a power point presentation on informed consent in surgery

1. CONSENT TAKING
IN SURGERY
By: Dr. GLORY ENOCHE ALAPA
House Officer
Department of Surgery UATH
Supervisor:
Dr. OKPAKO Isaac Oghenero.
Senior Registrar Plastic Surgery Division
Department of Surgery
University of Abuja Teaching Hospital Gwagwalda
Date 22/04/2024

2. Outline
 Introduction
 Historical perspective
 Types of Consent
 Components informed consent in surgery
 Benefits of an informed consent
 Who takes informed consent?
 Who can give informed consent?
 Stages of informed consent
 The informed consent form
 Informed consent in special cases
 Factors that make a faulty consent
 The UATH Experience
 Conclusion
 References

3. INTRODUCTION
 Informed consent is the process in which a health care
provider educates a patient about the risks, benefits, and
alternatives of a given procedure or intervention and as well
as seek permission to carry out the said
procedure/intervention
 The patient must be competent to make a voluntary decision
about whether to undergo the procedure or intervention.
 Informed consent is both an ethical and legal obligation of
medical practitioners and originates from the patient's right to
direct what happens to their body.

4. Historical perspective
 The concept of informed consent has a relative short history beginning
with a series of 4 judicial decision in the early 20th century
 The first was in 1905 with the case of Mohr vs Williams
 Pratt vs Davis
 Rolater vs Strain
 Schloendorff vs Society of New York Hospital
 However it was not until 1957 when it was publicly recorded in the court
document for the case of Salgo vs Leland Standford Jr University Board of
Trustees that the name and principles of informed consent came to be and
became legally binding

5. Historical perspective – Nigeria
 The professional conduct of medical doctors is guided by the Code of
Medical Ethics in Nigeria, in which Rule 19 of part A deals with
informed consent.
 Most laws in Nigeria emanates from the British legal system like wise
informed consent and this is not surprising as Nigeria was a colony of
the British empire
 There are not enough legal cases to set the rules for informed
consent in Nigeria a clear departure from the above was a landmark
judgment in 2001 between Medical and Dental Disciplinary Tribunal
vs. Okonkwo,

6. Historical perspective – Nigeria
 In Medical and Dental Disciplinary Tribunal vs. Okonkwo, the appellant, Dr Okonkwo, was found
guilty of professional misconduct.
 He had honoured the verbal and written wishes of a Jehovah’s Witness patient who refused blood
transfusion and consequently died during treatment.
 The Nigerian appellate court upheld Dr Okonkwo’s appeal and the Supreme Court concurred.
 The apex court ruled that an adult Nigerian has a right to refuse life prolonging medical treatment,
including blood transfusion. The court located that right in the constitutional right to privacy and
freedom of thought, conscience and religion.
 The court, in defining the limits of treatment in that judgment, stated:
 The patient’s consent is paramount... [Accordingly] the patient’s relationship [with the Doctor] is based on
consensus. It follows that the choice of an adult patient with a sound mind to refuse informed consent to
medical treatment, barring state intervention through judicial process leaves the practitioner helpless to
impose a treatment on the patient.

7. TYPES OF CONSENT
 - IMPLIED CONSENT : Is a consent given by a person’s Action or inaction ( like
a gesture) or can be inferred from certain circumstances by a reasonable
person
 - EXPRESS CONSENT : Is a consent given by a person involved directly with
explicit words or in writing
 - INFORMED CONSENT : Is a consent where the person involved is aware of all
the information concerning what they are agreeing To/with and with eventual
signing to a document

8. Component of an informed consent
 Diagnosis/ Clinical impression
 Treatment/Intervention
 Risk/complication
 Alternative treatment
 Prognosis

9. Benefit of an informed consent
 Gives greater inclusivity to patient on their treatment
 Improves treatment outcomes and compliance to post
intervention instructions
 Reduces post intervention complications
 Reduces the chances of litigation
 Increases the institution standard in compliance with regulatory
body requirements

10. Who takes informed consent
 Ideally the lead surgeon takes the consent
 however a team approach is advocated where
contribution is sort from the entire clinical staff, legal
counsel, administrative and/or clinical leadership

11. Who can give informed consent
 A competent person; this is defined as a person above the age of 18 years who have
cognitive and emotional maturity
 Gillick consent
 Health care power of attorney (e.g. Jehovah witness having a health care power of
attorney in their pocket requiring that they should not be transfused blood even
when found unconscious)
 Legal guardian
 Statutory surrogate
 In order of priority
 Spouse except legally separated
 Adult child of the patient
 Parent of a patient
 If the patient is unmarried the patient domestic partner
 Patient brother or sister
 A closed friend of the patient who is familiar with the condition
 For unconscious adult who does not have any of the above, Moral and legal
responsibility to act in patient best interest is considered

