Clinicians do not set out to deliberately cause harm to patients, but occasionally unexpected issues and avoidable deaths do occur. According to Human Factors Specialist and Consumer Representative, Dr Graham Beaumont, these occurrences are often a result of poor decision making.

Dr Beaumont has been working in the area of healthcare safety for more than 20 years as a member of the Clinical Excellence Commission, Collaborating Hospitals Audit of Surgical Mortality (CHASM) and the ANZ Audit of Surgical Mortality Committee.

“Surgeons report that the decision to operate is the most complex and testing aspect of their professional life. If this is the case, then sharing the decision making with other professionals through referral to peers or multi-disciplinary teams should ease the burden and produce more reliable decisions,” Dr Beaumont explained.

“Regardless, informed consent is integral to any decision to operate. Yet, the evidence suggests that patients are often not included in the process to the extent they should be,” said Dr Beaumont.

The process of obtaining informed consent is something that surgeons and anaesthetists learn on the job, rather than being taught formally. According to Dr Beaumont, this can be problematic.

“There appears to be no formal approach that is consistent when it comes to teaching clinicians about how to consent patients. While other high-risk professions have mandated decision-making training, surgeons rely heavily on the apprenticeship model to arm trainees with the required skills and knowledge,” Dr Beaumont said.

Informed consent relies on clear communication

Surgeons and anaesthetists cannot guarantee outcomes. However, according to Dr Beaumont, they can establish a reasonable expectation of an outcome which patients can consent to.

“With that being said, in many cases the patient does not necessarily understand what is going to happen to them in full, or does not really appreciate all the risks that might be applicable. They also may feel obliged to consent in the face of ignorance,” said Dr Beaumont.

According to Dr Beaumont, consent is a shared decision-making process between the surgeon and patient, and surgeons need to ensure that the patient is able to clearly understand the information provided.

Obtaining anaesthetic consent from patients immediately prior to surgery in the preoperative area can also be problematic. At this late stage, they are anxious or may already been given medication that inhibits their decision making.

“There needs to be more training for surgeons in terms of communication, the words they use, they way they ask the questions, and how they listen to the patient’s story – without the pressures of time,” said Dr Beaumont.

“Surgeons are very busy people, but that doesn’t take away the obligation to help the patient understand what is intended, so the consent that’s given is meaningful,” said Dr Beaumont.

Expanding the role of anaesthetists

When it comes to informed consent, anaesthetists could be viewed as the last line of defence. However, they need closer involvement in the decision-making process.

“In order for anaesthetists to provide this quality control function, their consenting processes and professional judgement need to function as an integral part of the decision to operate process. That should occur closer to the beginning of the patient journey, rather than outside the theatre doors,” said Dr Beaumont.

“That would require a full assessment of the patient before they are given any anaesthetic drugs, and a conversation with the surgeon if it is deemed surgery is problematic due to frailty – particularly near end-of-life where improved quality of life is difficult to define. Anaesthetists would need to be just as informed as the surgeon as the likelihood of a successful outcome,” said Dr Beaumont.

Harnessing all available resources is a cornerstone of safe systems. There is no doubt that expanding the decision-making team to meaningfully include patients and anaesthetists will help surgeons make consistently better decisions and avoid unfavourable outcomes.

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