Informed consent and decision making by cataract patients

Caregiver comprehension and satisfaction associated with informed consent for pediatric flexible bronchoscopy: A single-center experience

Pediatric flexible bronchoscopy (FB) is a relatively common procedure performed in children with respiratory concerns. Despite this, there is no data examining the informed consent process for FB. A prospective study evaluating informed consent comprehension and satisfaction was conducted in 71 primary caregivers of children undergoing outpatient FB. Most caregivers (97%) were overall satisfied with the consent process and reported understanding the potential benefits (97%) and minor risks (94%) associated with the procedure. A smaller percentage (83%) reported understanding major risks associated with FB. Patient safety was reported as the most important aspect of the consent process. Caregivers of children undergoing FB for the first time were more likely to want additional FB-specific information when compared to caregivers of children who had previously undergone FB (53% vs 16%, odds ratio: 5.97). In general, caregivers of children undergoing outpatient FB are satisfied with the informed consent process. Areas for improvement include ensuring adequate understanding of major risks associated with the procedure and considering a tailored approach based on the caregiver's level of experience.

An evaluation of the efficacy of a supplemental computer-based tutorial to enhance the informed consent process for cataract surgery: an exploratory randomized clinical study

Background

To assess whether informing patients with a computer-based tutorial in addition to standard informed consent influences the patient’s attitude towards surgery and increases patient’s knowledge.

Methods

In this prospective, exploratory, randomized clinical study, patients scheduled for their first eye cataract surgery were randomly allocated to two groups, receiving standard face-to-face informed consent (control group) or additionally using an interactive computer-based tool (CatInfo) containing an audiovisual presentation about cataract and its treatment (study group). Cataract-related knowledge and decisional confidence (decisional conflict scale (DCS)) were assessed as well as one-month postoperatively decisional regret (decision regret scale (DRS)) and willingness to exchange face-to-face discussion time for the use of such a tool.

Results

The study comprised 134 patients, 64 patients in the study group and 70 in the control group. Patients in the study group answered more questions correctly, 16.3 ± 2.0 (median 16.5, 11.0–19.0) versus 15.5 ± 1.9 (median 16.0, 8.0–19.0; p = 0.01). Patients showed a high decisional confidence with a study group mean DCS score of 92.4 ± 9.8 (median 96.9, 65.6–100) and control group score of 91.6 ± 10.9 (median 95.3, 43.3–100; p = 0.52). Mean DRS score in the study group was 2.5 ± 8.0 (median 0, 0–40) and 4.3 ± 12.5 (median 0, 0–75) in the control group (p = 0.14). Of study group patients 23 (67.6%) were willing to trade time, on average 158 ± 180 s (median 120 s, 45–900). Satisfaction with the tool was high with a mean of 9.1 ± 1.3 out of 10 (median 9.7, 5.0–10).

Conclusions

Cataract-related knowledge was generally good, with slightly higher scores in the study group. In both groups, decisional confidence was high and regret after surgery was low. A tendency towards slightly higher decisional confidence and lower regret was found in the study group, although these differences were not statistically significant. Additional use of an interactive computer-based tool may prove useful in the informed consent process in a high-volume cataract outpatient setting.

Trial registration

ClinicalTrials.gov, NCT04975126. Retrospectively registered – July 23, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02652-z.

User Friendliness of a Wearable Visual Behavior Monitor for Cataract and Refractive Surgery

A prospective feasibility study was conducted to determine whether a new wearable device, the Visual Behavior Monitor (VBM), was easy to use and did not present any difficulties with the daily activities of patients. Patients for cataract surgery and refractive lens exchange were randomly selected and screened for inclusion in the study. A total of 129 patients were included in the study as part of a multicenter study. All measurements were performed before surgery. Upon inclusion, patients were trained to wear the device, instructed to wear it for a minimum of 36 h, and were scheduled to return in one week. The VBM measures the distance at which patients’ visual activities are performed, the level of illumination, and head translational and rotational movements along the three axes. On the follow-up visit, patients completed a questionnaire about their experience in wearing the device. All patients underwent standard diagnostic testing, with their cataract grade determined by the Lens Opacities Classification System (LOCS) classification. Results indicate that 87% of patients felt comfortable using the wearable device while 8% of patients responded as not feeling comfortable (5% of patients did not respond to the question). In addition, 91% of patients found it easy to attach the wearable to the magnetic clip while 4% of patients did not find it easy, and 5% of patients did not respond. Overall, patients found the device easy to use, with most reporting that the device was not intrusive.

