Surgeons' opinions and practice of informed consent in Nigeria

Surgical informed consent practices and influencing factors in sub-Saharan Africa: a scoping review of the literature

INTRODUCTION

Current international standards in consent to surgery practices are usually derived from health systems in Western countries, while little attention has been given to other contexts such as sub-Saharan Africa (SSA), despite this region facing the highest burdens of disease amenable to surgery globally. The aim of this study was to examine how the concept of informed consent for surgery is interpreted and applied in the context of SSA, and factors affecting current practices.

METHODS

A systematic search of Medline, Embase and African Journal OnLine databases as well as grey sources was executed in May 2023 to retrieve relevant literature published since 2010 in English language against a set of given criteria. The socioecological framework for health was used for organising and summarising the identified evidence.

RESULTS

A total of 27 papers were included in the review. Findings revealed that consent to surgery practices is generally substandard across SSA and the process is not adequate. Patients' understanding of informed consent is limited, likewise awareness of their rights to decision-making. A range of factors at the individual, interpersonal, institutional and system/societal levels affect the informed consent process.

CONCLUSION

There is a need to find more culturally acceptable and ethical ways to include the participation of patients in the decision-making process for surgical treatment in the SSA and define standards more closely aligned with the local context.

Practice and Factors Associated with Informed Consenting Process for Major Surgical Procedures Among Health-Care Workers, South Eastern Ethiopia

Background

Medical malpractice, poor patient outcome and medical suits among health-care workers result from improper consenting practices. Therefore, this study aimed to assess practice and factors associated with the informed consenting process for major surgical procedures among health-care workers in public hospitals of Bale Zone, South Eastern Ethiopia.

Methods

An institutional-based cross-sectional study was conducted from March 9 to 24, 2020, among all nurses, midwives, doctors (general physicians, surgeons, gynecologists), emergency surgery officers, anesthetists) who were working at Bale Zone public hospitals during the study period. A self-administered pretested questionnaire was employed. Variables with a p-value of less than 0.25 (age group, sex, educational profession, working unit, work experience, adequate content of consent form, training on informed consent, policy/regulation in institution, administrative support, average number of patient cared per shift, time spent for consent process, knowledge, attitude) at 95% confidence interval in the binary logistic regression analysis were considered for multivariable regression model to control for possible confounding effect.

Results

Of the total sample size (639 health-care workers), 621 (97.2%) were included in this study, of which 311 (50.1%, 95% CI: 46.1-53.8) practiced proper informed consent during major surgical procedures. Being age above 35 (AOR: 3.032, 95% CI: 1.148-8.010), male (AOR: 1.607, 95% CI: 1.047-2.465), above 10 years of working experience (AOR: 2.339, 95% CI: 1.104-4.955), adequate content of consent form (AOR: 2.785, 95% CI: 1.772-4.377), having training on informed consent (AOR: 2.305, 95% CI: 1.204-4.414), spending more time (>30minutes) for consent process (AOR: 3.014, 95% CI: 1.095-8.298), having good knowledge (AOR: 1.808, 95% CI: 1.195-2.737) and favorable attitude (AOR: 2.188, 95% CI: 1.456-3.287) were significantly associated with good informed consent practice.

Conclusion

Only half of health-care workers practiced good informed consent. Further emphasis needs to be given to improve consent practice.

Junior doctor experiences and challenges in obtaining surgical informed consent: A qualitative systematic review & meta-ethnography

INTRODUCTION

Surgical informed consent (SIC) to procedures is necessary to ensure patient autonomy is adequately respected. It is also necessary to protect doctors, and their institutions, from claims of negligence. While SIC is often acquired by senior consultants, it also commonly falls to the junior doctors on a team to ensure SIC is adequately acquired and documented. A growing body of literature suggests that junior doctors are not sufficiently educated about the legal and practical issues concerned with obtaining medical consent. This may open up this cohort, and their hospitals, to medico-legal liability.

AIMS

to provide a systematic review of the qualitative literature on junior doctors' experiences and challenges in consenting surgical patients and to synthesize evidence on this issue in order to guide policy-makers in the medicolegal and medical education spheres.

METHODS

a systematic review of qualitative literature was performed. Analysis of the literature was guided by Noblit and Hare's seven-step approach to meta-ethnography, with the final synthesis presented as a thematic analysis of the literature.

CONCLUSION

This research concludes that a significant proportion of SIC is likely to be acquired by junior doctors, many of whom are Post-Graduate Year (PGY) 1-2 and who lack adequate training and education. This cohort face challenges in assessing capacity, in ensuring adequate disclosure related to surgical procedures, and in adequately documenting consent. This may impact the validity of any SIC they acquire. Medical educators and policy-makers should be aware of these issues when creating policies impacting SIC, and when designing surgical education programs for medical students and junior doctors alike.

