Surgical Consent Guidelines

Importance of obtaining informed consent

The informed consent process is fundamental in both law and ethics. Patients have a right to receive information and ask any questions about recommended treatments so that they can make a well-informed decision (Topcu et al., 2023). As part of good medical care practice, healthcare professionals are required to have the knowledge and skills to not only treat patients but also inform them, respect their wishes, and establish trust between themselves and the patient (Topcu et al., 2023).

Obtaining consent is one of the key steps in preparation for surgery. Once a relationship has been established between the patient and the medical professional, it is necessary to obtain informed consent.

Informed consent is more than just a signature on a piece of paper; rather, it is about ensuring that the patient is thoroughly informed on the whole procedure that is being performed by the surgeon (Topcu et al., 2023). The risks, benefits, and alternative treatments must be discussed. Further to this, it is important that the patient's wishes and concerns are both met and discussed in this manner; the patient must provide informed and deliberate consent for the proposed treatment prior to the surgery.

Surgical Consent Guidelines

There are various elements that need to be considered by the physician when obtaining surgical consent. These include (Topcu, et al., 2023):

Competence/capacity

It is important to assess the patient's ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision. Patients must be both the legal age of competency and possess the mental capacity to do so.  In the cases where patients are not able to provide consent, this is passed onto a surrogate or substitute decision make, typically a parent, spouse or offspring.

Disclosure

Patients should receive clear, relevant information to make informed, autonomous decisions that reflect their concerns and wishes. Communication should be simple and easy to understand, and if language barriers arise, a professional interpreter should be used.

Patients should be informed about their diagnosis, the specific medical intervention or procedure, its risks and benefits, possible additional procedures, alternative treatments (including no treatment), and anesthesia options with their associated risks.

While it's not practical to cover every possible risk, the most common and serious ones must be clearly explained. Patients need this information to make informed decisions, and physicians should focus on risks that are either frequent or significant.

Understanding

Ensure the patient understands by asking them to summarize the information and providing time for questions. Address any gaps in their understanding by clarifying and repeating key points as needed.

Voluntariness

Patients should be free to make voluntary decisions without pressure or coercion. Consent should be a process, not a one-time event, allowing time for discussion and reflection—unless it's an emergency. Patients can withdraw consent at any point before the medical treatment, and this must be respected.

Physicians may strongly recommend treatment, but coercion—using threats—is never acceptable. If a patient refuses a high-risk procedure, it’s important to document their decision.

Document informed consent

All discussions should be thoroughly documented in the patient’s records. Consent is finalized by the patient signing a standardized consent form, which should be supplemented with any relevant details. Any objections to specific instruments or additional procedures should also be clearly noted in the form.

In situations where a decision must be made urgently, such as an emergency, a patient typically cannot participate in decision-making (Topcu et al., 2023). If the surrogate is not available, physicians are able to initiate treatment prior to receiving informed consent, given that the treatment is needed, and waiting would put the patient's life at further risk.

In an emergency situation, it is crucial that the physician informs the patient/surrogate at the earliest moment and obtains consent for any ongoing treatment (Topcu et al., 2023).

How to use the Surgical Consent Guidelines

Our Surgical Consent Guidelines are adapted from the "FIGO Best practice guidance in surgical consent". The template lays out the guidelines based on the information from the reference authoreOud by Topcu and colleagues (2023). Here are the steps to use our free Surgical Consent Guidelines:

Step 1: Download the template

Access the Surgical Consent Guidelines template by clicking "Use template", allowing you to edit the resource via the Carepatron app. For a PDF copy, choose "Download."

Step 2: Familiarize yourself with the template

Review the Surgical Consent Guidelines template to understand its structure and content. The template provides a step-by-step guide to ensure all essential details are covered during the consent process.

Step 3: Use the template during consultations

Follow the template when discussing surgical procedures with patients. It will help ensure you provide clear and comprehensive information, including the nature of the surgery, associated risks, benefits, and possible alternatives.

Step 4: Provide the handout to patients

Share the Surgical Consent Guidelines handout with patients to reinforce the information discussed. This allows them to review the details at their own pace, empowering them to make informed decisions about their care.

Benefits of our free Surgical Consent Guidelines

Here are the key benefits of using our free Surgical Consent Guidelines to streamline your consent process and improve patient care:

Simplifies the creation of consent forms

Our Surgical Consent Guidelines streamline the process of creating consent forms by providing a structured template. This ensures that all critical aspects of a surgical procedure are clearly outlined and easy to follow, reducing the risk of missing important details.

Ensures comprehensive patient communication

The template is designed to facilitate clear and thorough communication with patients about their surgical procedure. By following the guidelines, healthcare professionals can confidently explain the risks, benefits, and alternatives, ensuring informed consent is obtained.

Saves time during consultations

Using our Surgical Consent Guidelines allows you to efficiently cover all necessary components of consent forms during patient consultations. This saves time while maintaining high standards of patient care and legal compliance.

Promotes consistency in consent documentation

By adhering to the guidelines, you can ensure consistency across all consent forms, regardless of the surgical procedure. This enhances documentation accuracy and supports compliance with medical and legal requirements.

Improves patient understanding and trust

Our guidelines help patients better understand the surgical procedure they are consenting to. This clarity fosters trust between patients and healthcare providers, ensuring a more positive healthcare experience.

Reference

Topcu, E. G., McClenahan, P., Pule, K., Khattak, H., Karsli, S. E., Cukelj, M., ... & Fogarty, P. (2023). FIGO Best practice guidance in surgical consent. International Journal of Gynecology & Obstetrics, 163(3), 795-812.