Principle of informed consent unquestionably important

Yulia Warhani, Jakarta

A friend who was admitted to a hospital in Jakarta recently complained that he felt he was getting worse after taking a prescribed medicine from his doctor. "You know, I'm getting worse because of these red-white capsules the doctor gave to me yesterday," he said.

The doctor diagnosed him with dengue fever. Three days later, however, the patient became really upset when he was given a bill for Rp 12 million (US$ 1,275), only for a case of dengue fever.

After I assessed the information about his medication, I then understood why he experienced such bad feelings while he was sick.

While it was true that he had dengue fever, he had actually entered Dengue Shock Syndrome. Unfortunately, the doctor failed to properly inform him about the diagnosis and treatment. The doctor neglected the patient's right to informed consent, and consequently the patient thought he was the victim of malpractice.

Nowadays, hospitals and doctors are facing growing numbers of lawsuits from people who are dissatisfied with their services. Meanwhile, data on alleged malpractice cases in Jakarta in 2003 -- 2004 indicates an increase in such cases.

The three most common forms of negligence were misdiagnosis, improper treatment or improperly performed procedures, and improper administration of medication.

The main sources of patient and family dissatisfaction were nursing and medical care problems, as well as interpersonal and communication problems. There are numerous complaints of patients being treated rudely by doctors, nurses or other hospital staff, with patients and their families not receiving proper explanations about medications or the diagnostic testing being conducted, without confirmation or explanation to patient.

Other frequent allegations included abandonment of a patient, lack of informed consent, and failure to refer or obtain consultation.

The principle of free and informed consent is unquestionably one of the most important when it comes to malpractice cases and medical ethics. It is the basis of the doctor-patient relationship.

Responsible consent to therapy must be informed consent, which means the patient must be told the nature of the proposed therapy, its probable benefits, its possible risks and other possible treatment choices.

Furthermore, the patient must be free to make their decision without pressure, persuasion or threat. The health care giver is obligated to explain clearly all aspects of procedures and treatment, side effects, advantages, and prognosis. Let the patients decide for themselves, depending on their capabilities.

A patient must be given sufficient information to make an informed decision about treatment. Treating a patient without consent or exceeding the consent may cause unnecessary problems. Although obtaining written consent is wise, informed consent need not be written. It is more important to give the patient the opportunity to ask questions, to explain all significant risks, benefits, and alternatives, and to document the conversation in the medical record. Documentation is crucial to avoid disputes.

In the case above, if my friend had been clearly informed by the doctor, I think he would have accepted the reality and the cost. Dengue Shock Syndrome is serious, and it needs special treatment. In some cases patients need to be treated in intensive care units.

Unfortunately, the situation in our hospitals is unsupportive of informed consent. The hospital climate does not facilitate the delivery of information in such a manner. The culture, habits and obstacles are still with us. Doctors, it seems, do not have enough time to go into detail about medical treatments because of time pressures and burdens of the work place. Just imagine, if a doctor has 10 patients in one hospital, and that same doctor works for, say, four hospitals. Meanwhile, s/he also has to attend to out-patients, so time spent doing "informed consent" may seem an unaffordable luxury.

In addition, in some cases doctors may be under pressure from managed care organizations to shorten hospital stays, limit the use of consultants, and avoid expensive ancillary tests.

On the other side, patients may not make enough effort to ask their doctors questions about their disease, diagnostic tests and treatments, because they feel intimidated. Many of us perhaps are afraid to ask questions, or feel embarrassed asking doctors or any other health care giver about our own health.

It often happens that doctors feel that they will frighten away a patient if they discuss all possible risks. However, this can backfire if patients subsequently feel that they were misled into undergoing a treatment. It is better to inform fully in all situations rather than face potential negligence claims.

One of the best methods for preventing malpractice lawsuits is the establishment of a strong patient-physician relationship based on trust and open communication. Patients who feel that their physician truly cares about them and has their best interests in mind are less likely to sue, even if something untoward has occurred.

It is important to be open and honest with patients in all circumstances, including discussion about examinations, test results and prognoses, benefits and risks. Never make guarantees about the outcome of a treatment.

Good listening and good understanding is needed when caring for patients and interacting with family members. Likewise, patients should not hesitate to ask questions.

Every entry in the medical record, whether in a hospital or office chart, should be dated and signed. Everything pertaining to the patient's medical care should be clearly documented.

Patient and family dissatisfaction with treatment, as well as interpersonal and communication problems, are often the triggers for malpractice lawsuits.

The writer is a lecturer at Saint Carolus Nursing School, Jakarta.