Solomon, son of David)
"My son, if sinners entice thee, consent thou not."
*************************************************************888
Informed Consent
Hello. As introduced I am a Family Physician. I got to spend a month on an Indian Reservation in the Grand Canyon this last spring. With no cable TV, no home or old car repairs to distract me, I found myself reading a book recommended by a friend in his first year of law school. It was titled "The Silent World of Doctor and Patient," by Jay Katz. It was a scholarly piece addressing the long history of the lack of communication between physicians and the people they care for. Dr. Katz chose to focus on the legal doctrine of informed consent. This concept is centered on the idea "that patients are entitled not only to know what the doctor proposes to do but also to decide whether an intervention is acceptable in the light of the risks and benefits and available alternatives, including no treatment." So, a judge in California came up with the idea that patients have some responsibility in their care, and doctors need to respect this. I wish to explore this subject today and invite your reflection.
First, let me ask, are there any lawyers here?
I ask to offer my apology, since I am not a legal scholar. The concept of informed consent arose in US law in the late 1950s. Notice I say this came from judges and has been somewhat reluctantly accepted by doctors. I will not cite case law, but it makes for good bedtime reading.
So I guess I should ask, are there any physicians besides me here today? I'm trying to get a sense of the audience, since doctors have a certain perspective on this topic.
Finally, how many of you have personal experience with signing an informed consent document? I have been a patient too, and if your experience was like mine, the process is treated as an inconvenience, a legal formality. Today I wish to convince you, all of you, the mistake in this casual approach.
It may or it may not surprise you that most doctors (80-90 percent in multiple polls) believe most patients are not capable of giving truly informed consent. So let's see what you all think. How many of you believe you can become informed about a medical decision and then consent or refuse for your treatment?
And not?
I'll admit to my skepticism. I often thought it was best for me to just decide, since the subtleties of the treatments, the odds of success or failure can be quite complex. But I think what I was confusing for an "informed" decision was instead what I considered the "right" decision. And that illusion, that there can be a "right" decision in the morass of uncertainty surrounding a person and their illness can be quite intimidating. But, as you heard Hippocrates advise, we doctors should at least act confident, even if we are unsure. I'll admit it. Often, I don't know what the right decision is. For instance, just to make this level of uncertainty of treatment clear to you, lets talk about heart disease. A heart attack. Acute myocardial infarction. Statistically, there's got to have been one or two of you out there who have gone through this. Most people have known some one with such a medical episode. Modern treatment of heart attacks includes intervention. In the old days we gave medicines and oxygen, observed in the hospital for arrhythmias. Now a days we intervene either with bypass surgery or angioplasty and stents. Do you know how many lives are saved with these interventions? We do know this number. Three good studies came up with the same results. If you separated 2000 acute MI patients, treated 1000 with the medicines and bed rest, the other 1000 with angioplasty or surgery, you would save four lives per thousand in the treated group. You need to treat 250 patients with this intervention to save one life. So what is the right decision in that setting? Medical culture is strongly on the side of intervention. How would you like to have a detailed discussion about the pros and cons, risks and benefits of this intervention when you're clutching your chest and dripping sweat, panting and short of breath? I'll admit to skipping the informed consent process in such settings. And I have skipped it when ordering a routine test. And for this I apologize. But it does not make the concept invalid because it may be difficult or inconvenient.
So let's add another confusing motivation. We have a profession, doctors, who deal with uncertainty, yet are trained to portray confidence. Most are private businessmen, dependant on a discriminating marketplace for their livelihood, and now I am suggesting they should openly share their uncertainty with their patients. Would this openness be welcome? Would it sell? Would this doctor have high moral standards and no patients? Does financial pressure affect a physician's ability to openly communicate? There are lots of studies that show doctors order more tests when they profit from these tests. But there are lots of reasons, on both sides of the doctor patient relationship why frank discussions might be avoided. For instance, just this last year the President of the American Board of Hematology/ Oncology chided his colleagues. In the last 10 years the percentage of patients dying of cancer who received chemotherapy within two weeks of their death almost doubled. More people trying to beat what will kill them. And why has this gone up so? Have doctors lost the skill of prognosis? Or are doctors just afraid to pass on bad news? Or is there a shared deceit that serves both parties in an unhealthy way?
I believe physicians and patients are often supporting each other in a mutual charade. Doctors are taught to be confident. Patients want answers. Why not give it?
There is a long history in the medical profession of reluctance in sharing information with patients. As physicians we are sworn to do no harm. Hippocrates gets credit for that. And as you heard in the opening words, four thousand years ago he thought lots of information was best kept from the patient. The worry was that information can cause harm. There is no doubt it can cure. The placebo effect is testimony to that. Doctors have known, for millennia, in an intimate and daily way, the power of information to affect a patients well being. It was long considered inappropriate to share grave news with patients. Sir Thomas Percival wrote advice to physicians in the 19th century:
"This office (delivering gloomy prognostications), however, is so particularly alarming, when executed by the attending physician, that it ought to be decline . . . However it can be assigned to any other person of sufficient judgment and delicacy."
