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 a physician's respect for a patient's right to make autonomous decisions about their healthcare. Informed consent is both an ethical practice and a legal requirement for all procedures and treatments.
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.1 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 fullest 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 (nonacute care is increasingly sought in the ED) and addresses the full spectrum of society (patients from diverse health literacy, language origins, socioeconomic backgrounds, and other recognized vulnerable populations—elderly, children, prisoners). Emergency Physicians need to be prepared to address the broad clinical needs of diverse patients under pressure without the historical physician–patient relationship. Systemic constraints exacerbate this challenged professional context as patients have no choice in the treating physician or the treating facility, which is often dictated by EMS 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 1-1 Challenges for the Emergency Physician to Spend Time Engaged in Conversation with a Patient ||Download (.pdf)
Table 1-1 Challenges for the Emergency Physician to Spend Time Engaged in Conversation with a Patient
- Time pressure
- Little privacy
- Pace of care challenges lay person decisions
- No prior relationship
- Lack of facility choice
- Public health- or system-imposed constraints
The torrent of complex medical information physicians provide patients is overwhelming in the most controlled settings, and is only made worse in the high emotion and high stress environment of the ED. Emergency Physicians often make rapid decisions ...