A randomized, controlled trial of video supplementation on the cataract surgery informed consent process

PURPOSE

To assess the effects of the American Academy of Ophthalmology's 2015 patient education video on patient information retention and anxiety preoperatively, on the day of surgery and postoperatively.

METHODS

This is a prospective, surgeon-blinded randomized controlled trial at the University of Chicago Medical Center. Ninety-one patients with a diagnosis of first-eye cataract were randomized into either a video or control group. Subjects in both groups received face-to-face discussion with the surgeon and an informational brochure at the preoperative evaluation. Participants in the video group then viewed a four-minute educational video at the preoperative evaluation and on the day of surgery. Both groups completed an information retention quiz and a state anxiety assessment at the preoperative visit, on the day of surgery, and on the postoperative week one visit. Subject understanding of cataract surgery was measured using a twelve-question multiple choice quiz. State anxiety was measured by State Trait Anxiety Inventory-Y1 survey score.

RESULTS

Participants in the video group did not score significantly higher on the information retention quiz compared with the control group at the preoperative evaluation (8.7 ± 2.4 vs 7.7 ± 2.5, P = 0.07), but did so on the day of surgery (11.2 ± 0.8 vs 8.4 ± 1.7, P < 0.001) and postoperative week 1 visit (10.8 ± 1.5 vs 9.0 ± 2.0, P < 0.001). Subjects in the video group were significantly less anxious on the day of surgery (26.4 ± 5.1 vs 41.1 ± 10.3, P < 0.001).

CONCLUSIONS

Video supplementation to the traditional informed consent process demonstrated an improvement in patient understanding of cataract surgery at multiple timepoints and decreased anxiety on the day of surgery.

Informed consent in refractive surgery: in-person vs telemedicine approach

Purpose

The aim of this study was to compare the quality of consent process in refractive surgery between patients who had a preoperative consent discussion with the surgeon using a telemedicine approach and those who had a face-to-face discussion.

Methods

Patients treated between January and December 2017 (8,184 laser vision correction [LVC] and 3,754 refractive lens exchange [RLE] patients) that attended day 1 and 1-month postoperative visit were retrospectively reviewed. Preoperative consent preparation included a consultation with an optometrist, observation of an educational video, and written information. Patients then selected either a face-to-face appointment with their surgeon (in-clinic group) or a telemedicine appointment (remote group) for their consent discussion, according to their preference. Patient experience questionnaire and clinical data were included in a multivariate model to explore factors associated with consent quality.

Results

Prior to surgery, 80.1% of LVC and 47.9% of RLE patients selected remote consent. Of all LVC patients, 97.5% of in-clinic and 98.3% of remote patients responded that they were adequately consented for surgery (P=0.04). Similar percentages in the RLE group were 97.6% for in-clinic and 97.9% for remote patients (P=0.47). In a multivariate model, the major predictor of patient's satisfaction with the consent process was postoperative satisfaction with visual acuity, responsible for 80.4% of variance explained by the model. Other significant contributors were postoperative visual phenomena and dry eyes, difficulty with night driving, close-up and distance vision, postoperative uncorrected distance visual acuity, change in corrected distance visual acuity, and satisfaction with the surgeon's approach. The type of consent (remote or in-clinic) had no impact on patient's perception of consent quality in the regression model.

Conclusion

The majority of patients opted for telemedicine-assisted consent. Those who chose it were equally satisfied as those who had a face-to-face meeting with their surgeon. Dissatisfaction with surgical outcome was the major factor affecting patient's perception of consent quality, regardless of the method of their consent.

A randomized trial of multimedia-facilitated informed consent for cataract surgery

Objective

The aim of this study was to evaluate the value and role of patient’s education videos in the informed consent process for patients undergoing preoperative assessment of cataracts.

Design

The study is a single-center prospective randomized controlled trial.

