I met Sarah in 2013 at the ante-natal clinic when she was
expecting her third baby at 31 years of age. I must admit that I had difficulty
wrapping my head around the fact that she had a surgical scar on her abdomen
resulting from a surgery two years back; and despite having signed on the
dotted line, she had no idea what the surgery was about.
Several times, as doctors who are required to perform
emergency caesarean sections, we have ended up with poor outcomes because of
delay in obtaining consent for the surgery. The patient is not allowed by her
social circumstances to consent to the surgery as consensus must be sought from
the spouse, parents, siblings and even the in-laws. In the process we end up
losing a baby, having severe haemorrhage or even possible loss of the mother’s
life.
The most socially restrictive challenges to the patient
accessing the care they need happen in matters to do with contraceptive use.
Many women will take up contraceptive use when they get married and hence the
importance of partner participation. It is sad to see the woman cede her right
to choose a preferred method because the spouse does not approve of it.
Ill health is a point of extreme vulnerability for all of us.
When your life is at stake, it is very easy to go along with any treatment
option offered, if only to stay alive or be rid of the pain. For this reason,
the health care providers tend to have the upper hand in influencing decisions,
which may inadvertently be abused even with the best of intentions.
In my view, after patient confidentiality, informed
consent is the second most important patient right. Yet only a handful
of patients in Kenya even know about it. It is enshrined in the Patient
Rights Charter yet it is poorly appreciated. Informed consent is built
upon seven key tenets that cannot be divorced from each other:
1. Patient's
role: the doctor is obligated to help the patient understand
his/her role in the decision-making process, so as to ensure the patient is a
partner in their care process;
2. The treatment
option: the patient must understand his/her condition, having
been appropriately explained, in a language he/she understands, and the logical
process that leads to the planned treatment, its process and expected duration
of care;
3. Other treatment
alternatives: all other treatment alternatives must be fully explored
and understood, including those that may not be available locally available and
understanding the option of no treatment;
4. Risks
and benefits: the doctor has to elaborate the well known risks
that may arise as a result of the treatment and the sought after benefits; and comparing
them to the risks and benefits of the alternative treatment options;
5. The
unexpected: the patient must be prepared well for the unexpected
eventualities that may arise in the course of treatment;
6. Patient
fitness: the patient must be considered mentally and physically fit
to process and understand the information provided, without undue influence
from drugs or excruciating pain or unconscious state; and
7. Choice: with
all the aforementioned tenets considered, then the patient is fully informed
and capable of making an informed choice/preference in their care plan.
Putting this into perspective goes to demonstrate just how
many patients go through medical care without really having consented to it.
For consent to be valid, the patient must be fit to give consent, adult (over
18 years), having understood their condition, the treatment, the options, risks
and benefits, the unexpected issues and willingly and knowingly take their
preferred choice of treatment.
In the event that the patient is unfit to give consent,
either by mental incapacity or by being in unconscious state, then there is
need for a next of kin to take up this role. This person is commonly listed in
the patient record and assumes authority to make medical decisions for the
patient. Therefore it is important to always ensure that whoever is listed as
your next of kin is someone you trust to take such weighty decisions for you.
When dealing with children, then the matter of informed
consent does not apply by virtue of their age. The parents/guardians are
authorized to approve the treatment choice. However, their decisions must
always be in the best interest of the minor, otherwise they shall be overruled
by a court of law. This can get complicated when dealing with, for instance,
the health of an infant born to a teenage mom who isn’t an adult herself yet.
Our laws then may require strengthening in defining the role of emancipated minors
in this case.
In special circumstances however, exception may be made where
the risk to life, limb or sight, is imminent and the patient is unable to give
consent and a next of kin cannot be located. In this case, at least two doctors
must agree to the life-saving procedure and shall state in writing that they
have taken up the responsibility of consenting on behalf of the patient, in the
best interest of the patient. In the case that the patient’s condition is not
an emergency, then the court shall appoint a custodian to take the decision of
behalf of the patient.
Voluntary presence of a patient in a hospital implies consent
to care but not to every procedure available. Verbal consent must be sought for
physical examination and uncomplicated procedures such as collection of
laboratory specimens, insertion of medical devices such as IV lines and
catheters and performance of pelvic examination. Surgical interventions,
exposure to diagnostic and treatment radiation, insertion of medical devices
that alter body function and other complex interventions must have a written
and signed consent.
As a patient, when you find yourself in need of medical
intervention, kindly ensure you have given a valid informed consent. It is
important to remember that you have a right to seek a second opinion before
taking a decision. You are also entitled to the best possible care within the
confines of the treatment options you consent to, even if you decline what is
regarded as the best option of care.
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| Photo credit - FB |
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