Working with doctors Working for patients

 

Introduction

Amber, who is 35, has been referred by her GP to Dr Rosin, a consultant in obstetrics and gynaecology. Amber is profoundly deaf and her preferred language is British Sign Language (BSL), although she does also lip-read.

Dr May and Dr Rosin are discussing a patient, Amber, who has been suffering from pelvic pain. Both doctors agree that the best course of action in Amber's case would be a diagnostic laparoscopy. Amber is deaf and her preferred language is British Sign Language (BSL).

Dr Rosin

Dr Rosin

Okay...so you're happy to take her through the purpose of further investigation and the various options, answer any concerns she may have about them. Then, if she agrees to the laparoscopy, you can talk her through the procedure, and give her any other information she needs to prepare for it

Dr May

Dr May

Ok...yep...So basically you want me to consent her for the operation.

Dr Rosin

Dr Rosin

I'd like you to seek her consent, yes. It's not just ticking a box you know. You need to make sure you've given her all the necessary information about risks and benefits, and you must be confident that you've addressed any concerns she may have. You'll see from the notes that Amber is profoundly deaf. There aren't any interpreters available today unfortunately, but she lip-reads so it should only be a question of taking the extra time to make sure she understands what you say.

Dr May

Dr May

I haven't got any extra time! Honestly I don't see why we have to go through this rigmarole - patients don't understand risk anyway!

Dr Rosin

Dr Rosin

You'll find that making assumptions about your patients' understanding is generally unwise, Dr May. And if they don't understand, you might want to ask yourself whether you've explained the issues adequately, using language and ideas that they're familiar with and so on... Now then...are you clear about what you're doing?

What should the doctor do...? (Select A,B or C)

A

Refuse to see Amber without an interpreter as he could not be sure she had understood everything and so her consent may not be valid?

B

Reschedule his remaining patients for the afternoon to ensure that he has enough time with Amber?

C

Talk Amber through the laparoscopy including risks and benefits but, because of the time constraints, do not discuss any alternative options in detail?

Dr May

See what the doctor did

Dr May allowed some extra time for his consultation with Amber and remembered to keep his face turned towards her most of the time to allow her to lip-read. However, during the consultation Dr May made an insensitive comment about Amber's deafness. Amber made a complaint about Dr May to the hospital management. This was investigated and resolved with an action plan including an apology from Dr May and his agreement to undergo additional training in disability awareness and communication skills.

References

19. You should give information to patients in a balanced way. If you recommend a particular treatment or course of action, you should explain your reasons for doing so. But you must not put pressure on a patient to accept your advice.

20. You may need to support your discussions with patients by using written material, or visual or other aids. If you do, you must make sure the material is accurate and up to date.

21. You should check whether the patient needs any additional support to understand information, to communicate their wishes, or to make a decision. You should bear in mind that some barriers to understanding and communication may not be obvious; for example, a patient may have unspoken anxieties, or may be affected by pain or other underlying problems. You must make sure, wherever practical, that arrangements are made to give the patient any necessary support. This might include, for example: using an advocate or interpreter; asking those close to the patient about the patient's communication needs; or giving the patient a written or audio record of the discussion and any decisions that were made.
(Consent: patients and doctors making decisions together, paragraphs 19-21)

8. You should not make assumptions about
a. the information a patient might want or need
b. the clinical or other factors a patient might consider significant, or
c. a patient's level of knowledge or understanding of what is proposed.

9. You must give patients the information they want or need about:
a. the diagnosis and prognosis
b. any uncertainties about the diagnosis or prognosis, including options for further investigations
c. options for treating or managing the condition, including the option not to treat
d. the purpose of any proposed investigation or treatment and what it will involve
e. the potential benefits, risks and burdens, and the likelihood of success, for each option; this should include information, if available, about whether the benefits or risks are affected by which organisation or doctor is chosen to provide care
f. whether a proposed investigation or treatment is part of a research programme or is an innovative treatment designed specifically for their benefit
g. the people who will be mainly responsible for and involved in their care, what their roles are, and to what extent students may be involved
h. their right to refuse to take part in teaching or research
i. their right to seek a second opinion
j. any bills they will have to pay
k. any conflicts of interest that you, or your organisation, may have
l. any treatments that you believe have greater potential benefit for the patient than those you or your organisation can offer.

10 You should explore these matters with patients, listen to their concerns, ask for and respect their views, and encourage them to ask questions.

11. You should check whether patients have understood the information they have been given, and whether or not they would like more information before making a decision. You must make it clear that they can change their mind about a decision at any time.
(Consent: patients and doctors making decisions together, paragraphs 8-11)