“Risk is the category where litigation pops up and where you see the most challenges,” says O’Rourke, because the patient filing a claim may say, “ ‘Well, the doctor didn’t tell me about this risk and had I known this occurred, I would have elected to forego this procedure; I would have chosen one of the other alternatives.’ ”
If a patient develops a complication and the hospitalist must initiate a new intervention, then it’s the hospitalist’s duty to get informed consent for that next intervention. “Every time a physician undertakes a particular intervention, the patient has to be informed in why that intervention is being taken and what the risks, benefits, and alternatives are,” says O’Rourke.
If a patient is incapable of giving consent, then consider whether there is a significant risk in waiting until the patient is capable of giving informed consent. If the answer is “no,” then consider whether or not to delay the intervention. “If there’s no potential harm caused by waiting until the patient hits a higher level of consciousness,” says O’Rourke, “then that’s perfectly appropriate.”
In an emergency situation, a surrogate may need to make the decision. If neither one of those alternatives is available, “the law presumes that the patient is going to do what is reasonable and necessary in order to preserve his or her health, unless there’s been some instruction otherwise,” notes O’Rourke.
Teach Back
Studies show that when patients are asked to repeat what they understood from their informed consent discussions, they have greater recall and comprehension of the risks and benefits of surgical procedures.2,15 “Teach back” is an especially valuable technique to use with low literacy patients. The NQF discovered that the providers and departments using teach back were widely recognized by their peers as having the most well-informed patients compared with departments that did not use this method.2 (See “Teach Back in Action,” above right.) A number of studies have found that when a provider asks a patient to restate information or instructions, the benefits include providing a check for lapses of recall and understanding, revealing health beliefs, reinforcing and individualizing health messages, and motivating patients by activating dialogue.15
In May 2003, the NQF published Safe Practices for Better Healthcare, which endorsed a set of consensus standards for 30 healthcare practices, one of which (Safe Practice 10) recommends that all healthcare professionals ask patients to teach back what they have been told by their providers during their informed consent discussions.2
In its 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices (project director, Robert M. Wachter, MD), the Agency for Healthcare Research and Quality suggested that special attention be paid to implementing 11 particular practices, one of which was “asking that patients recall and restate what they have been told during the informed consent process.”16
Even if you are not asking for a signed form, physicians, nurses, interpreters, and any professional who communicates with patients regarding their healthcare decisions is involved in the informed consent process and should use teach back—especially with those patients who find even basic health information difficult to understand. Although the NQF found that physicians were reluctant to incorporate this technique into their communications, the providers reported anecdotally that teach back takes less than a minute to complete; research backs up the claim that the more the technique is practiced, the speedier it gets.2
The provision of this “interactive communication loop,” as it has been called,15 has also been shown to affect clinical outcomes. In a study by Schillinger and colleagues conducted at an outpatient general internal medicine clinic and at San Francisco General Hospital, physicians assessed recall and comprehension of any new concept in 12 (20%) of 61 outpatient visits by diabetic patients for 15 (12%) of 124 concepts.15 The patients whose physicians assessed their recall by means of teach back were more likely to have hemoglobin A1c levels below the mean compared with patients whose doctors did not. The two variables found to be independently associated with good glycemic control were higher health literacy levels and physicians’ application of the teach-back strategy.