Do we reach the Montgomery Standard for Informed Consent in Trauma & Orthopaedic Surgery?

Background

The Montgomery vs.Lanarkshire case is a precedent and is driving the modernisation of consenting in our practice. Our aims were to establish consenting documentation practice, provide guidance for surgeons and to improve the patient experience during decision-making.

Methods

A three-cycle audit of consecutive elective patients from three-week theatre block schedules were included. Documentation from all sources were assessed and the following criteria were reviewed: grade of consenting clinician, documented alternative treatment options, description of specific risks, place and timing of consent and whether the patient received written information or a copied clinic letter. Findings from cycle 1(C1) were implemented into departmental education and thereafter two further cycles of data were collected.

Results

C1: 111 patients. C2: 46 and C3: 50 patients. Each cycle assessed 14 consultants’ cases. Consent was undertaken by consultants (54%), junior doctors (34%) and AHPs (11%). Specific patient and procedural risks were documented in 43%(C1) and 85%(C2), 42%(C3). Alternative treatment options in 48%(C1), 80%(C2) and 54%(C3). Only 14%(C1), 15%(C2) and 2%(C3) had documented written information provision. Provision of a copied letter to the patient was 6%(C1) and 35%(C2) and 4%(C3). The majority (95% all cycles) were consented in clinic, with 28% consented within dedicated consenting clinics. Documentation from dedicated consenting clinics outperformed standard clinics.

Conclusion

Highlighting poor documentation habits to clinicians can lead to improvements in practice. Documentation of all the alternative treatment options is required, doing away with medical paternalism. Clinicians should reflect on how they communicate and document information to the patient and how to demonstrate adequate time for pre-operative patient reflection. Cultural changes have occurred in that consent has rightly moved away from the pre-operative bedside and into the clinic. Clinicians should individually reflect on how to address their own shortcomings and other units should strongly consider a similar audit.

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