An Audit of Consent for Minor Surgery in a General Practice in ...

An Audit of Consent for Minor Surgery in a
General Practice in Northern Ireland
Paula Burns, 5 th Year Medical Student, Queen’s University Belfast
Address for Correspondence: M127 Monea Road, Brughas, Springfield, Enniskillen,
County Fermanagh, BT74 5DQ. Email: b1213803@qub.ac.uk
Audit Aims: To achieve and maintain a high standard of care for patients
by investigating whether informed consent was obtained for minor
surgical procedures and to try to continue or to improve standards of
care for patients. The audit identifies from patients medical records,
within Health Centre X, who had injection, incision or excision performed
and whether consent was recorded. Audit Design: An audit of all
patients who have had minor surgery (incision, injection and excision)
between the dates, April 2005 until April 2006. The study consisted of a
computer search of three general practitioners (Drs A, B and C) within
Health Centre X to identify minor surgery procedures (excision, incision
and injection) which were carried out and if informed consent was
recorded on the computer. All procedures carried out were included in
the audit which resulted in a sample size of 122 procedures. Re-audit
aims: To evaluate the changes from the previous audit. Re-audit design:
The re-audit consisted of the same design, except between the dates,
22 nd Jan until 2 nd April 2007. It also included all procedures of excision,
incision and injection carried out within the time period which resulted in
a sample size of 16. Results of Audit 2005-2006: The study found 45
(36.9%) procedures had no record of consent documented by the doctor,
77 (63.1%) had consent documented. 85.7% of incision, 29.1%
excisional and 38.3% for injections had no consent recorded.
Recommendations were implemented by the practice and a re-audit was
carried out. Results of re-audit Jan 2007-April 2007: The re-audit found
that 100% of the excisions and injections had recorded consent obtained
with 0% of incisions with recorded consent obtained. Conclusion:
Consent documented for minor surgery was not sufficient to meet the
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standards set of 100%. After the audit from April 2005-2006 consent for
injection and excision required a vast improvement. However, after
changes were implemented and a re-audit was undertaken the record of
documented consent drastically improved to 100%. The considerable
improvement may have been as a consequence of the recommendations
of the first audit, due to more consent practiced with excision and
injection procedures or a heightened regard by the doctors for acquiring
consent for these procedures. With incisions, results from the 2005-2006
audit found a staggering 85.7% had no recorded written consent and
after changes were implemented the re-audit found 0% had recorded
written consent. These results may have been due to the small sample
size in both audits; the infrequency of incisions, or the possibility that
incisions were deemed less dangerous, than injection and excision, by
the general practitioner; and possibly verbal consent was being obtained
but not recorded. Discussion: As a general standard, consent of a
patient prior to a procedure or treatment is respectful and should be
undertaken by all healthcare professionals. It is a legal requirement that
healthcare professionals obtain consent from a patient before any form of
contact occurs. Consent before a procedure on a patient converts what
would otherwise be seen as a form of assault or battery into a lawful act.
Good communication is vital for gaining consent. Each patient should be
fully informed about treatment options, the treatment proposed, what is
involved in the procedure, whether you think it is appropriate, likely risks
of having treatment and not having treatment. If consent is to be valid it
must be given freely, be specific, applicable to the procedure and
treatment to be carried out, based on a proper understanding of the
major implications, complications and proposed treatment and/or
procedure and given by a person who is legally able to consent. The
doctor has an ethical obligation to help the patient make choices about
the therapeutic intervention as well as alternatives consistent with good
medical practice. The paternalistic approach is no longer socially
acceptable. Doctors must respect the autonomous choices of the patient
as this runs deep in moral principles. J NI Ethics Forum 2008, 5: 108-129
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Audit on Consent for Minor Surgery Procedures
April 2005 to April 2006
Introduction
Consent is a legal procedure in which a patient knows all of the risks and
benefits of a particular treatment and makes an informed decision about
their care. Valid informed consent is fundamental to the duty of any
doctor and there are criminal and/or civil legal implications if consent is
forgotten or acquired incorrectly. Within the setting of a general practice,
informed consent should always be sought before performing any
procedure. This audit records whether informed consent was obtained for
particular minor surgical procedures and the legal and ethical issues if
consent is missed or incorrectly recorded.