Subjects, participants, and/or controls

Participants enrolled in this study were specifically those undergoing first-time phacoemulsification cataract surgery with the placement of a monofocal lens implant.

Participants and methods

Subjects were randomized to either face-to-face surgeon-informed consent with a preceding education video or face-to-face surgeon-informed consent alone.

Main outcome measures

The main outcome measures assessed were time to complete the informed consent process, patient’s satisfaction, and patient’s comprehension.

Results

The video and control groups were similar in satisfaction (4.67±0.104 video vs. 4.53±0.133 control; P=0.43) and comprehension (79.4%±2.82% video vs. 79.3%±3.39% control; P=0.99). Counseling time was statistically significantly different (117.5±10.9 seconds video versus 241.6±13.0 seconds control; P<0.0001).

Conclusion

Use of a patient’s education video for cataract surgery was associated with reduced physician counseling time yet similar comprehension and patient-reported satisfaction when compared with traditional counseling methods.

Video-Assisted Informed Consent for Cataract Surgery: A Randomized Controlled Trial

Purpose. To investigate whether adding video assistance to traditional verbal informed consent advisement improved satisfaction among cataract surgery patients. Methods. This trial enrolled 80 Chinese patients with age-related cataracts scheduled to undergo unilateral phacoemulsification surgery. Patients were randomized into two groups: the video group watched video explaining cataract-related consent information and rewatched specific segments of the video at their own discretion, before receiving traditional verbal consent advisement; the control group did not watch the video. Outcomes included patient satisfaction, refusal to consent, time to complete the consent process, and comprehension measured by a ten-item questionnaire. Results. All 80 enrolled patients signed informed consent forms. Compared with the control group, members of the video group exhibited greater satisfaction (65% versus 86%, p = 0.035) and required less time to complete the consent process (12.3 ± 6.7 min versus 5.6 ± 5.4 min, p < 0.001), while also evincing levels of comprehension commensurate with those reported for patients who did not watch the video (accuracy rate, 77.5% versus 80.2%, p = 0.386). Conclusion. The video-assisted informed consent process had a positive impact on patients' cataract surgery experiences. Additional research is needed to optimize patients' comprehension of the video.

Role of the treating surgeon in the consent process for elective refractive surgery

Purpose

To compare patient’s perception of consent quality, clinical and quality-of-life outcomes after laser vision correction (LVC) and refractive lens exchange (RLE) between patients who met their treating surgeon prior to the day of surgery (PDOS) or on the day of surgery (DOS).

Design

Retrospective, comparative case series.

Setting

Optical Express, Glasgow, UK.

Methods

Patients treated between October 2015 and June 2016 (3972 LVC and 979 RLE patients) who attended 1-day and 1-month postoperative aftercare and answered a questionnaire were included in this study. All patients had a thorough preoperative discussion with an optometrist, watched a video consent, and were provided with written information. Patients then had a verbal discussion with their treating surgeon either PDOS or on the DOS, according to patient preference. Preoperative and 1-month postoperative visual acuity, refraction, preoperative, 1-day and 1-month postoperative questionnaire were compared between DOS and PDOS patients. Multivariate regression model was developed to find factors associated with patient’s perception of consent quality.

Results

Preoperatively, 8.0% of LVC and 17.1% of RLE patients elected to meet their surgeon ahead of the surgery day. In the LVC group, 97.5% of DOS and 97.2% of PDOS patients indicated they were properly consented for surgery (P=0.77). In the RLE group, 97.0% of DOS and 97.0% of PDOS patients stated their consent process for surgery was adequate (P=0.98). There was no statistically significant difference between DOS and PDOS patients in most of the postoperative clinical or questionnaire outcomes. Factors predictive of patient’s satisfaction with consent quality were postoperative satisfaction with vision (46.7% of explained variance), difficulties with night driving, close-up vision or outdoor/sports activities (25.4%), visual phenomena (12.2%), dry eyes (7.5%), and patient’s satisfaction with surgeon’s care (8.2%).

Conclusion

Perception of quality of consent was comparable between patients that elected to meet the surgeon PDOS, and those who did not.

