Tuesday, July 4, 2017

Consent Revisited: Inability to manage complications leads to violence

Consent, as we know, is the authorization or grant of permission by the patient for treatment or any diagnostic, surgical or therapeutic procedure to be carried out by the doctor. A doctor has to take consent from the patient before proceeding with his treatment. It is ethical and in today’s scenario, a legal requirement. Any act done without permission is “battery” or physical assault and is liable for punishment.

A valid consent has three components: Disclosure, Capacity and Voluntariness i.e. provision of relevant information by the doctor, capacity of the patient to understand the information given and take a decision based on the adequate information without force or coercion. This is informed consent. Any permission given under any unfair or undue pressure makes the consent invalid.

The Hon’ble Supreme Court of India has defined ‘adequate information’ in the landmark case of Samira Kohli vs Dr Prabha Manchanda. This includes “(a) nature and procedure of the treatment and its purpose, benefits and effect (b) alternatives if any available (c) an outline of the substantial risks and (d) adverse consequences of refusing treatment.”

No doctor practices medicine without taking informed consent. Yet we read and hear of incidents of violence against doctors from all parts of the country. So, are we going wrong somewhere? Are we doing something wrong somewhere?

“Medicine is an art based on science”, said Dr. William Osler. Complications, adverse events or untoward incidents may occur at any time during the treatment. What is important here, how competent, we are, as doctors, or how competent is the hospital or the clinical establishment, in managing these complications or untoward incidents in a non-emergent situation.

Not being able to manage complications leads to violence.

The patient should be informed of every possible complication that may occur during this treatment, however rare they might be; even a complication rate as low as 0.1% might be 100% for that particular patient. No surgery can be called as a ‘minor’ surgery.

Mistakes are made, but we believe that nothing will happen either to us or the patient. As I wrote few days back, it’s the case of "Kya pharak padta hai" to "bahut pharak padta hai". If nothing goes wrong, then "chalta hai". But, if something does go wrong or an unanticipated event occurs, then this becomes unacceptable “chalta nahi hai”.

The key word here is ‘anticipation’.

Anticipate what all can happen in the course of a treatment and be prepared to handle them or keep your patient informed. For example, you may need to shift the patient in an emergency to a higher care center and your establishment does not have an ambulance. Outsourcing an ambulance will delay patient transportation, and in an emergency situation, the longer the delay, more agitated are the patients or family members and may become violent.

Let’s take another example. You might need the services of a specialist, say a urologist, neurosurgeon, or a nephrologist. If your hospital does not have these specialty doctors on its staff, then subsequent delays in procuring their services will increase risk of violence.

Should you have these services and other such facilities as standby? Yes, everything must be on standby. The standby fee is 25%, while presence fee is 100%.

This may increase the cost of treatment. The time has come when the patient must know that safety comes at a price in bigger hospitals.

Inform the patient and the family members beforehand, let the patient choose and accordingly the consent should be taken. Safety of the patient is very important and should be our primary objective.

A small set-up may not have all facilities as their bigger and better equipped counterparts. These smaller set-ups should keep the patient and/or family members informed about this lack of facilities and take consent.

Good communication can reduce the rapidly increasing problem of violent attacks on doctors and healthcare establishments.

‘Adequate information’ for consent should include not only the competency of the doctor to treat the case, but also include the competency of the doctor and/or the hospital to manage any emergencies or untoward incident in a non-emergent situation. Any breach in this duty is negligence.

This, I believe, is an area which we need to work on. It is the inability to manage complications that leads to violence.

As doctors we SERVE our patients and the community and provide

·  Service which we have professionally trained for, which is
·  Excellent i.e. anticipated
·  Responsible, give our 100% to the patients and take responsibility
·  Value – Group; each member of the group knows the duties of another, so no gap in service may result
·  Enthusiasm: A positive happy atmosphere

This is how we can avoid incidents of assault and violent attacks on doctors from happening.

Dr KK Aggarwal

National President IMA & HCFI

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