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

11. You must try to make sure the information you share with patients about the options is objective. You should be aware of how your own preferences might influence the advice you give and the language you use. When recommending an option for treatment or care to a patient you must explain your reasons for doing so, and share information about reasonable alternatives, including the option to take no action. You must not put pressure on a patient to accept your advice.

(Decision making and consent, paragraph 11)

21. You must give patients clear, accurate and up-to-date information, based on the best available evidence, about the potential benefits and risks of harm of each option, including the option to take no action.

(Decision making and consent, paragraph 21)

24. You should consider using visual or other explanatory aids to support patients to understand their personalised risk, taking account of their individual clinical and personal circumstances, compared with population level risk.

(Decision making and consent, paragraph 24)

27. Patients need relevant information (see paragraph 10) to be shared in a way they can understand and retain, so they can use it to make a decision. To help patients understand and retain relevant information you should:

a. share it in a place and at a time when they are most likely to understand and retain it
b. anticipate whether they are likely to find any of it distressing and, if so, be considerate when sharing it
c. accommodate a patient's wishes if they would like to record the discussion
d. accommodate a patient's wishes if they would like anyone else - a relative, partner, friend, carer or advocate - to be involved in discussions and/or help them make decisions
e. use an interpreter or translation service if they have difficulty understanding spoken English
f. share it in a format they prefer - written, audio, translated, pictures or other media or methods
g. give them time and opportunity to consider it before and after making a decision.

28. You should be alert to signs that patients may need support to understand and retain the relevant information, use it to make a decision, or communicate that decision to you.

(Decision making and consent, paragraphs 27-28)

10. You must give patients the information they want or need to make a decision.

This will usually include:

a. diagnosis and prognosis
b. uncertainties about the diagnosis or prognosis, including options for further investigation
c. options for treating or managing the condition, including the option to take no action
d. the nature of each option, what would be involved, and the desired outcome
e. the potential benefits, risks of harm, uncertainties about and likelihood of success for each option, including the option to take no action.

By 'harm' we mean any potential negative outcome, including a side effect or complication.

13. Other examples of information that might be relevant and, if so, should be shared with patients include:

a. whether an option is an innovative treatment designed specifically for their benefit
b. whether there is a time limit on making their decision and what the implications of delaying might
c. the names and roles of key people who will be involved in their care, and who they can contact (and how) if they have questions or concerns
d. their right to refuse to take part in teaching or research
e. their right to seek a second opinion
f. any bills they will have to pay
g. any conflicts of interest that you or your organisation may have
h. any treatments that you believe have greater potential benefit for the patient than those you or your organisation can offer.

16. You must listen to patients and encourage them to ask questions.

30. You must check whether patients have understood the information they have been given, and if they would like more information before making a decision.

(Decision making and consent, paragraphs 10, 13, 16 and 30)