Litigation trends and costs in otorhinolaryngology

BACKGROUND

Litigation in surgery is increasing and liabilities are becoming unsustainable. This study aimed to analyse trends in claims, and identify areas for potential risk reduction, improved patient safety and a reduction in the number, and cost, of future claims.

METHODS

Ten years of retrospective data on claims in otorhinolaryngology (2003-2013) were obtained from the National Health Service Litigation Authority via a Freedom of Information request. Data were re-entered into a spreadsheet and coded for analysis.

RESULTS

A total of 1031 claims were identified; of these, 604 were successful and 427 were unsuccessful. Successful claims cost a total of £41 000 000 (mean, £68 000). The most common areas for successful claims were: failure or delay in diagnosis (137 cases), intra-operative problems (116 cases), failure or delay in treatment (66 cases), failure to warn - informed consent issue (54 cases), and inappropriate treatment (47 cases).

CONCLUSION

Over half of the claims in ENT relate to the five most common areas of liability. Recent policy changes by the National Health Service Litigation Authority, over the level of information divulged, limits our learning from claims.

A survey of potential and previous cataract-surgery patients: what the ophthalmologist should know

Objective

This study utilized a phone survey to characterize patient perceptions of cataract surgery and the manner in which the ophthalmologist contributes to the patient’s understanding in electing cataract surgery.

Patients and methods

Calls were made from a randomized membership list of the American Association of Retired Persons until 1,000 respondents 50 years of age or older had been recruited. Three groups were recruited: persons with no prior diagnosis of cataracts, persons diagnosed with cataracts but who had not had surgery, and persons who had had cataract surgery on both eyes within the past 5 years. A series of fixed-choice and open-ended questions was then presented to qualified participants. Questions related to vision, quality of life, and the understanding and perceptions of cataract surgery.

Results

Two-thirds of respondents reported having frequent eye examinations. More than half indicated that they had discussed cataract surgery with an eye doctor, most often with an ophthalmologist. They reported that the benefits of surgery were most often mentioned (68%), but lens options were infrequently mentioned (39%). Of those who had had surgery, 81% elected to do so on the advice of their health care professional. About 85% of respondents who had had surgery felt well educated about the procedure, though only 75% felt they understood their lens and vision options. Three-quarters of those who had had cataract surgery wished they had had the surgery sooner, and reported that they were enjoying life more after surgery.

Conclusion

The ophthalmologist plays an important role in preparing patients for cataract surgery. Discussing both the timing of the surgery and the patient’s lens options are critical for appropriate care; the survey results suggest room for improvement in this regard. Respondents reported they wished they had had surgery sooner, based primarily on their improved quality of life postoperatively.

Research methodologies in informed consent studies involving surgical and invasive procedures: time to re-examine?

OBJECTIVE

We conducted a review of informed consent studies involving surgical and invasive procedures and report the degree to which current research targets a broader scope of patient outcomes beyond comprehension.

METHODS

Using PubMed, Cumulative Index to Nursing and Allied Health Literature, and Excerpta Medical Database, we identified 97 articles for review. Six members coded articles and generated scores of study design quality.

RESULTS

The mean quality score (10.7 out of a total score of 20) was low. Most studies were single institution-based, relying on one-time data collections. Randomly assigning subjects to study conditions, using power analysis to determine subject numbers, and reporting psychometric evidence, such as reliability and validity, were not widely reported. Most frequently targeted patient outcomes were knowledge, understanding and satisfaction. Core informed consent outcomes (e.g. capacity, voluntariness, decision making) and emotional factors (e.g. anxiety) were not extensively addressed.

CONCLUSION

Informed consent research may benefit from applying qualitative methods to more directly tap into patients' beliefs and decisions by eliciting in patients' own words their emotions and reasoning around processing informed consent content.

PRACTICE IMPLICATIONS

Research that addresses patient perspectives toward surgical interventions should tap into underexplored ethical and emotional factors that shape decision making.

Pain intensity and patients' acceptance of surgical complication risks with lumbar fusion

STUDY DESIGN

Cross-sectional study with prospective recruitment.

OBJECTIVE

To determine the relationship of pain intensity (back and leg) on patients' acceptance of surgical complication risks when deciding whether or not to undergo lumbar spinal fusion.

