iCONSENT
HOW TO HAVE BETTER CONSENT CONVERSATIONS
This module focuses on the actual consent conversation. Where you have these conversations and how you approach them can substantially improve or undermine decision makers’ understanding and satisfaction.
Setting - It is best to avoid coercive environments when possible both in terms of location and who else is present.
Approach - We created the iCONSENT acronym to provide an evidence based approach to enhance consent conversations described further below.
Body Language and Other Tools - These can also augment these conversations which will be discussed in this and the next module.
WHERE TO HAVE THE CONVERSATION AND WHO SHOULD BE PRESENT
Location - It is best to avoid having these conversations in environments where patients may feel they cannot choose not to have an intervention such in the procedure/operation room or peri-procedural areas. This is not always feasible, but having conversations in clinic or hospital rooms tend to be less coercive environments and support better informed decision making.
Who Else is Present - Some patients feel more comfortable making medical decisions with their family present, particularly in certain cultures. As such, it can be helpful to ask whether they want others present or would like you to call anyone to be part of the conversation.
The Overbearing Family Member - Other times there may be coercive relationships or a family member seems to speak over and for the patient. This often comes from a sincere place of concern for their loved one.
In these situations, it is often helpful to let the family member say what they have to say, validate it, and then ask to hear from the patient, e.g., “Thanks for letting me know that, [the patient] is lucky to have you as an advocate for them. If it’s okay with you, I’d also like the hear how [the patient] feels about [the potential intervention].”
If this is unsuccessful or there seems to be a more coercive relationship present, it can be helpful to come back another time when the family member is not present and confirm that the plan aligns with the patient’s goals of care.
ICONSENT APPROACH TO CONSENT CONVERSATIONS
I Introduce yourself and your role
C Clarify your patient’s understanding of their disease and options
O Overview of their options including risks/benefits/alternatives
N “Need more information?”
S Stop & listen to their questions/concerns
E Explain
N “Need more information?”
T Test their understanding through teach-back
Ideal consent conversations should empower the decision maker with information on the risks, benefits, and alternatives of a recommended intervention including the option of what would occur with no intervention.
It is helpful to first establish rapport with introducing yourself and asking what the patient and/or family knows about what is going on and why you came to talk to them. This helps you know where they are starting from and what are their means concerns/questions that may need to be answered before they are ready to internalize additional information. It also gives you a sense of their health literacy to adjust your language accordingly (more on this is the next module).
You will also see that we included asking whether they need more information and confirming understanding multiple times. It is often more effective to provide information in smaller chunks and pause to confirm understanding along the way rather than launching into a 5 minute lecture and only asking whether they have questions at the end. This method is called “chunk and check.”
CONSIDER THIS ESSAY BY HOWARD BRODY
“My Story Is Broken; Can You Help Me Fix It?”
This essay explores some ethical implications of a narrative con- ception of the physician-patient relationship. I shall argue that the moral basis of the relationship is best preserved and enhanced when the physician and patient go about developing meaning within their en- counter in a particular way. Ideally, the physician-patient relationship should be both ethically sound and therapeutically effective. Construct- ing certain sorts of narratives within that relationship attaches meaning to the patient's illness experience in a way that enhances the healing potential of the encounter. Moreover, when narratives are jointly con- structed, power is shared between physician and patient, and the sharing of power constitutes an important ethical safeguard within the relationship.
Questions for reflection or group discussion
Can you think of a time that you noticed a difference between curing and healing in healthcare?
How can we balance the importance of listening to a patient’s story with time constraints?
What is our role as co-narrators? How can this be both helpful and harmful?
SHARED DECISION MAKING - AN IDEAL APPROACH TO CONSENT
Shared Decision Making has increasingly become the ideal model for informed consent. With the rise of medical ethics, there was a shift away from paternalism to a focus on patient autonomy. Rather than clinicians telling patients what was best for them, there was acknowledgment that patients should make their own health decisions.
However, there was also concern that simply deferring to patient autonomy and doing whatever patients request also is not ideal. Many patients do not have formal medical training and part of the fiduciary duty of clinicians is provide guidance and recommendations.
Shared decision making can be thought as a balance where patients and clinicians make a shared decision together. Clinicians respect patient’s autonomy and preferences while also providing guidance and recommendations.
BODY LANGUAGE AND OTHER TOOLS
Body Language - Simply sitting with open body language rather than standing over patient can substantially improve consent conversations. There is an inherent power differential in the clinician-patient relationship, particular for patients with limited health literacy and other barriers. Sitting helps lessen this power gaps and signals that you are not in a rush and there to hear what the patient has to say.
Be Empathetic and Curious - First impressions go a long way. It is helpful to be empathetic and curious about who you are talking to, what do they know, what do they want to know, and what are their values. This lets you establish lasting rapport early in the conversation, making the rest of the conversation more effective. People usually are not at their best when you are meeting them to discuss a procedure. They may be in pain, anxious, or have had previous bad experiences with healthcare. Being sensitive to this and keeping it in mind can help us connect with our patients and establish a better clinical relationship with them.
Lean into Tension - Illness and disease can be devastating and frustrating. Many patients have also had previous poor experiences with healthcare or hold historic distrust. They may be angry, scared, and/or anxious. In these cases, it is helpful to lean into this tension. Slow down, lead with compassion, and name it gracefully. Try to avoid saying things like “I know how you feel.” or “Don’t worry it’s not that bad.” These comment invalidate their experience. Instead try “I can only imagine what you must be going through, tell me more.” or “You’ve been through a lot.” or “I would be angry/frustrated too.” Listen and try to get to the root of their frustration, validate it, and apologize if warranted.