This chapter is designed as a practical reference for the Emergency Physician (EP). It focuses on the unique challenges of informed consent in the Emergency Department (ED). It presents a practical guide for the informed consent process, reviews the exceptions, and offers suggestions on difficult scenarios of informed consent in the ED.
The right of a patient to make decisions about their body, including the refusal of recommended procedures and treatment, is an important concept in medical practice with foundations in law and medical ethics. Informed consent is the process of communication that demonstrates respect for a patient’s right to make autonomous decisions about their health care. Informed consent is an ethical practice and a legal requirement for all procedures and treatments.1
UNIQUE CHALLENGES OF INFORMED CONSENT IN THE ED
Each practice environment presents its own challenges to the process of obtaining informed consent. Physicians frequently fail to fulfill all the requirements of obtaining informed consent.2-4 The ED presents significant challenges, which despite assumptions to the contrary, results in a greater need to spend time delivering information and engaging patients in their care decisions to the extent possible (Table 1-1). Time pressure and acuity are the most critical factors that influence the care paradigm in the ED. Care provided in the ED spans the full continuum of care as nonacute care is increasingly sought in the ED. Care in the ED addresses the full spectrum of society with patients from diverse health literacy, language origins, socioeconomic backgrounds, and recognized vulnerable populations (e.g., children, elderly, and prisoners). EPs need to be prepared to address the broad clinical needs of diverse patients under pressure without the traditional physician–patient relationship. Systemic constraints exacerbate this challenged professional context as patients have no choice in the treating physician or the treating facility. The location to transport the patient is often dictated by prehospital protocols. Tension may arise when a patient’s wishes conflict with greater societal or institutional needs for efficiency and protocol compliance independent of the patient’s preferences and needs. Examples include a trauma activation or a public health emergency. Increasing space constraints and crowding found in most EDs create a lack of privacy that can impede the free exchange of sensitive information. Procedural interventions in the ED are often concurrently diagnostic and therapeutic, further complicating informed decisions.
TABLE 1-1Challenges for the EP to Spend Time Engaged in Conversation with a Patient |Favorite Table|Download (.pdf) TABLE 1-1 Challenges for the EP to Spend Time Engaged in Conversation with a Patient
Lack of facility choice
No prior relationship
Pace of care challenges lay person decisions
Public health or system-imposed constraints
The torrent of complex medical information physicians provide patients is overwhelming in the most controlled settings. It is ...