Common medical ethical issues faced by healthcare professionals in KSA

Objective

There are growing concerns about ethical issues in the healthcare system. This study was conducted to determine the nature of common ethical issues faced by healthcare providers in a tertiary-care hospital in KSA.

Method

This cross-sectional study comprised a self-administered questionnaire given to the physicians working at King Abdulaziz Medical City Hospital-Riyadh, Ministry of National Guard Health Affairs (KAMC-RD, MNGHA). We used a convenience sampling technique during symposia and conferences.

Results

We distributed 240 questionnaires amongst the physicians and recorded a response rate of 80%; 68% (136) of the respondents were men, while 82.5% were Saudis. The mean age of the group was 34.08 ± 10.43 years. Only 69% (138) of the physicians had ever received any formal teaching in bioethics. Most physicians (77.5%) demanded clear guidelines to help them to take appropriate ethical decisions on therapeutic futility, whereas 54% felt that they sometimes overtreat their patients.

Conclusion

This study reported a lack of knowledge in certain healthcare-related ethical issues in a significant proportion of the physicians. There is a need for a standard educational agenda for medical ethics for healthcare providers, not only during medical school but also after graduation and during clinical rounds.

Surgical consent in sub-Saharan Africa: a modern challenge for the humanitarian surgeon

Surgical consent is one of the pillars of ethical conduct in Western world surgical practice. Recent studies have described the consenting processes for clinical trials in low- and middle-income countries (LMICs), but only a few have explored its practice before surgical procedures. The recent World Medical Association (WMA) Declaration of Lisbon recommends autonomy and independent decision-making. However, informed consent is influenced by cultural background, family structure, socioeconomic status, religion and education. The authors of the paper support the WMA recommendations, but agree the process for obtaining informed consent should be reviewed and developed to integrate in a culturally appropriate manner. This commentary reports the author's personal experience of surgical consent in Burundi and reviews the literature describing its practice and the specific challenges faced in Sub-Saharan Africa. Its aim is to encourage a debate among surgeons as to how surgical consent can be undertaken in different scenarios of LMICs.

Informed consent for clinical treatment in low-income setting: evaluating the relationship between satisfying consent and extent of recall of consent information

BACKGROUND

Treatment informed consent aims to preserve the autonomy of patients in the clinician - patient relationship so as to ensure valid consent. An acceptable method of evaluating understanding of consent information is by assessing the extent of recall by patients of the pieces information believed to have been passed across. When concerns are not satisfactorily addressed from the patients' perspective, recall of consent information may be low.

METHODS

This study is a questionnaire - based cross - sectional interview of consecutive adult surgical patients who could give their respective medical histories and who were booked for elective major surgical procedures over a period of 7 months in a tertiary health institution in southeastern Nigeria. Four to five days after a formal consent session, during ward admission, extent of recall of information on the nature of the disease condition or diagnosis, the nature of the planned procedure and the risks involved in the planned procedure were assessed and analyzed on the background of how satisfying the consent sessions were from individual patient's perspective.

RESULTS

Generally, the recall of nature of disease condition and nature of planned procedure is better than recall of risks involved in the planned procedure. More specifically however, recall in these 3 domains is significantly better among the patients that affirmed that their concerns were satisfactorily addressed.

CONCLUSION

The findings from this study support that no effort should be spared in ensuring that the consent information are satisfying to the patients from the patients' viewpoint.

Doctors' perspectives of informed consent for non-emergency surgical procedures: a qualitative interview study

BACKGROUND

The need to involve patients more in decisions about their care, the ethical imperative and concerns about ligation and complaints has highlighted the issue of informed consent and how it is obtained. In order for a patient to make an informed decision about their treatment, they need appropriate discussion of the risks and benefits of the treatment.

OBJECTIVES

To explore doctors' perspectives of gaining informed consent for routine surgical procedures.

DESIGN

Qualitative study using semi-structured interviews selected by purposive sampling. Data were analysed thematically.

SETTING AND PARTICIPANTS

Twenty doctors in two teaching hospitals in the UK.

RESULTS

Doctors described that while consent could be taken over a series of consultations, it was common for consent to be taken immediately prior to surgery. Juniors were often taking consent when they were unfamiliar with the procedure. Doctors used a range of communication techniques to inform patients about the procedure and its risks including quantifying risks, personalizing risk, simplification of language and use of drawings. Barriers to effective consent taking were reported to be shortage of time, clinician inexperience and patients' reluctance to be involved.