Background
This audit examines whether written consent was recorded for every
minor surgery procedure, of excision, incision and injection, with an aim
of ensuring a high standard of care for patients attending Health Centre
X. Every patient deserves to make a well informed decision about their
own care, and it is the legal duty of their doctor to accommodate this by
communicating information effectively for every minor surgical procedure
they are undertaking, provided the patient wishes to be informed and has
the capacity to understand the information. Informed consent enhances
patient care, protects the autonomy of the patient, and protects the
doctor from the legal consequences of unduly harming patients [1] [2] [3] .
Minor surgery usually refers to any surgical procedure that involves local
anaesthesia only without respiratory assistance. This audit specifically
concentrates on excision, incision, and injection. An excision is
something removed by cutting, an incision is a cut into a body tissue or
organ and an injection is the forceful insertion of a substance under
pressure. The British Medical Association (BMA) states that in each case
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of minor surgery the patient should be fully informed of the treatment
options and the treatment proposed and that the patient should give
written consent for the procedure to be carried out and the completed
NHS consent form should be filed in the patient’s lifelong medical record.
[4] In accordance with this, the Practice Consent Policy for Health Centre
X, is to use written consent forms for every minor surgical procedure
provided the patient is competent to make an informed decision, has
received adequate information and has not been coerced. This aims to
develop and implement a person-centred consent policy [5] .Each doctor,
when registered, is expected to follow a set of principles of good practice
when seeking patients’ consent. The right of the patient to make a well
informed decision is protected by law, if the patient has not received
enough information on which to base their decision the consent may not
be valid, even though it has been signed. In addition the patient is also
allowed to change their mind after signing the form provided they have
adequate capacity to do so. The form is only an aide-memoir and should
not be substituted for face-to-face discussion. If a patient is 16 or over
they can provide consent if presumed to be competent. The GMC
requires doctors to tell patients about ‘serious or frequent’ risks and to
answer honestly any questions asked [6, 7] .The Medical Defence Union
(MDU) preformed a risk management analysis of minor surgery claims
and it demonstrated that lack of consent and inadequate medical records
featured heavily in 26 claims settled over a five year period. This was
most noticeable is the largest group of claims, for excisions or excision
biopsy, in which scarring was the main injury [8] The old traditional
paternalistic role of the doctor has now shifted to one based on the
patient’s autonomy and integrity. Informed consent reflects this, for
example, a 1957 case (Salgo versus Leland Stanford Jr University Board
of Trustee) in which the plaintiff was paralysed after myelography. His
doctor had not informed him that paralysis was a risk. The plaintiff won
his case even though, back then, the doctor had made no mistake. This
was the first occasion the terms ‘informed’ and ‘patient’s consent’ were
coupled together. The court found that had the patient been properly
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informed he would have refused myelography. [9] Inadequate information
about risks can lead to treatment options appearing in an undeservedly
positive light and patients may agree to treatments that they would
otherwise reject if given more accurate outcome probabilities [2] .Each
patient requires a duty of care from their doctor. Within this, nonmaleficence,
autonomy, beneficence and justice are included which all
underpin well informed consent. In addition, there is an increased
awareness amongst patients that they can now take action against
mistreatment in the form of complaints or even claims. Therefore gaining
and documenting informed consent for minor surgery is in the best
interests of the patient and their doctor [3] .
Aim
The aim of this audit is to improve the practice of recording consent for
patients attending the General Practitioner for minor surgery.
Additionally, it aims to ensure that informed consent is obtained for each
minor surgery procedure and that it is recorded in the patient’s medical
notes in the same manner as other patients receiving the same
treatment. The overall aim of this audit is to achieve and maintain a high
standard of care for patients by investigating whether informed consent
was obtained for minor surgical procedures and to try to continue or to
improve standards.
Criteria
Identify from patient’s medical records who had:
a. Minor surgery done- injection Read code: 9877
b. Minor surgery done- incision Read code: 9879
c. Minor surgery done- excision Read code: 987A
And whether consent was recorded for each procedure.
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Standards set
Record of recording INFORMED CONSENT- 100%
Record of recording TYPE OF PROCEDURE-100%
100% for all criteria
Preparation and Planning
Meeting was held with GP/mentor and nurse practitioner regarding the
issue of recording consent before minor surgery procedures and the
possibility of improvements within the practice. Throughout the audit
multiple meetings were held with my GP/mentor to discuss the audit,
possible improvements and changes to the practice.
