18 May 2021
Informed consent – more than a signature? Improving the consent process in practice
Recently updated guidance on communication and consent from the Royal College of Veterinary Surgeons (RCVS) suggests that consent should be a process, held in advance of the day of surgery if possible, obtained by an appropriate member of staff, and should involve the discussion of reasonable treatment options. Using an elective neutering scenario, this article discusses what ‘good practice’ in informed consent looks like and makes recommendations for improving consent protocols in practice. These recommendations incorporate time allocation and timing of consent discussions, who should obtain consent, the content of the discussion, and what happens on the day of surgery.
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It’s coming to the end of morning surgery in your practice. As the senior RVN, you have been running a busy and diverse nurse clinic, and you feel a sense of relief when you see that the next patient is Karla, a beautiful black Newfoundland who was in for a routine spay last week. It is a bit early for stitch removal, but you hope it is just a routine check. Opening the door to the waiting room, you notice that your client is looking uncharacteristically grumpy. As you call him in, he is shaking his head and muttering “Doesn’t look right, it’s not healing.”
After examining Karla’s wound, you agree with him. There is swelling and inflammation along the line of stitches, with some brownish discharge. You empathise with both the client and the patient. After referring your client on to the next available veterinary surgeon, you think back to Karla’s admission. You remember going through post-operative care with Mr Beddow, especially the need for Karla to wear a plastic cone to prevent interference with the wound.
At lunchtime, the vet who saw Karla explains that she has started Karla on antibiotic therapy, and that despite wearing the cone, the wound has become infected because Karla is so large and spends most of her time lying on her belly. She jokes that it’s just as well that the practice has such a good relationship with the client, or he may have complained about not having been offered a laparoscopic spay!
Later, you reflect on her words. Although you realise that laparoscopic (“keyhole”) spays are ideal for larger breeds, the practice has neither the equipment nor the expertise to offer them. The nearest practice that offers them is 11 miles away. Should you have discussed this with Mr Beddow when you admitted Karla? Let’s unpick what has happened here, examining your practice’s protocol for consent.
Time and timing
As in many other practices, you obtain informed consent for elective surgery, such as neutering, on the day that you admit the patient for the procedure. In human medicine, this would be seen as poor practice, with medical organisations advising that consent conversations should be held in advance of the procedure where possible (Royal College of Surgeons of England [RCSE] 2016, S4.8, General Medical Council [GMC] 2008, S18).
In giving clients the information needed to make an informed decision, it is important that they have sufficient time to consider the information and then to decide whether to proceed (Berry, Unwin, Ross, Peacock & Juma, 2007). The Royal College of Veterinary Surgeons (RCVS) endorses this view, recommending that ‘(f)or non-urgent procedures, the consent discussion should take place in advance of the day of the treatment/procedure where possible.’ (RCVS, 2019, S11.2).
There are additional benefits to holding the consent discussion in advance of the surgery (Gray 2019). For example, clients are often worried if they are leaving their pets for surgery, so may not listen carefully to important information. There is less time to hold a proper discussion during early morning admissions slots, with clients anxious to get off to work or school. Bringing the consent conversation forward gives the client time to consider the procedure and ask questions when there is less emotional pressure, while giving the veterinary professional time to go through all the required elements of the consent discussion without unrealistic time constraints. In an observational study of consent conversations conducted in advance of the day of surgery, all conversations fitted comfortably into the allocated 15-minute slots (Gray 2019, p274).
You therefore submit an item for the agenda of the next practice meeting: “For elective surgery, this practice should schedule 15-minute consultations to conduct the consent discussion several days before surgery appointments.”
In your practice, registered and student veterinary nurses assume responsibility for obtaining consent for routine procedures, such as neutering. Is this acceptable?
The recently updated RCVS guidance on consent has been formulated along similar lines to the GMC guidance regarding training and suitability of personnel for consent discussions:
… the veterinary surgeon can delegate the responsibility to someone else, provided the veterinary surgeon is satisfied that the person they delegate to:
a. Is suitably trained, and
b. Has sufficient knowledge of the proposed procedure or treatment, and understands the risks involved.
(RCVS, 2019, S11.3-11.5)
The RCVS lists those to whom the delegation would be appropriate, from veterinary surgeons, through veterinary nurses to student veterinary nurses, subject to the provisos above. It seems that your protocol in this area is acceptable, but you will suggest that the training of student nurses in obtaining consent is reviewed at your next practice meeting.
