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Have we gone too far with informed consent, or not far enough?

A patient came to see me recently after she suffered a weekend-warrior sports-related injury and ended up going to a freestanding urgent care clinic for evaluation and treatment.

She reported that she had a wonderful evaluation by the team of providers there, and ultimately after undergoing a physical examination and an x-ray she was told she had a sprained knee, and she was given the traditional RICE recommendations -- rest, ice, compression, elevation.

What struck me most, however was that buried within the extensive paperwork that she brought with her I found something labeled "Procedure Note."

Has It Come to This?

At first, I was puzzled, and wondered if they'd had to tap the joint to relieve a hemarthrosis, or whether they'd given her a steroid injection to try to cut some of the inflammation.

Upon reading through the paperwork, trying to discern what they had done, I finally found out that this procedure note was for the placing of an Ace bandage.

Seriously, has it come to this?

The procedure note, although much longer than this, read something like this:

Preferred language: English

General procedure information: procedural/sedation administered: no

Procedure performed by: (name of provider)

Procedure type: other

Preparation: patient was placed in a sitting position, the procedure site was prepped with (blank)

Complications: procedure tolerated well with no complications

Additional comments: upon patient's verbal consent, the Ace wrap was applied. The patient tolerated the procedure well with no complications. Ace wrap use instructions and precautions were described to the patient in detail prior to discharge

Electronic signature: (name of provider)

This seems like an awful lot of unnecessary electronic gibberish, just to document that we are putting a supporting bandage on a sprained knee.

And did an actual full informed consent process really take place for this?

The American Medical Association, in its Code of Medical Ethics, in part in the following way:

"Patients have the right to receive information and ask questions about recommended treatments so that they can make well-considered decisions about care. Successful communication in the patient-physician relationship fosters trust and supports shared decision making.

The process of informed consent occurs when communication between a patient and physician results in the patient's authorization or agreement to undergo a specific medical intervention."

Now I can see that this makes the most sense when you're doing an invasive procedure, when you're operating on a major body part, when really risky things are happening, but shouldn't there be a point on the scale from the sublime to the ridiculous at which we can just go ahead and put a Band-Aid on a boo-boo?

Too Much of a Good Thing?

Everything we do in healthcare should really be done in an environment of informed consent. Patient should be educated about the things we're doing to them and for them, and they should fully understand the risks, benefits, and alternatives available to them.

Gone (for good reasons) are the days of paternalism, where what the doctor says is what goes.

But if we break down the process of healthcare so that every single thing we do requires an extensive informed consent discussion and documentation of a procedure note, well, I don't think we're going to get anywhere.

Every once in a while in our practice patients say they don't want to be weighed, or don't want their blood pressure checked, or don't want to be examined, and all of these are well within their rights.

Taking someone's blood pressure without their consent can be construed as assault and battery, especially if they requested that you not do that.

Over the years of doing outpatient medicine, we've often had situations arise where it's been important for us to do these tests to safely take care of the patient, and yet a patient, seemingly well-informed, declines an intervention.

Clearly if we think the intervention is medically important and the patient declines, we should be able to very clearly describe to them why we're checking their blood pressure or taking their temperature, and if they decline that we should be documenting in the medical record why this wasn't done.

Expectations of Patients

As we go further along the spectrum of care, past vital signs and physical examination, into the realm of ordering lab tests, imaging, referring to specialists, prescribing of medicines, and all the other treatments we ultimately get to as we go down our medical decision-making pathways, inherent in this process is informed consent and explaining to our patients why we are choosing to do this particular things to them, with them, for them.

But if we expect every provider to have an informed consent decision discussion with every patient about measuring their height, taking their blood pressure, looking in their ears, then we're never going to be able to get anywhere.

If you think about it, there's risk in doing each of those things just mentioned.

Everything we do -- from the vital signs to the physical examination to the ordering of tests to the prescribing of medicines -- has the potential to open up a whole new can of worms.

• If I measure your height, and you've gotten shorter, I may want to do a bone density test, which ultimately may lead to a diagnosis of osteoporosis, which may lead to treatment with medicines which have potential side effects.
• If I listen to your lungs and I hear an abnormality, I may need to do imaging, which may lead to a biopsy, which may lead to a complication.
• If I order a CBC on you, there's a whole plethora of abnormalities which may come back, each of which could lead us down another path of diagnoses and treatments and complications and side effects.

I think different providers set these things at different levels for themselves, and differently for different patients.

We often find that when patients agree off the bat to undergo the recommended interventions, we are less worried about documenting a detailed informed consent discussion than when they decline.

If a patient agrees to take a blood pressure medicine, that's usually when our discussion ends. But when they go against our best medical advice, and if they decline treatment for their high blood pressure, that's when we start documenting the risks that might occur, the potential harm that might ensue, the downstream implications.

So how much is too much, and how much is too little?

Every provider does this differently, and clearly there are things that really absolutely positively need a clear discussion including fully detailed risk of possible side effects and complications and alternatives.

But putting on an Ace bandage?

Certainly, our patients can refuse to let us put a bandage on them, and if they don't want their knee wrapped maybe we should tell them that they risk having it get more swollen and more painful. But I just don't think we need a procedure note that ends up cluttering the electronic medical record, confusing our patients and not helping anybody.

That's a wrap.

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