Explaining risks and seeking informed consent
Shirin is 23 and self-conscious about her 32AA chest. She books a consultation with a clinic who specialises in breast enlargement and augmentation.
She is told that she will receive a no obligation consultation with one of the patient advisers who can talk her through the procedure to help her decide whether to go ahead. She is also told that she will have the opportunity to talk to her surgeon at a second consultation, before proceeding.
Shirin meets with Samantha, the patient adviser at her first consultation.
Samantha shows Shirin ‘before and after’ photographs of previous clients. Shirin says she’d like to be a DD cup after surgery and Samantha confirms that this is not a problem. Samantha recommends a particular type and size of implant.
Samantha tells Shirin that as with any surgery there are risks, but that the procedure is perfectly safe. She gives Shirin a leaflet about risks to read at home and recommends she signs up for the surgery and pays her deposit now so won’t have to wait months.
Shirin pays the deposit and Samantha books her in to see the surgeon in a month and have the procedure 10 days later.
Samantha gives Shirin a consent form to declare that she’s been given information about the procedure, had an opportunity to ask questions and understands the risks involved. Shirin signs it and leaves, planning to read the leaflet.
What happened next
One month later, Shirin has her second consultation with Mr Johnson.
Mr Johnson asks if she has any concerns or questions about the procedure but Shirin can’t think of anything specific and says so.
Mr Johnson hands her another consent form for her signature and asks Shirin to confirm that she has read the leaflet and asking if Samantha has gone through the risks. Embarrassed that she has not read the leaflet, Shirin nods and signs the second consent form.
After the form is signed, Mr Johnson confirms him that he will see her in ten days and waits for her to leave.
Shirin leaves confused. She thought Mr Johnson would ask about her medical history, any allergies to anaesthetic and go through the risks with her. She feels really rushed and blames herself for not reading the leaflet beforehand.
What the doctor should have considered.
- Seeking informed consent is more than paperwork it is a process, an exchange of information, sometimes over more than one discussion. It’s not just signing a form, although that may be part of it. (Guidance for doctors who offer cosmetic interventions paragraphs 17 and Decision making and consent paragraphs 6-7, 8-9, 30, 54-55)
- Patients need time. We don’t specify how long to leave between the consultation and the patient making a decision, but some clinics have a minimum ‘cooling off period’ e.g. two weeks. The length of time, and amount of information needed will vary from patient to patient, and from procedure to procedure. It’s important that the patient doesn’t feel rushed into making a commitment and that they know they can change their mind at any time. (Guidance for doctors who offer cosmetic interventions paragraphs 24 - 26)
- Consent is the doctor’s responsibility. Patients need information about risk to make informed decisions. There are numerous risks involved in surgery, anaesthesia and sedation, and it wouldn’t be reasonable to expect the surgeon to go through every single one with every patient. Written information has a role to play but it should be made clear to the patient how important it is to read the leaflet and note any particular concerns they’d like to discuss with the surgeon.
- Patient advisers should only give generic advice about the procedure e.g. how to prepare for surgery, what happens during the procedure, and how much time recovery usually takes. Any discussion about the risks, benefits, implications and limitations of cosmetic surgery, or the likely outcome in a specific case must be with the surgeon.
- The doctor carrying out the procedure must seek the patient’s consent themselves. (Guidance for doctors who offer cosmetic interventions paragraph 16)
- Doctors must talk to their patients about the potential adverse physical and psychological impact of the intervention going wrong, or failing to meet their expectations.
- Doctors should do their best to understand the patient’s views and preferences, and the outcomes they’re most concerned about. It’s important that doctors have a discussion with patients about this, rather than making assumptions. This includes risks that might result in a serious adverse outcome, even if the likelihood is very small, less serious side effects or complications if they occur frequently, and what to do if they experience any of them and risks, complications and side effects the patient is most concerned about. (Guidance for doctors who offer cosmetic interventions paragraphs 22 - 23 and Decision making and consent paragraphs 11-12,16-24, 27-30, 58f, 66-67).