Reflections

As an emergency medicine resident, I found the topic of informed consent especially interesting. I work with patients every day in a range of situations, from the life threatening where there is a lack of time to consent, to the elective procedure. The majority of the patients I see did not wake up that morning planning to be in the emergency department, or seeing a doctor. Many of them are in pain, emotionally and or physically. While we try to treat the physical pain, we cannot always treat the emotional pain, the stress, fear, concern about the unknown. Yet I and my physician colleagues around the country ask these patients to make difficult decisions in this environment. Often times in the ED, it is not possible to sit down with the patient for 45 minutes, or to allow them to go home and think about their options for a week or two. However, I agree that we are not truly giving the patient the right to informed consent under these circumstances of pain, drowsiness post treating the pain, and stress. While having patient advocates are important and valuable, not all patients are able to have their family or close friend with them. I do not quite know the answer of how to effectively ask these patients to make difficult decisions in short periods of time with the conditions they are dealing with, though our discussions of the video did provide some starting points.

A comment was also made regarding use of psychiatry to deem competence and the slippery slope nature . While I have myself called psychiatry in such situations a handful of times, it is not because I thought the patient to be “crazy” for not listening to my opinion, but rather because I (and at the end of the day my attending) at some level are covering our own legal behinds if this patient ends up going home, has a probable bad outcome, and a family member sues us saying how could you let me love one leave, he/she “clearly wasn’t competent to make the decision to not have X done”. I find it unfortunate that so many of our actions are dictated by the legal climate and fear of the ability to continue practicing our profession, which hurts patient care. I do believe that changes to the litigious nature of healthcare, or perhaps just that perception, is needed for improvement in shared decision making and overall patient care.

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