He goes on to explain that the power of the physician to heal may be diminished by conveying such news. And if the goal is to heal one must maintain that power.
So the paternalistic role of physician is ancient, well established. Is it not desirable to patients that their physician fit the image? In an illness we may be vulnerable. When we seek care, are we seeking the responsibility of our illness and the treatment, which is required if we are to participate in a decision, or do we, the patients want to revert to a childlike state where our needs are decided for us? This psychological explanation for the paternalism of the doctor- patient relationship is most likely inadequate, and most definitely beside the point. But this does beg the question, can a sick person make a healthy choice, or should that choice be made for them? Doctors have often chosen the latter. Maybe patients have too. The doctrine of informed consent instead expects physicians and patients to communicate as adults, with mutual respect and dignity regarding their care. Both parties need to be in conversation. One shares an intimate knowledge of their life, their illness, their circumstances and desires; the other brings knowledge of disease processes and treatments. If the two are able to share, to speak, and to listen, to share their fears, what they know and do'’t know, the patient interests may be met.
And is the burden of uncertainty too great to bear? The truth of this world is that often two things can be true and yet seem to contradict. And for this we need faith. Often in medicine we need to make a decision based on partial information. Why not share this uncertainty with the person most affected by this decision? For too long the medical profession has shouldered the load of doubt, treating the patient like a child. This unequal relationship has lead to many misunderstandings. We can do better.
In summary, I support the concept of shared responsible decision making that is behind the doctrine of Informed Consent. I believe it is aligned with our Unitarian Values. All people, sick or well, have inherent worth and dignity. As a physician I should not let my fear of uncertainty, nor let the patient's desire for certitude interfere with the free and responsible search for truth.
Thank you for your time and attention. I invite your response.
*************************************************************************************
Closing words:
Jay Katz MD JD
. . . Informed consent could play a vital role in containing the much lamented explosion in medical cost. A greater clarity about the elective nature of many treatments may change patterns of utilization of medical services in significant ways. The time costs of conversation may turn out to be much less than the costs of intervention. . . . "Second medical opinions" may be one answer, but "first patient opinions": may be a better answer.
Hippocrates, Decorum
Advice to physicians:
"Perform these duties calmly and adroitly, concealing most things from the patient while you are attending to him. Give necessary orders with cheerfulness and serenity, turning his attention away from what is being done to him; sometime reprove sharply and emphatically, and sometimes comfort with solicitude and attention, revealing nothing of the patient's future or present condition."
**********************************************************************
Word for meditation:
Proverbs 1:10 (Advice from King Solomon, son of David)
"My son, if sinners entice thee, consent thou not."
*************************************************************888
Informed Consent
Hello. As introduced I am a Family Physician. I got to spend a month on an Indian Reservation in the Grand Canyon this last spring. With no cable TV, no home or old car repairs to distract me, I found myself reading a book recommended by a friend in his first year of law school. It was titled "The Silent World of Doctor and Patient," by Jay Katz. It was a scholarly piece addressing the long history of the lack of communication between physicians and the people they care for. Dr. Katz chose to focus on the legal doctrine of informed consent. This concept is centered on the idea "that patients are entitled not only to know what the doctor proposes to do but also to decide whether an intervention is acceptable in the light of the risks and benefits and available alternatives, including no treatment." So, a judge in California came up with the idea that patients have some responsibility in their care, and doctors need to respect this. I wish to explore this subject today and invite your reflection.
First, let me ask, are there any lawyers here?
I ask to offer my apology, since I am not a legal scholar. The concept of informed consent arose in US law in the late 1950s. Notice I say this came from judges and has been somewhat reluctantly accepted by doctors. I will not cite case law, but it makes for good bedtime reading.
So I guess I should ask, are there any physicians besides me here today? I'm trying to get a sense of the audience, since doctors have a certain perspective on this topic.
Finally, how many of you have personal experience with signing an informed consent document? I have been a patient too, and if your experience was like mine, the process is treated as an inconvenience, a legal formality. Today I wish to convince you, all of you, the mistake in this casual approach.
It may or it may not surprise you that most doctors (80-90 percent in multiple polls) believe most patients are not capable of giving truly informed consent. So let's see what you all think. How many of you believe you can become informed about a medical decision and then consent or refuse for your treatment?
And not?
