Retractive Consent

5 11 2012

Retroactive Consent

Wow, it’s really been a while since I’ve posted!  I had assumed that being in graduate classes rather than medical school clerkships would free up a decent amount of my time.  It has, but somehow all of those extra hours have been filled with activities like volunteering, leadership activities, shadowing, longitudinal clerkships, and an internship for my public health degree.  Add that to my effort to get 8 hours of sleep each night and work out almost every day—which I am carrying out with gusto—and I’ve had no trouble staying ‘off the streets.’

All that said, there are still a few bytes left from my surgery clerkship that really should be told before delving into my tales of neurology clinic and the world of public health.

This particular vignette calls to mind the title of this post.  Retroactive consent.  Never heard of this before?  You are not alone; I hadn’t, either.  In fact, this idea is not only very sketchy, but also unethical in the vast majority of situations.  The rule does not apply if there is a need for emergent treatment and the patient is either unconscious or mentally unable to give consent, or a child.

For example, if you are in a car accident and end up with a ruptured aorta, in shock, and passed out, the surgeon is not going to glance your way and say “Well, no consent, no surgery, this one’s SOL.”  Along those lines, a physician will still provide lifesaving emergency treatment for a child even if the parents refuse to consent, but that is an entirely different debate altogether.

The first time I saw retroactive consent, it did not directly involve a patient, but rather a nurse and an internal medicine resident.  The conversation went like this:

Nurse: “Dr. X, can you write a morphine order for this patient?”

Resident: “No.  He can have Percocet, but no morphine.”

Nurse: “Why not?  He’s in pain.”

Resident: “We don’t want him to have I.V. pain meds.”

Nurse: “Well, I didn’t know that.  Can you please put in the morphine order?”

Resident: “No, but I’ll write for Percocet if he is in pain.”

Nurse: “But I already gave the morphine.”

I watched a similar conversation escalate almost to a shouting match when a resident refused to write for a drug that a nurse had given without permission.  It was not either of their finest moments, clearly, but from the cavalier way that the nurse approached the issue, I had the impression she had done this before but usually faced no resistance from physicians.  The bottom line in all of this was that the patient was not harmed in any way (with the exception of having an IV put in unnecessarily).

The case I witnessed during my surgery rotation, however, may have resulted in patient harm.  That patient—we’ll call him Ted (for HIPAA’s sake)—was admitted to have a peri-rectal abscess drained.  The surgery was very quick and went smoothly until the attending surgeon saw that Ted also had some gnarly internal hemorrhoids (the kind that bleed, but don’t hurt).  She decided that since we were there, and he was already under anesthesia, and we had the OR for another 45 minutes, she wanted to fix the hemorrhoids.

Her exact words were, “It’s the right thing to do.”

The surgical resident assisting made a weak case against it.  I wimped out completely, went for tact, and asked about the conditions under which surgeons were allowed to perform procedures that the patient hadn’t specifically consented to, which earned me an expression resembling a sneer from the surgeon, who went to re-scrub without answering.

Fast-forwarding through a completely normal and complication-free hemorrhoidectomy to the next day.  Ted was in an unusual amount of pain.  I never did know how much Ted knew about the spontaneous hemorrhoid treatment, but it is very unusual to have that amount of pain from either draining an abscess or getting rid of a hemorrhoid.  At first, the surgeon did not believe he was in that much pain.  Then, she became convinced only after the resident and I both conveyed how exquisitely tender the site was (we were unable to remove the packing more than a centimeter, he was cursing and crying so much).

Her approach changed.  She became convinced that, certainly, Ted was on pain medication at home and had built up a tolerance to opiates.  That had to be it, there was no way that he could really be in that much pain from an I&D and hemorrhoidectomy.

The real trouble began when she asked the resident to approach the patient about opiate use.  When he asked about it, the tone sounded very unassuming to me.  He explained why it was important for Ted to let us know about chronic pain meds.  He asked again, “You aren’t taking any pain medications on a regular basis?”  Again, a tone that sounded very neutral.  Ted didn’t see it that way.  He became visibly upset, accusing the resident of calling him a faker, drug seeker, and addict.

Patient relations had to get involved.

The resident, a very arrogant-surgical-resident type who had never given the impression that he cared much about his patients on a personal level, was visibly distressed by this.  He was almost obsessed, asking me at least half a dozen times whether his tone had been accusatory, his wording conveyed doubt, even about what his facial expressions and body language had conveyed.

I could not see anything, aside from asking Ted only once whether he was on pain meds chronically, that the resident could have done differently.  I told him so.  And yet, this resident was tormented the next day as well.

He just kept saying “Every person has that one bad experience in health care.  I am going to be Ted’s terrible experience forever.”

Whether or not his extraordinary pain was caused by the impromptu surgical procedure, a complication of the abscess drainage, or some other external factor, I never did know (his post-op day 2 was my last day on the rotation).  This story is one of those that will stick with me, though, because of the surgeon’s gall, Ted’s pain and fury at the perceived accusation , and (perhaps most of all) the surgical resident’s torment over the miscommunication and the idea that he will forever be a black mark in Ted’s memory.

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One response

3 08 2013
Home Remedies for Piles

Dear Lord, doctors can just do that! Don’t get me wrong, I love the pragmatism of “well, while we’ve got him here, let’s fix it” but, damn. Hope you don’t mind if I cite your article in some of my own.

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