Methodology
1 A computer search identified all patients who had minor surgery
between the dates, 1 st April 2005 until 1 st April 2006.
2 A computer search identified the minor surgery procedures
which were carried out in respect of the patient group. (Some
patients may have had more than one procedure carried out
within the time period these where all analysed.)
3 A computer search identified if consent was recorded as,
'Informed consent obtained' on individual patients files for each
procedure.
4 All minor surgery procedures of, incision, excision or injection,
were checked during the time period.
5 Sample size was 122 procedures
6 Over a time period from 01/04/2005 until 01/04/2006
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Results of Minor Surgery Audit
Total number of minor surgery procedures = 122
All patients notes were collected and analysed who were recorded on
computer to have had one, of the three, procedures.
Number of procedures which involved:
Excision= 55
Incision= 7
Injection= 60
Informed consent for a procedure recorded in notes
With Recorded
Consent
Without Recorded
Consent
Number of procedures 77 45
Percentage 63.1% 36.9%
Whilst 45 (36.9%) procedures had no record of consent documented by
the doctor it was possible that a consent form was completed and held
separately and not recorded correctly on the computer. A reminder of the
correct and prompt method of documentation onto the computer could
help avoid misinterpretation arising. Additionally, the pressure of time
during a busy practice on a general practitioner to obtain fully informed
consent and to document this during each consult must also be
considered throughout.
Informed consent for each procedure recorded in notes
Consent No consent Total
recorded recorded
Excision 39 16 55
Incision 1 6 7
Injection 37 23 60
122
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% of informed consent for each procedure recorded in notes
% with consent % without consent
Excision 70.9 29.1
Incision 14.3 85.7
Injection 61.7 38.3
With regard to recorded consent for incision minor surgery there were
85.7% of procedures without recorded consent this may be because
there were only 7 incisional minor surgical procedures within that time
period and this may not have been a true reflection on the practice.
However, it must be borne in mind that possibly because it is a relatively
infrequent procedure that the method of recording consent is less
practised and therefore consent is not recorded as thoroughly.
Conclusions
The standards set were not achieved in any of the investigated areas.
Overall 36.9% of the procedures either had incorrectly or no consent
recorded on the computer. With regards to consent for excisions, 29.1%
and for injections 38.3% had not been recorded correctly. Of the small
sample of incisions 85.7% had not recorded written consent on the
computer. This could be due to the small sample size, because of the
inconsistency of the doctors to practice this procedure may have led to
mistakes occurring more frequently.
Recommendations
1. Development of an ISIS for minor surgery which includes correctly
documenting written informed consent for excision, incision and injection
procedures on computer.
2. An alert for every minor surgery procedure to check for written
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informed consent.
3. Patient information leaflets to be given to the patient whilst waiting for
the minor surgery procedure so that informed consent can be given
promptly. Plus this may act as a method of reminding the doctor as the
patient may object or initiate conversation regarding consent.
4. Easy access to the documents for written consent in the doctor’s
surgery.
5. Visual aids in the doctor’s surgery to remind the doctor to record
consent.
6. Re-training on the Practice consent policy, paying particular attention
to recording written informed consent for incisions. This could take place
at an audit meeting, lunch-time meeting or out-of-hours.
7. Re-audit
Re-Audit
Aim: Changes to be evaluated from previous audit.
Criteria
Identify from patient’s medical records who had:
a. Minor surgery done- injection Read code: 9877
b. Minor surgery done- incision Read code: 9879
c. Minor surgery done- excision Read code: 987A
And whether consent was recorded for each procedure.
Standards set
Record of recording INFORMED CONSENT- 100%
Record of recording TYPE OF PROCEDURE-100%
100% for all criteria
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Methodology
1 A computer search identified all patients who had minor surgery
between the dates, 22 nd January 2007 until 2 nd April 2007.
2 A computer search identified the minor surgery procedures
which were carried out in respect of the patient group. (Some
patients may have had more than one procedure carried out
within the time period and these were all analysed.)
3 A computer search identified if consent was recorded as,
'Informed consent obtained' on individual patients files for each
procedure.
4 All minor surgery procedures of, incision, excision or injection,
were checked during the time period.