12. STAGES OF INFORMED CONSENT
 1. Assessment of preconditions
 -Patient competence and voluntariness
 2. Provision of information
 -Patient education
 -Recommendation of a care plan
 -Understanding of this information by the patient
 3. Stage of consent
 -Patient consenting to the surgical procedure
 -Recording of this authorization

13. The informed consent Form
• The consent form must have
• A title
• Information of the consenter (Age, Sex,
Occupation, signature)
• Diagnosis of the condition
• Treatment being offered
• Express agreement that patient understands the
diagnosis, options of care, procedure/treatment,
complications prognosis
• Information of the doctor giving the consent
• Information of the doctor performing the surgery
• Information of the members of the team
• Information of Witness (Age, Sex, Occupation,
Relationship to patient, address, signature)

14. Informed consent in special cases
 Informed consent in children
 Informed consent in pregnant women
 Informed consent from a patient with different language
 Informed consent from an illiterate
 Informed consent from an unconscious patient

15. Consent in special cases - Informed consent
in children
 Informed consent in children
 The children are generally not deemed competent hence consent
should be taken from parents or other surrogate decision maker
preferably with the assent of the child
 If there is disagreement with care in regards to inappropriate decision
of the care give (e.g. blood transfusion) a court order may be sort for

16. Consent in special cases - Informed consent
in pregnant women
 Informed consent in pregnant women
 It is best to obtain consent from both partners however if the
treatment/research is to meet the health need of the mother the
consent of the husband is not needed.

17. Consent in special cases - Informed consent
from a patient with different language
 Informed consent from a patient with different language
 It is advisable to use a translator to translate to the patient own
language
 The consent form may not be substituted for a version that has been
translated

18. Consent in special cases - Informed consent
from an illiterate
 Informed consent from an illiterate
 The consent must be properly explained to the individual and the
individual may thumb print or use a written mark as his signature on
the consent form

19. Consent in special cases - Informed consent
from an unconscious patient
 Informed consent from an unconscious patient
 Consent may be taken from
 Health care power of attorney
 Legal guardian
 Statutory surrogate
 The surgeon who has the Moral and legal responsibility to act in patient
best interest especially when the above are not available

20. Factors that can make a faulty consent
 Mental retardation
 Mental illness
 Alcohol intoxication
 Altered mental state
 Severe brain injury
 Minor

21. The UATH experience
 Consent taking is a perquisite to any procedure and it is strictly
adhered to as there have not been any litigation case in view of either
not taking a consent or poorly taken consent

22. Conclusion
- The concept of informed consent is continuously evolving, and it is necessary
for the surgeon to be conversant with the application of informed consent.
- Informed consent Protects the patient’s human right and upholds a Surgeon
integrity in practicing Medicine .
- Consent obtained by fraud, under the influence of drugs or anesthetics, from
an insane person, or without giving sufficient information about the surgical
ailment, the treatment proposed, and the attendant risks to enable the patient
to understand the position fully and make an intelligent decision, is not an
acceptable informed consent.
- Informed consent should be a simple document, adaptable to most situations

23. REFERENCES
 Ezeome ER, Marshall PA. Informed consent practices in Nigeria. Dev World Bioeth. 2009 Dec;9(3):138-48.
doi: 10.1111/j.1471-8847.2008.00234.x. Epub 2008 Apr 29. PMID: 18452553.
 Bazzano LA, Durant J, Brantley PR. A Modern History of Informed Consent and the Role of Key
Information. Ochsner J. 2021 Spring;21(1):81-85. doi: 10.31486/toj.19.0105. PMID: 33828429; PMCID:
PMC7993430.
 - Anderson, O. and Wearne, I. (2007) Informed consent for elective surgery
 -Medical and Dental Council of Nigeria: Codes of Medical ethics in Nigeria.
 - examination of the consent form of the Ahmadu Bello University Teaching Hospital Zaria MR3
 - Federal Republic of Nigeria. Constitution of the Federal Republic of Nigeria. Apapa: Federal
printing Press; 1999.
 - The Doctrine of informed consent- African online journals –YZ Lawal 2007
 Informed consent | PPT (slideshare.net)

24. THANK YOU