Electronic Aids Enhance Informed Consent?

Rosemary Flanigan

April 30, 2010

A few years ago a Health Affairs article authored by Annette M. O’Connor, et al. (“Toward the ‘Tipping Point’: Decisions Aids and Informed Patient Choice.” 2007.Health Affairs 26(3)716-725) noted that "preference-sensitive treatment decisions involve making value trade-offs between benefits and harms that should depend on informed patient choice. There is strong evidence that patient decision aids not only improve decision quality but also prevent the overuse of options that informed patients do not value. . . .”

I have long been interested in real informed consent determination, and if “decision aids when used as adjuncts to counseling improve decision quality and reduce the overuse of surgical treatments by 25%,” then I guess they can’t be all bad.

These “decision aids” are growing like rabbits, and the article states that “An important element of these practice models is the key supportive role played by specially designed IT systems. For example, [one breast care program] is attempting to improve clinical care quality by incorporating IT to screen patients, inform physicians, cue the decision aid, assess naïve and informed preference, flat emotional distress and monitor decision quality”

WOW!! And all of this to help the patient decide risks/harms.

But wait, we’re not finished: The article goes on to say that the practice models for these “decision aids” can be used as examples for developing national standards (for health professionals and for health care organizations) AND certification is not far behind.

TELL ME, TELL ME, are we so bad with our present system of gaining informed consent that we might be attracted to these (computer-generated) aids??? (Or is my anti-electronic bias showing??? Might it not be just as well to suggest some people I could talk to if I can’t decide on a treatment modality?) HELP!

Informed consent and decisional capacity

Rosemary Flanigan
April 2, 2010

I’ve was thinking of the implication of enhancing one’s decisional capacity AND the validity of one’s informed consent.

Now, because I have been blessed with good genes and am lucky, I am not well informed first-hand about the informed consent process in hospitals, but I have heard that healthcare professionals are less liable to argue with a patient who readily signs the form than with the patient who hems and haws.

We all know that the signed form represents little in the way of evidence of real informed consent. I know how increased information, illustrations and stories can enhance decisional capacity for the patient who is decisionally problematic. But what about brain enhancement that minimizes risk, safety, self-preservation?

Are we careful enough in the informed consent process to address both sides of the issue: the cognitive/affective underbelly and the cognitive/affective over-stimulated?

Rosemary lambasted? Not quite.

Rosemary Flanigan, PhD

February 16, 2010

I am grateful to you all for NOT lambasting me over my analysis of the right thing to do in the Hastings Center Report case.

Even the ER doc on our Carondelet Health ethics committee urged me to bring the young woman into the discussion and not act simply because she said, “No” to re-doing the pregnancy test. And I like having a nurse around—good point.

On reflection, I thought it ironic that I, who have moaned over the loss of the sharp edge to informed consent requests would so easily slide right over it because the 14 year old refused—and I would get the information ANYWAY.

But what if I had acted so AND the test came out positive? How could I re-establish trust with my patient?

I shall tell you a presupposition that led to my heavy-handedness: I’ve taught 14 year olds. They are VERY young. But guidance need not be accompanied by a heavy tread.

THANKS.

Testing for Pregnancy without Consent

Rosemary Flanigan
February 12, 2010

The recent issue of the Hastings Center Report has a case study, the content of which surprised me. And then I knew that, if I offered it to you,, I would learn a lot. So here it is:

Samantha is a pale and withdrawn fourteen-year-old brought to the ER by her mother. She is fatigued, nauseated, and has been vomiting. Her mother tells the physician on call that she’s very worried; Samantha lately refuses to eat, has lost weight, has stopped going to soccer practice, and has missed several days of school.

The doctor examines Samantha and then asks if she may speak to her alone. Samantha and her mother agree; her mother leaves the room.

In response to the doctor’s questions, Samantha says that she first menstruated at age eleven, that her periods have been regular, and that she last had one four weeks ago. When the doctor asks whether she is sexually active, she admits that she had her first sexual contact right before her last period. She says it was consensual and that her partner used a condom.

She says she knows she’s not pregnant—she took a home pregnancy test the day before, and the results were negative.

The doctor asks if she can test Samantha again, and Samantha starts to cry. “I already told you, the test said I’m not,” she says. "I’m not pregnant!”

The question for us, of course, is whether or not the physician, who strongly suspects pregnancy, can test again as part of her workup.

And I shall argue (remember, it’s been a long time since I was 14) that if the physician fears the young woman will walk out of the ER without any tests, then the physician should talk fast about the need for blood tests to check for diabetes and a urine test to check for an infection.

Of course, the tests will also make clear whether or not she is pregnant (won’t they?) But I would risk not getting explicit informed consent if I could get consent for the other tests. It’s not ideal, but I can justify it.

Am I going to be lambasted??????? HELP!!!