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consent process. Patients may understand the information
presented, but some patients may decide not to decide and
choose to rely solely on their surgeon’s recommendation.
In general, patients should be encouraged to be more active
participants in the decision-making process, with the sur-
geon avoiding being the person actually making decisions
for the patient. Even though recommendations are permis-
sible, outright declarations of what “should be done” ought
to be withheld.
8,10
In general, surgeons should avoid mak-
ing declarations of “what to do,” but surgeons can still offer
clear recommendations and attempt to persuade patients
about a certain course of therapy if it seems clearly in the
patient’s best interest to do so. This does not mean that the
patient’s choices will be ignored, but rather that in discuss-
ing options with patients, the surgeon can still be clear that
a particular choice may appear to be a “poor” one in the
surgeon’s judgment.
After disclosure of information from the physician to the
patient, patients must then synthesize everything they have
learned from the treating surgeon, other consulting physi-
cians, family, friends, and any independent research to
make a final decision. It is important to remember that
patients need adequate time to process information, reflect
on their values and interests, and make an informed choice.
Surgeons similarly need time to learn enough about a pa-
tient’s life story, values, and priorities to help guide patients
in their decisions. The time and place in which the in-
formed consent process could be initiated include a variety
of conceivable scenarios, from the outpatient clinic setting
to the inpatient bedside. Depending on the type of opera-
tion for which consent is being obtained and the level of
discussion that the patient requests, the process of in-
formed consent may be best facilitated over the course of
multiple preoperative visits, during which enough time can
be allocated for the surgeon and patient to achieve a col-
laborative understanding of the patient’s best interests. Be-
cause informed consent is not a static event but rather an
ongoing process, several preoperative visits (or phone calls)
are preferable to a single preoperative visit. In addition,
viewing informed consent as an ongoing process serves to
strengthen the physician-patient relationship and improves
patient compliance.
8
Obviously, in the situation of a surgi-
cal emergency, much of this process may be lost because of
the urgency of the situation. The surgeon should keep in
mind, however, that in these situations the informing pro-
cess can also occur after the operation as part of the ongoing
development of the physician-patient relationship.
Obtaining consent from the patient
The second component of informed consent is the “con-
sent” process. The consent process can technically be done
without satisfying any of the essential elements of the “in-
formed” component. Although this is clearly not desirable,
it unfortunately may often be the case that patients consent
to procedures or interventions without properly being in-
formed. Having a patient simply sign an informed consent
form to satisfy a legal requirement does not necessarily
reflect that the patient understands the goals of care or
whether these goals are aligned with their values and inter-
ests. As such, although written consent is a routine and
necessary part of the informed consent process, surgeons
should not overly focus on the paper while ignoring the
process.
Still, the patient’s signature is almost always necessary
for an operation to proceed, so some form of documenta-
tion must exist.
18
Sometimes the essential elements of the
information disclosure are carried out before the patient
signs the consent document. It is permissible for the actual
signature to be obtained by residents, physician assistants,
or other properly trained staff after the surgeon has prop-
erly informed the patient,
19
but it is generally preferable
that both components of informed consent be carried out
together. In addition, although the process ideally should
occur during a preoperative clinic visit to allow adequate
time for questions, the surgeon should also see the patient
and personally confirm his or her consent on the day of the
operation.
The actual informed consent document needs to fulfill a
number of criteria (
Table 2
). First, the informed consent
document should provide a clear description of the
planned procedure and its attendant risks and benefits.
Second, the document must adequately articulate antici-
pated outcomes, both positive and negative, in the near and
distant future. Third, there should be some notation of the
questions asked by the patient during the informed consent
process — a particularly important element considering
that for some patients, a more complete understanding is
achieved only on reading the informed consent form. Sim-
ilarly, the physician’s response to these questions should be
noted, for example, in the surgeon’s preoperative clinic
note. The documentation should also record the presence
of all individuals involved in the informed consent process.
Last, the patient must authorize the surgeon and the surgi-
Table 2.
Essential Components of Documenting Consent
1. Clear description of the planned procedure and its risks and
benefits.
2. Details of possible alternative therapies, including the option of
no treatment, as well as their attendant risks and benefits.
3. Documentation that patient had chance to ask questions (eg,
clinic note “patient had chance to ask questions and all were
answered to their satisfaction”).
4. Authorization with signature of patient or surrogate decision-
maker. Confirmation of patient authorization with signature of
physician and witness.
Informed
Consent
and
the
Surgeon
Vol. 208, No. 4, April 2009
Childers et al
68