DISCUSSION AND CONCLUSION

Current consent processes do not appear to be ideal for many doctors. In particular, junior doctors are often not confident taking consent for surgical procedures and require more support to undertake this task. This might include written information for junior staff, observation by senior colleagues when undertaking the task and ward-based communication skills teaching on consent taking.

The quality of obtaining surgical informed consent

Background:

Informed consent goes beyond signing a form; it is a process of providing necessary information, helping patients make an informed decision, and actively participate in their treatment.

Aim/objective:

This study aimed to assess the quality of obtaining surgical informed consent in hospitals affiliated with Tehran University of Medical Sciences.

Research design/participants/context:

In a cross-sectional, descriptive-analytical study, 300 patients were chosen through stratified sampling from seven hospitals affiliated with Tehran University of Medical Sciences. Data were collected using a questionnaire developed by the researchers and analyzed using descriptive and analytical statistics on SPSS software.

Ethical considerations:

Ethical approval of this study was granted by Tehran University of Medical Sciences research ethics committee. Written informed consent for participation was obtained. The participants were reassured that their information will be used anonymously and their answers will not affect their treatment and care.

Findings:

The mean score of quality of acquisition of informed consent was 17.13 out of 35, indicating that the quality falls in the inappropriate category. The results indicate that 48% of the signatories do not even read the form before signing it. Among the 52% who did read the consent form, 61.3% mentioned varying degrees of incomprehensibility of the consent form and 94.2% mentioned the presence of incomprehensible technical, medical and legal vocabulary. Only 12% and 18% of respondents reported that they were not in hurry and they had no fear or anxiety, respectively, when signing the form. The quality of obtaining informed consent was higher in women, younger patients, patients with higher education, and those who had special surgeries.

Discussion:

This study shows a poor practice in obtaining surgical informed consent in Iran. It seems necessary to consider fundamental changes in the process of acquiring consent based on the temporal and local conditions of the patients.

Adherence to informed consent standards in Shiraz hospitals: matrons' perspective

BACKGROUND

Informed consent is an important part of the patients' rights and hospitals are assigned to obtain informed consent before any diagnostic or therapeutic procedures. Obtaining an informed consent enables patients to accept or reject their care or treatments and prevent future contentions among patients and medical staff.

METHODS

This survey was carried out during 2011-2. We assessed adherence of 33 Shiraz hospitals (governmental and non-governmental) to informed consent standards defined by Joint Commission International (JCI) Accreditation, USA. The questionnaire was designed using the Delphi method and then filled out by hospital matrons. We calculated valid percent frequency for each part of the questionnaire and compared these frequencies in governmental and non-governmental hospitals using analytical statistics.

RESULTS

Considering 63% of the hospitals that filled out the questionnaire, no statistically significant difference was observed between the governmental and non-governmental hospitals in adherence to informed consent standards.

CONCLUSION

This study shows a relatively acceptable adherence to standards about informed consent in Shiraz hospitals but the implementation seems not to be as satisfactory.

[Informed consent of the surgical patient]

The article analyses the consequences of the paradigm shift in the surgical practice in the last fifty years. The earlier, paternalistic physician-patient relationship has been replaced by an equal one, which is based on informing the patient and involving him or her in the treatment decisions. This shift did not happen uniformly in various medical subspecialties. In this respect, surgery is more conservative than general medicine. The article analyses the most frequent problems of informing patients, and examines the major elements of information, together with their technical conditions in surgery. It reflects on specifics of surgical information disclosure and conditions of refusing medical interventions.

Evaluating the quality of informed consent and contemporary clinical practices by medical doctors in South Africa: an empirical study

BACKGROUND

Informed consent is a legal and ethical doctrine derived from the principle of respect for autonomy. Generally two rights derived from autonomy are accorded legal protection. The constitutional right to bodily integrity followed by the right to bodily well-being, protected by professional negligence rules. Therefore healthcare professionals treating patients' without valid consent may be guilty of infringing patients' rights. Many challenges are experienced by doctors obtaining informed consent in complex multicultural societies like South Africa. These include different cultural ethos, multilingualism, poverty, education, unfamiliarity with libertarian rights based autonomy, and power asymmetry between doctors and patients. All of which could impact on the ability of doctors to obtain legally valid informed consent.

METHODS

The objective of this study was to evaluate whether the quality of informed consent obtained by doctors practicing in South Africa is consistent with international ethical standards and local regulations. Responses from 946 participants including doctors, nurses and patients was analyzed, using a semi-structured self-administered questionnaire and person triangulation in selected public hospitals in Durban, KwaZulu-Natal, South Africa.