By following the layout of your consent form, you usually structure your consent discussion to cover the procedure (explaining that for a spay, the uterus and ovaries will be removed), the risks (you always mention the very small risk of death for any general anaesthetic), the costs (with an estimate clearly provided on the form) and the aftercare for the patient.
The RCVS requires discussion of ‘common and serious’ risks (RCVS, 2019, S11.2b). One interpretation suggests an evidence-based approach to risks, meaning that only those reaching a specified level of occurrence, for example 10%, would be included. An alternative definition of ‘serious’ could be a risk that, even if uncommon, has devastating consequences for the patient and the client. For elective neutering procedures, the serious risk involved is death. With more evidence emerging on post-neutering complications for both sexes (Adin 2011, McKenzie 2010, O’Neill and others 2017, Reichler 2009, Torres de la Riva et al 2013), these should also be discussed, balanced with the individual and societal benefits of neutering.
This scenario, however, involves the failure to offer alternatives to a traditional midline spay. The RCVS advises that the client should be given ‘a range of reasonable treatment options’ (RCVS, 2019, S11.2). The definition of ‘reasonable’ is open to debate, but there is probably a balance between giving clients too many options and not giving them any options. Of course, the costs of each option are an essential part of the discussion. Reasonable treatment options would include treatments available at your practice, in view of current personnel and equipment, and the offer of referral to another practice if an alternative treatment, unavailable at your practice, would be in the animal’s best interests. With this in mind, should clients be informed that laparoscopic spays are available at the neighbouring practice if the individual patient would benefit from this procedure?
You decide that this is another topic for discussion. If the practice protocol is changed to offer referral for laparoscopic spay, you will need to find out the costs involved to enable your clients to make an informed decision.
Client review of information
Because your practice’s current consent process is carried out at the time of admission of the patient, clients do not have a chance to review the information given, or to formulate questions and concerns that they may have. Moving the discussion in advance of the procedure gives clients this opportunity. Alternatively, they could be sent written information in advance of the appointment, enabling them to arrive at the practice with some prepared questions. At the very least, the client should leave the consent discussion with a copy of the consent form, signed by both parties. Currently, your practice protocol is to print one copy of the form, kept with the patient’s records, and to require only the client’s signature. You will add these recommendations about copies and signatures to the agenda for the next meeting.
Admission – questions and affirming consent
If the consent discussion takes place in advance of the day of surgery, what happens during admissions? Can we take consent prior to surgery, and how long is it valid? The advice given to human surgeons by the RCSE seems appropriate:
There is no time limit to the validity of a patient’s consent. Consent will cease to be valid only when, in the intervening period between the consent discussion and the procedure, circumstances have changed in a way that has significantly altered the patient’s condition, the material risks or any other aspect of the treatment.
(RCSE, 2016, S4.9)
On the morning of admission, you would undertake a final check that nothing has changed since the consent discussion, deal with any client questions or concerns, and conduct another health check on the patient.
Summary of proposed consent protocol
- The consent discussion should be scheduled to allow sufficient length of time (e.g., 15 minutes). For elective procedures, it should be in advance of the day of surgery
- The consent discussion should be scheduled to ensure the availability of an appropriate member of practice staff to conduct the conversation
- The client should be asked if they have questions or concerns
- The risk of death should be specified for general anaesthesia
- The risks and benefits of the procedure for the individual animal should be explained.
- Clients should be offered alternative treatment options, where these exist
- Clients should be informed of the costs for each reasonable treatment option
- Consent forms should require the signatures of both parties, with a copy given to the client.
- Clients should be provided with a copy of the information discussed in advance of the day of surgery.
To implement changes, it is useful to discuss what needs to change, then to change one aspect at a time. Feedback from clients and staff will help to monitor the improvement in informed consent.
In our original scenario, the client had trust in the practice and did not wish to pursue the matter further. If he had been a new client, or if he didn’t have a good relationship with the practice, the outcome may have been different. However, rather than improving consent as a means of avoiding claims and complaints, getting it right should increase client satisfaction (Carlsen & Aakvik, 2006), improve patient care and welfare through improving adherence to treatment (Munthe, Sandman, & Cutas 2012) and, as a consequence, may lead to better wellbeing amongst veterinary professionals.
Notes on contributors
Carol A. Gray
Following 13 years as a lecturer in communication skills at Liverpool vet school, I did a PhD in the School of Law at the University of Birmingham. Since October 2019, I have been a postdoctoral fellow in the School of Law and Social Justice at the University of Liverpool. Emails: firstname.lastname@example.org, Carol.Gray@liverpool.ac.uk