legal (consent) issues in clinical practice
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Some Legal Issues in
Clinical Practice (Consent)
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Aitkenhead AR, The Pattern of Litigation Against Anaesthetists.
BJA 1994, 1993; 73:10-21
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Files Opened 2003-2012
World Anaesthesia (MPS Data)
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Questionnaire prior to pre-op visit
Information received & patient satisfactionAnaesthesia: 64% spoke to nobody
beforehand
62% received no information59% would have liked more
Nurses (40%) most frequent providers
Williams OA, Patient knowledge of operative care.
Journal of the RSM. 1993. 86(6): 328-31.
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What makes a good consent form
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HIPPOCRATES
Perform your duties calmly and adroitly,
concealing most things from the patient while
you are attending to him turning his attention
away from what is being done to him revealing nothing of the patients future or
present condition
Hippocrates, Decorum. Havard UP, MA 1967: 267.
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CONSENT IS ADVICE
In Past Drs = No duty to provide information HippocratesPhysicians take active steps to
conceal information from patients
Providing information may cause distress,confusion and jeopardise recovery
Limited information
Silence and ? Deception
Hatcher v Black (Times, 2July 1954)
Denning His Peers did not condemn him and
neither should we
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Paternalistic approachDr-centric
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AutonomyPatient Centric
Schloendorff v Soc. Of New York Hospital (1914)
Hucks v Cole (1993) Rogers v Whittaker (1992), Chappel v Hart (1998)
Hong Chuan Lay v Dr Eddie Soo Fook Mun (1998)
.. It was for the court, and not medical men,to judge the adequacy of information
disclosed
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Patients Expectation
Akkad (2006)
88% = legal requirement
68% = give authority to Drs
46% = to protect hospital
41% = made their wishes be known
10% = did not know what they agreed to sign
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KS Hoe, BM Karis MedJ Malaysia, 57 June 2002
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22 KS Hoe, BM Karis MedJ Malaysia, 57 June 2002
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23 KS Hoe, BM Karis MedJ Malaysia, 57 June 2002
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Patients Expectation (Beresford 2001)
Royal Brompton & Univ College Hosp. London
Pts undergoing cardiac surgery (CABG)
42% = dont want information of risks
50% = dont want to know risk of death
54% = dont want to know risk of stroke
Statistical figures just confuse
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Asian Patients Expectation
I leave it to GOD
I have faith in you
Dr do what you think is best
If you are the patient what would you decide
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Consent For Transfusion
Culture of just, openness & transparency Allows patient to make consent decision
Allows doctors to document reason for
transfusion Management of unexpected outcome
seroconversion
Medico-legal aspect : Duty to inform In accordance with current international best
practice.
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Seroconversion Cases:2011/12 IJN
2011 2012
Total number 7 7
Donors seroconverted
with Hepatitis C
2 2
Donors seroconvertedwith HIV 2 4
Donors seroconverted
with Syphilis
3 1
No of cases closed5 3
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2011 : No of cases clo sed = 5 ( 1 deceased, 3 tested non reactive, 1
disc arded )
2012 : No of cases c losed = 3 ( 1 HCV tested negative, 1 HIV not
transfused, 1 syphi l is)
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(National Bld. Trans. Services)
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MMC Consent Guide 2011 & 2013
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Consent Validity
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MMC Consent Guideline 2013
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MMC Consent Guideline 2013
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Abdul Razak Datuk Abu Samahv
Raja Badrul Hisham Raja Zezeman Shah and others
Facts of the case: Colorectal surgeon and insertion of Ryles tube
Assigned consent to Trainee Officer
Patient refused Decision to do it under anaesthesia
Patient had aspiration and subsequently died
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NO ABBREVIATIONS
TO BE USED
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Example Aneasthesia Consent
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Severe Left Main Stem with
Possible Difficult Intubation:
Limited Mouth Opening
Poor dentition
Dr: : Your operation will
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IS OUR EXPLANAITION CLEAR?
Dr: : Your operation will
be done with local
anaesthetic
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There is yet no legal duty to
ensure patients understand
information that is communicated
to them.
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Most Frequently Lost Documentation:
Anaesthetic Records & Charts
D t i d Cl i 2008 2012
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Determined Claims 2008-2012
World Anaesthesia
1 Augus t 2011
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DOCUMENTATION
IS ONE OF THE
MOST
PROBLEMATIC
AREAS INMEDICAL
LITIGATION
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Informed Consent
Western Idea of Autonomy
Influenced by
Social, Cultural, Family, education standard
Disease type, severity, specialty
Clinical, research, nursing
Law Use Professional Guidelines
? Reformulate IC for Asian Culture
Asian Judges use Western philosophy/case law
Asian Patients use Asian values 49
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Lancet 1994
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However the landscape is changing with awareness of medical indemnity