Lack of preoperative consent

Activity summary

This text case portrays a situation in which surgery was postponed due to a misunderstanding during the consent process. The facilitation questions and suggestions to faculty focus on helping learners to identify what went wrong and how to improve the consent process.

Case scenario

A 37-year-old female, mother of 3 children, presents with a history of irregular and heavy menses. Physical examination by a gynecologist reveals an enlarged and bulky uterus, suggestive of fibroids. Investigations indicate normal thyroid function, but hemoglobin and hematocrit levels are both low. Conservative measures including the use of hormonal medication, and non-steroidal anti-inflammatory medications have not proven beneficial. An endometrial biopsy showed hyperplasia but no dysplasia. 

The following note is dictated by the gynecologist to the family physician:

"We saw Susan Smith today in follow-up. She was in good spirits. The uterus is moderately enlarged and she continues to have irregular bleeding. She has given it quite a bit of thought and wishes to have permanent relief of this bleeding and pain. We will bring her in for a total abdominal hysterectomy and possible bilateral salpingectomy. Hopefully we can do this early in the New Year." 

The patient's pre-op assessment is on March 4, in anticipation of surgery on March 11. During the pre-operative visit the nurse explains the planned procedure, telling the patient she will have a single incision across her lower abdomen in the bikini area and that she will need 6 to 8 weeks off work to recover. The nurse also gives the patient a brochure on abdominal hysterectomy. 

The patient is surprised. Based on her sister's experience, she had understood the surgery would be done laparoscopically (laparoscopic assisted vaginal hysterectomy) through 3 small incisions. The nurse tells the patient she should contact the surgeon’s office for clarification. The nurse also leaves a message with the surgeon’s office asking that the patient be contacted. 

After several attempts at trying to connect with each other, the patient and surgeon speak by phone on the afternoon of March 10. The patient is upset because she had made arrangements for a much shorter recovery, and she is unable to be off work or get help at home for 6 to 8 weeks at this time. The surgeon feels frustrated, believing that they had discussed the recovery time at the earlier office visit when the decision to operate was made. Nevertheless, the surgeon cancels the case the following day and arranges for another office visit with the patient to discuss the operation in greater detail.

Facilitation questions

1. What general information categories would you typically include in an informed consent discussion? When should this take place?
2. How might this misunderstanding have been avoided?
3. The patient assumed that her surgery would be the same as her sister's hysterectomy. How might the surgeon have elicited this assumption on the part of the patient?
4. How could the documentation reflect a consent discussion that included strategies to avoid assumptions and misunderstandings?

Suggestions to faculty

This text case can also be used to discuss the CMPA Good practices, “Professionalism and ethics: Professionalism” and “Physician-team: Team communication”

1. Professionalism
   
   • Discuss the surgeon's reaction to the patient's last minute refusal to consent.
2. Team communication
   • Discuss how the members of the team, the office nurse, the booking clerk, and the nurse in the pre-op clinic could have decreased the likelihood of this event.
     

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.