I vividly remember, as a resident, watching a renowned attending ask a patient for consent for cataract surgery by simply pointing to the line at the bottom of the page and saying “Sign here.” “Wait a sec,” said the patient, “can you tell me if there are any complications I should worry about? What are the bad things that could happen with surgery?” The attending looked at him. “Do you trust me?” he queried the patient. “Of course!” was the answer. “Then sign here,” repeated the attending impatiently. The patient signed.
In the internet era of information overload and increasing awareness of patient rights, I can’t imagine dismissing a patient’s concerns so callously. My patients deserve a thorough and informed discussion of the risks, benefits, and alternatives associated with any procedure that we consider for their treatment. But I admit that the art of obtaining informed consent in a responsible, yet efficient manner can be a challenge. Any one of the procedures that we perform has an associated laundry list of potential adverse events that range from trivial to horrible. I struggle with how deeply to dive into the discussion of infrequent events, especially when my clinic is overbooked, my imagers are already running behind, and there is a huge backlog of charts sitting in front of my exam room door.
There are several approaches to informed consent, which can broadly be categorized as providing information that a typical physician would give, that the average patient would need to know to make an informed choice, or that a particular patient needs to know to make an informed choice. The precise legal requirements for informed consent differ in various states. Regardless of legalities, however, my personal approach is to provide information to each patient that covers the most common associated adverse events as well as those that could lead to substantial or lasting damage to vision or ocular structures. Whether the procedure is an intravitreal injection or a combination vitrectomy/scleral buckle, I also try to set realistic expectations by discussing my expectations for visual outcome, likelihood of need for other treatments, and the probable recovery period. I talk about what will be required from my patients to ensure best chances of success. Will they need to position? Will they need to refrain from air travel? Can they go back to work the week after surgery? Even when a patient says to me “Just do whatever you think is best, doc,” I also take the time to talk about possible alternative approaches.
Despite the time that it adds to my clinic appointments, I’ve found a thorough informed consent discussion to be invaluable in my patient care toolbox. Not only is the conversation educational, but it empowers my patients by allowing them to take an active role in their health care. In listening to my patients’ questions, I get a much better sense of what is important to them. Not infrequently, I’ve tailored aspects of their therapy based on concerns or priorities that patients have raised. The reaction I receive to the informed consent process often clues me in as to how an individual patient might react if faced with challenges during the postoperative period. Perhaps most importantly, the informed consent helps me form a deeper, more substantive relationship with my patient. It is a priceless opportunity to have an open and honest discussion that builds patient trust in both my professional acumen and personal compassion.
In the midst of these broad generalizations, there are specific resources that can help provide guidance. The American Academy of Ophthalmology provides a library of consent forms in both English and Spanish for common ophthalmic procedures that can be readily accessed online. Societies such as the American Society of Retina Specialists have also provided access to revised consent forms in the past relevant to specific issues, such as silicone oil droplets from intravitreous injections.
The discussion of risks related to retina procedures is always a challenge. None of us want to dwell on the downsides of a surgical intervention when we are trying to convince a patient that a particular procedure is in their best medical interest. And yet engaging a patient with a thorough informed consent process is not only ethically imperative, but also a smart move that benefits both doctor and patient.