SUMMARY OF BACKGROUND DATA

To formulate informed decisions regarding lumbar fusion surgery, preoperative discussions should include a review of the risk of complications balanced with the likelihood of symptom relief. Pain intensity has the potential to influence a patient's decision to consent to lumbar fusion. We hypothesized that pain intensity is associated with a patient's acceptance of surgical complication risks.

METHODS

Patients being seen for the first time by a spine surgeon for treatment of a nontraumatic or non-neoplastic spinal disorder completed a structured questionnaire. It posed 24 scenarios, each presenting a combination of risks of 3 complications (nerve damage, wound infection, and nonunion) and probabilities of symptom relief. For each scenario, the patient indicated whether he or she would or would not consent to a fusion for low back pain (LBP). The sum of the scenarios in which the patient responded that he or she would elect surgery was calculated to represent acceptance of surgical complication risks. A variety of other data were also recorded, including age, sex, education level, race, history of nonspinal surgery, duration of pain, and history of spinal injections. Data were analyzed using bivariate and multivariate regression analyses.

RESULTS

The mean number of scenarios accepted by 118 enrolled subjects was 10.2 (median, 8; SD, 8.5; range, 0-24, or 42.5% of scenarios). In general, subjects were more likely to accept scenarios with lower risks and higher efficacy. Spearman rank correlation estimates demonstrated a moderate association between the LBP intensity and acceptance of surgical complication risks (r = 0.37, P = 0.0001) whereas leg pain intensity had a weak but positive correlation (r = 0.19, P = 0.04). In bivariate analyses, a history of spinal injections was strongly associated with patients' acceptance of surgical complication risks and willingness to proceed with surgery (54.5% of scenarios accepted for those who had a history of spinal injections vs. 27.6% for those with no history of spinal injections, P = 0.0001). White patients were more willing to accept surgery (45.9% of scenarios) than non-white patients (28.4%, P = 0.03). With the available numbers, age, sex, history of nonspinal surgery, education, and the duration of pain demonstrated no clear association with acceptance of surgical complication risks. Although education overall was not an influential factor, more educated males had greater risk tolerance than less educated males whereas more educated females had less risk tolerance than less educated females (P = 0.023). In multivariate analysis, LBP intensity remained a highly statistically significant correlate (P = 0.001) of the proportion of scenarios accepted, as did a history of spinal injections (P = 0.001) and being white (0.03).

CONCLUSION

The current investigation indicates that the intensity of LBP is the most influential factor affecting a patient's decision to accept risk of complication and symptom persistence when considering lumbar fusion. This relationship has not been previously shown for any surgical procedure. These data could potentially change the manner in which patients are counseled to make informed choices about spinal surgery. With growing interest in adverse events and complications, these data could be important in establishing guidelines for patient-directed surgical decision making.

Patient preferences for shared decisions: a systematic review

OBJECTIVES

Empirical literature on patient decision role preferences regarding treatment and screening was reviewed to summarize patients' role preferences across measures, time and patient population.

METHODS

Five databases were searched from January 1980 to December 2007 (1980-2007 Ovid MEDLINE, Cochrane Database of Systematic Reviews, PsychInfo, Web of Science and PubMed (2005-2007)). Eligible studies measured patient decision role preferences, described measures, presented findings as percentages or mean scores and were published in English from any country. Studies were compared by patient population, time of publication, and measure.

RESULTS

115 studies were eligible. The majority of patients preferred sharing decisions with physicians in 63% of the studies. A time trend appeared. The majority of respondents preferred sharing decision roles in 71% of the studies from 2000 and later, compared to 50% of studies before 2000. Measures themselves, in addition to patient population, influenced the preferred decision roles reported.

CONCLUSION

Findings appear to vary with the measure of preferred decision making used, time of the publication and characteristics of the population.

PRACTICE IMPLICATIONS

The role preference measure itself must be considered when interpreting patient responses to a measure or question about a patient's preference for decision roles.

Should patients set the agenda for informed consent? A prospective survey of desire for information and discussion prior to routine cataract surgery

Purpose:

To ascertain the level of information relating to specific risks desired by patients prior to cataract surgery.