I'll admit to my skepticism. I often thought it was best for me to just decide, since the subtleties of the treatments, the odds of success or failure can be quite complex. But I think what I was confusing for an "informed" decision was instead what I considered the "right" decision. And that illusion, that there can be a "right" decision in the morass of uncertainty surrounding a person and their illness can be quite intimidating. But, as you heard Hippocrates advise, we doctors should at least act confident, even if we are unsure. I'll admit it. Often, I don't know what the right decision is. For instance, just to make this level of uncertainty of treatment clear to you, lets talk about heart disease. A heart attack. Acute myocardial infarction. Statistically, there's got to have been one or two of you out there who have gone through this. Most people have known some one with such a medical episode. Modern treatment of heart attacks includes intervention. In the old days we gave medicines and oxygen, observed in the hospital for arrhythmias. Now a days we intervene either with bypass surgery or angioplasty and stents. Do you know how many lives are saved with these interventions? We do know this number. Three good studies came up with the same results. If you separated 2000 acute MI patients, treated 1000 with the medicines and bed rest, the other 1000 with angioplasty or surgery, you would save four lives per thousand in the treated group. You need to treat 250 patients with this intervention to save one life. So what is the right decision in that setting? Medical culture is strongly on the side of intervention. How would you like to have a detailed discussion about the pros and cons, risks and benefits of this intervention when you're clutching your chest and dripping sweat, panting and short of breath? I'll admit to skipping the informed consent process in such settings. And I have skipped it when ordering a routine test. And for this I apologize. But it does not make the concept invalid because it may be difficult or inconvenient.
So let's add another confusing motivation. We have a profession, doctors, who deal with uncertainty, yet are trained to portray confidence. Most are private businessmen, dependant on a discriminating marketplace for their livelihood, and now I am suggesting they should openly share their uncertainty with their patients. Would this openness be welcome? Would it sell? Would this doctor have high moral standards and no patients? Does financial pressure affect a physician's ability to openly communicate? There are lots of studies that show doctors order more tests when they profit from these tests. But there are lots of reasons, on both sides of the doctor patient relationship why frank discussions might be avoided. For instance, just this last year the President of the American Board of Hematology/ Oncology chided his colleagues. In the last 10 years the percentage of patients dying of cancer who received chemotherapy within two weeks of their death almost doubled. More people trying to beat what will kill them. And why has this gone up so? Have doctors lost the skill of prognosis? Or are doctors just afraid to pass on bad news? Or is there a shared deceit that serves both parties in an unhealthy way?
I believe physicians and patients are often supporting each other in a mutual charade. Doctors are taught to be confident. Patients want answers. Why not give it?
There is a long history in the medical profession of reluctance in sharing information with patients. As physicians we are sworn to do no harm. Hippocrates gets credit for that. And as you heard in the opening words, four thousand years ago he thought lots of information was best kept from the patient. The worry was that information can cause harm. There is no doubt it can cure. The placebo effect is testimony to that. Doctors have known, for millennia, in an intimate and daily way, the power of information to affect a patients well being. It was long considered inappropriate to share grave news with patients. Sir Thomas Percival wrote advice to physicians in the 19th century:
"This office (delivering gloomy prognostications), however, is so particularly alarming, when executed by the attending physician, that it ought to be decline . . . However it can be assigned to any other person of sufficient judgment and delicacy."
He goes on to explain that the power of the physician to heal may be diminished by conveying such news. And if the goal is to heal one must maintain that power.
So the paternalistic role of physician is ancient, well established. Is it not desirable to patients that their physician fit the image? In an illness we may be vulnerable. When we seek care, are we seeking the responsibility of our illness and the treatment, which is required if we are to participate in a decision, or do we, the patients want to revert to a childlike state where our needs are decided for us? This psychological explanation for the paternalism of the doctor- patient relationship is most likely inadequate, and most definitely beside the point. But this does beg the question, can a sick person make a healthy choice, or should that choice be made for them? Doctors have often chosen the latter. Maybe patients have too. The doctrine of informed consent instead expects physicians and patients to communicate as adults, with mutual respect and dignity regarding their care. Both parties need to be in conversation. One shares an intimate knowledge of their life, their illness, their circumstances and desires; the other brings knowledge of disease processes and treatments. If the two are able to share, to speak, and to listen, to share their fears, what they know and do'’t know, the patient interests may be met.
And is the burden of uncertainty too great to bear? The truth of this world is that often two things can be true and yet seem to contradict. And for this we need faith. Often in medicine we need to make a decision based on partial information. Why not share this uncertainty with the person most affected by this decision? For too long the medical profession has shouldered the load of doubt, treating the patient like a child. This unequal relationship has lead to many misunderstandings. We can do better.
In summary, I support the concept of shared responsible decision making that is behind the doctrine of Informed Consent. I believe it is aligned with our Unitarian Values. All people, sick or well, have inherent worth and dignity. As a physician I should not let my fear of uncertainty, nor let the patient's desire for certitude interfere with the free and responsible search for truth.
Thank you for your time and attention. I invite your response.
*************************************************************************************
Closing words:
Jay Katz MD JD
. . . Informed consent could play a vital role in containing the much lamented explosion in medical cost. A greater clarity about the elective nature of many treatments may change patterns of utilization of medical services in significant ways. The time costs of conversation may turn out to be much less than the costs of intervention. . . . "Second medical opinions" may be one answer, but "first patient opinions": may be a better answer.
posted by UUCP Sermons at 1:47 PM