RESULTS

The median age of 168 doctors participating was 30 years with 51% females, 28% interns, 16% medical officers, 26% registrars, 30% consultant/specialists. A broad range of clinical specialties were represented. Challenges to informed consent practice include language difficulties, lack of interpreters, workload, and time constraints. Doctors spent 5-10 minutes on consent, disclosed most information required to patients, however knowledge of essential local laws was inadequate. Informed consent aggregate scores (ICAS) showed that interns/registrars scored lower than consultants/specialists. ICAS scores were statistically significant by specialty (p = 0.005), with radiologists and anaesthetists scoring lowest, while internists, GPs and obstetricians/gynaecologists scored highest. Comparative ICAS scores showed that professional nurses scored significantly lower than doctors (p ≤ 0.001).

CONCLUSIONS

This study shows that though doctors had general knowledge of informed consent requirements, execution in practice was inadequate, with deficiency in knowledge of basic local laws and regulations. Remedying identified deficiencies may require a 'corps' of interpreters in local hospitals to assist doctors in dealing with language difficulties, and continuing education in medical law and ethics to improve informed consent practices and overall quality of healthcare service delivery.

Surgical informed consent in Iran—how much is it informed?

Introduction:

Informed consent constitutes one of the most important legal, professional, and ethical principles of a surgical operation. Consent obtained from a patient is only valid when the patient has received enough information regarding the proposed treatment option. This study aims to determine how much the patients are informed before undergoing surgery, as well as the factors influencing it in hospitals affiliated with Tehran University of Medical Sciences.

Method:

This is a cross-sectional, descriptive–analytic study of 300 patients undergoing surgery in 7 teaching hospitals affiliated with Tehran University of Medical Sciences. The patients were recruited through clustered sampling. Data were collected using a questionnaire completed by interview. Data were analyzed on SPSS software using descriptive and inferential statistics.

Result:

The mean score of data provision for patients was 27.09 out of 60, indicating the level of information provided as unacceptable. Among 12 questions dealing with data provision, patients had received an intermediate level of information about nature of the disease, type of surgery, benefits and importance of the surgery, and complications of rejecting the recommended therapy. On the contrary, they had not received enough information about the surgical procedure, type of anesthesia, potential complications of surgery, potential risks of surgery, other therapy options instead of surgery, length of hospital stay for surgery, postsurgical follow-up, and expenses of the surgery. In the majority (85%) of cases, the surgeon was reported to be the information provider. Among the variables studied, level of information received was directly related to the patient’s education level.

Discussion:

The findings of this study indicate that during the process of obtaining an informed consent for surgery, patients do not receive sufficient information, and it is necessary to provide the essential information in an understandable manner adjusted for the patient’s level of education.

Surgeon-patient information disclosure practices in southwestern Nigeria

OBJECTIVE

This study examined the practice of information disclosure to patients by surgeons in Nigeria.

SUBJECTS AND METHODS

A 55-item self-administered semi-structured questionnaire was sent to 150 surgeons in southwestern Nigeria in 2004-2005. The data obtained from the completed questionnaire were analyzed using descriptive statistics.

RESULTS

Of the 150 surgeons, 102 completed the questionnaire, giving a response rate of 68.0%. Of these 102, 85 (85.3%) were men, 44 (43.1%) were consultants and 55 (54.0%) were senior and junior surgical trainees. Most were from surgical subspecialties and obstetrics and gynecology. A documented policy statement about information disclosure was not available in most hospitals. A third, i.e. 35 (34.3%), of the surgeons did not routinely engage patients in discussions about disease diagnosis, management and prognosis. Most, i.e. 73 (71.6%), would rather disclose worsening disease progression to the patient's spouse. Others would disclose such information to the patient's children, family members or clergy. This was presumably to shield the patient from psychological distress. Only 22 (21.6%) of them routinely disclose operative findings to patients or their families. Thirty (29.4%) of them had been involved in disclosing medical errors to their patients in the past while 63 (61.8%) respondents did not know if surgical errors with potentially negative consequences should be disclosed.

CONCLUSION

Most of the surgeons in southwestern Nigeria did not routinely provide detailed information to patients about their illness and possible outcome of illness even in the presence of worsening disease progression and prognosis. When surgical errors with potential negative consequences occurred, the majority did not know if such errors should be disclosed.

Ethical and Legal Issues in Biobanking for Genomic Research in Nigeria

The pursuit of genomic research and biobanking has raised concerns and discussions about the ethical and legal implications. Given the specific challenges that surround such enterprise in low and middle income countries, it is pertinent to examine them in the light of the advent of Biobanking and Genomic research in Nigeria. In this paper I discuss the issues and suggest model solutions derived from advanced jurisdictions. These ethical and legal issues are discussed within the context of the legal system of a typical African country whose jurisprudence derives from that of its erstwhile colonial master, the United Kingdom. This includes issues relating to law and human rights, informed consent, native and customary law.