Setting:

Dedicated cataract surgery pre-assessment clinics of 2 hospitals in South West Wales, UK.

Methods:

Consecutive patients (106) were recruited prospectively. Of these, 6 were formally excluded due to deafness or disorientation. Eligible patients (100) were asked a set of preliminary questions to determine their understanding of the nature of cataract, risk perception, and level of information felt necessary prior to giving consent. Those who desired further information were guided through a standardized questionnaire, which included an audio-visual presentation giving information relating to each potential surgical complication, allowing patients to rate them for relevance to their giving of informed consent.

Results:

Of the entire group of 100, 32 did not wish to know “anything at all” about risks and would prefer to leave decision making to their ophthalmologist; 22 were interested only in knowing their overall chance of visual improvement; and 46 welcomed a general discussion of possible complications, of whom 25 went on to enquire about specific complications. Of these 25, 18 wished to be informed of posterior capsular (PC) tearing, 17 of endophthalmitis, 16 each of dropped lens, retinal detachment and corneal clouding, and 15 of bleeding, sympathetic ophthalmia, and PC opacification.

Conclusion:

Patients differ in their desire for information prior to cataract surgery, with one significant minority favoring little or no discussion of risk and another wishing detailed consideration of specific risks. A system of consent where patients have a choice as to the level of discussion undertaken may better suit patients’ wishes than a doctor-specified agenda.

Patient expectation and satisfaction after macular hole surgery

PURPOSE

To assess patient expectation, visual improvement, and patient satisfaction after macular hole surgery.

METHODS

Fifty-three consecutive patients completed a self-administered questionnaire after macular hole surgery. Responses for expectation of visual improvement before surgery and subjective visual assessment after surgery were scored from 0 to 10 (0 = no improvement in vision, 10 = full improvement). Visual acuity was measured using Snellen charts and converted to logMAR equivalent for statistical analysis. Wilcoxon and Mann-Whitney U tests were performed using the Minitab statistical software program; p < 0.05 was considered significant.

RESULTS

Thirty-eight (71%) patients were satisfied with the outcome, 14 (26%) were not, and 1 was uncertain. Both satisfied and dissatisfied patients had no difference in baseline preoperative best-corrected visual acuity (BCVA; 6/60 and 6/60, respectively). There was also no significant difference in median postoperative BCVA between both groups (6/24 and 6/29, respectively, p = 0.6). In satisfied patients, median vision expectation score of 6 was equally similar to the median subjective postoperative vision improvement score of 6, p = 0.7. However, in dissatisfied patients, median vision expectation score (8) was significantly higher than median postoperative subjective vision improvement score (1), p = 0.0001. The commonest reason for dissatisfaction was perceived visual reduction (7/14 patients).

CONCLUSIONS

In the dissatisfied patients, expectation was significantly higher, and subjective assessment of vision after surgery was lower than in satisfied patients, although they had similar improvement in BCVA. Visual acuity and patient satisfaction are not always directly correlated. An important factor in patient satisfaction is expectation.

Remote Indigenous Australians with cataracts: they are blind and still can’t see

Aboriginal and Torres Strait Islander people are three times more likely than non-Indigenous Australians to report vision loss due to cataracts, but are four times less likely to have cataract surgery. To increase access for Aboriginal and Torres Strait Islander people to cataract surgery, we need to identify the barriers to current services and trial strategies to overcome these barriers. Barriers to cataract surgery exist at the health service, community and individual level. Health service factors include infrastructure, cost, and provision of interpreters, escorts and transport. Community factors include social support, perceptions about the success of surgery, and beliefs about the causes of cataracts. Individual factors include ignorance that cataracts can be cured, fear of surgery or poor outcome, and comorbidity. Strategies proven to increase uptake of cataract surgery in other countries could be trialled in remote Australia.

Standards in consent for cataract surgery

Consent forms for cataract surgery performed at Burnley General Hospital (BGH) and Blackburn Royal Infirmary (BRI) from October 4 to December 7, 2004, were prospectively reviewed to ensure that the East Lancashire Hospital's National Health Service (NHS) Trust Policy on consent to treatment and Department of Health (DoH) guidelines were being followed when seeking consent for cataract surgery. A set of 22 criteria derived as standards were formulated from the reference guide published by the DoH and from the East Lancashire trust policy document for consent to treatment. Each consent form was measured against these standards. Cases were randomly selected between BRI and BGH prospectively. All consent forms completed by physicians involved in formulating the standards were excluded. The review showed the NHS Trust Policy and DoH guidelines were largely followed when seeking consent for cataract surgery. However, certain areas were found to be deficient. If a health professional fails to obtain proper consent and the patient suffers harm as a result of treatment, it may be a factor in a claim of negligence against that health professional. Subsequent recommendations may include simple solutions that can be implemented to improve clinical practice when obtaining informed consent.

Informed consent in the intensive care unit: ensuring understanding in a complex environment

PURPOSE OF REVIEW

Informed consent in the intensive care unit continues to receive marked attention. As greater numbers of patients enter into the intensive care unit with devastating illness, patients and families are faced with more complex medical problems and decisions regarding therapy. Furthermore, research investigations of critical illness add a level of complexity to informed consent and decision making that mandates a careful approach.

RECENT FINDINGS

Publications in the past year evidence the potential obstacles for appropriate informed consent. Physicians demonstrate variability in interpretation for the need for informed consent and frequently lack formal training in communicating informed consent. Critical care researchers must communicate the goals and benefits of trial participation carefully, avoiding the demonstrably common pitfall of therapeutic misconception. Excellent consensus statements now exist to guide the researcher in pursuing critical care research, creating informed consent documentation, and recognizing the appropriate setting for waiver of consent. As expected, extended discussion is the most effective tool for improving the quality of informed consent.

SUMMARY

Quality of informed consent for the critically ill improves as attention is paid to standardizing indications and formalizing training for physicians. In research, conflicts of interest should be recognized and used to guide the investigator's dialogue on research benefits and risks. Patient safety must be maintained as the primary priority; however, waiver of consent may be considered in situations in which the benefit to medical knowledge far exceeds patient risk.

The consent and counselling of patients for cataract surgery: a prospective audit

PURPOSE

The aims of ideal preoperative informed consent include educating the patient adequately to enable an autonomous decision to be made without causing undue anxiety. We study how the paternalistic and nonpaternalistic approaches meet this ideal. The influence of the new patient consent forms is also assessed.

METHODS

Two cycles of a prospective clinical audit are presented. An assessment of relevant patient knowledge was performed by patient interview. Visual analogue scales were used to quantify patient anxiety.

RESULTS

The first cycle, examining a paternalistic approach, demonstrated: 37% of patients understood what a cataract was and 48% understood what surgery involved. 48% misunderstood that cataract surgery was completely risk free. In total, 80% of patients undergoing second eye surgery believed that it was completely risk-free. Average anxiety visual analogue scores (VAS) for cataract surgery were low (2.89). The second cycle, examining the nonpaternalistic approach combined with the implementation of new consent forms showed that, despite more explicit repeated preoperative consent: 39% of patients understood correctly what a cataract was, 28% understood what surgery involved and 43% misunderstood that surgery was completely risk-free. All patients undergoing second eye surgery thought that it was risk-free. The average anxiety VAS for cataract surgery were moderate (5.00).

CONCLUSIONS

Both paternalistic and non-paternalistic approaches to informed consent are inadequate in meeting the demands of the ideal informed consent. The new patient consent forms appear to have little effect in influencing patient knowledge about their surgery. Patients undergoing second eye surgery often have an overoptimistic view of cataract surgery.

L’anesthésie topique en chirurgie de la cataracte ambulatoire de l’adulte sans anesthésiste présent

To review the local anesthesia environment in France in adult out-patient cataract surgery. The author considers the presence or absence of an anesthesiologist in the operating room. The report shows that in many circumstances there is no need for an anesthesiologist if the following criteria are respected: the adult is fully informed, in rather good health, with no acute risk factors, and surgery is performed by a senior surgeon in a certified operating room. In France, a move toward more flexible regulations is expected, with a new cooperation between ophthalmologists and anesthesiologists that will lead to a new true risk/benefit/obligation ratio. Respect of the individual and safety remain crucial requirements making systematic generalizations impossible.