5 Sample size was 16 procedures
6 Over a time period from 22/01/2007 until 02/04/2007
Data Collection 2: Results
With Recorded Without Recorded Consent
Consent
Number of 15 1
procedures
Percentage 93.75% 6.25%
Informed consent for each procedure recorded in notes
Consent No consent Total
recorded recorded
Excision 5 0 5
Incision 0 1 1
Injection 10 0 10
16
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Percentage of informed consent for each procedure recorded in
notes
% with Consent % without consent
Excision 100% 0%
Incision 0% 100%
Injection 100% 0%
Conclusion
Out of a possible sixteen, on only one occasion was consent missed for
an incision. However, due to the small sample size, during this time only
one incision was performed leaving 100% of the incisions with no
recorded consent. The time period for this re-audit was only 3 months
and so a re-audit from 2007-08 year would be more beneficial as there
would be a larger number to analyse. Although, the method of informed
consent for the injections and excisions where both 100%, this suggests
improvements have been made in these areas, but again due to the
small sample size and short time period, a re-audit over a year would be
of more benefit.
Recommendations
Re-iterate the importance of obtaining and recording written consent for
all patients coming for minor surgery, with emphasis on incisional cases.
Re-audit from April 2007–April 2008
Discussion
Our results from the audit, April 2005- April 2006, suggest that the
consent documented for minor surgery procedures of excision, incision
and injection was not sufficient to meet the standards set of 100%.
Although the standards set are high it is of medico-legal importance that
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consent is acquired for every minor surgical procedure performed. For
injection and excision the number of procedures for which there was fully
informed written consent, which was documented, was below 75%
demonstrating much needed improvement. The procedures which
involved excising the wound had recorded consent on 70.9% of cases,
highest compared to the other procedures. The reason for this may be
due to chance, due to the general practitioner’s views on the importance
of minor surgery and the associated risk or the pressure of time during a
busy practice on a general practitioner to obtain fully informed consent
and to document this during each consult must also be considered. For
instance, the risk management analysis of minor surgery claims made by
the Medical Defence Union showed that the lack of consent and
inadequacy of medical records featured heavily in claims settled over a
five year period, most noticeably the largest group of claims was for
excisions, in which scarring was the major injury. These results may
demonstrate this knowledge within general practitioners and hence
explain the possible increased attention to asking for consent for
excisions. [8]
With injections, 61.9% of procedures had documented written consent.
Injections were the most commonly carried out procedure within this
minor surgery audit, having had 60 procedures recorded throughout the
audit year, compared to 7 incisions and 55 excisions. The result for
documentation of consent for injection was much better than the 14.3%
for incisions and this may be due to the larger frequency of the injection
procedure within the practice. The increased frequency of injections
when compared to incisions suggests that as a result of the doctors
increased practice of injections that they are more inclined to ask for
written consent and documentation of it, than for incisions. In addition,
due to the larger sample size a more realistic interpretation of injections
can be made. However, neither 61.9% nor 70.9% were the desired result
for documentation of consent after injection and excision respectively,
and action will be required to enhance the outcome. In the re-audit, the
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documentation of consent for injection and excision reached 100%,
highlighting the importance of re-iteration and re-training on consent.
Furthermore, the minor surgery specification for the directed enhanced
service by the BMA, clearly states that regular audits should be
conducted to sustain a continued high level of activity, and to ensure
records of all procedures are maintained and up-to-date and readily
accessible which is clearly demonstrated with this audit. 1 However,
because of the small sample size of 16, and short time period of the reaudit,
an audit after a year would be more beneficial and accurate at
estimating whether the first audit will have a significant impact on future
practice.
Unfortunately, with incisions, only 14.3% had documented written
consent and with the re-audit 0% had documented written consent. With
regard to the first audit, from April 2005- April 2006, there were only
seven incisions within the whole year, unfortunately six of which had no
documented consent. Were these results due to the small sample size;
due to the forgetfulness of the general practitioners and the general
infrequency of the procedure or is there a general acceptance that
incisions are not perceived as important enough for written consent?
Again in the re-audit our questions were not answered, only one patient
had an incision to which consent was not documented. Future plans to
re-educate the doctors within the practice on the practice’s consent
policy on minor surgery and specifically incision will need to be
undertaken, as there appears to be a lack of consent documented with
regards to incisions. Obtaining and documenting informed consent within
a busy practice must also be addressed as although time consuming it is
very important and must not be forgotten.
Incidence
Another audit was carried out from 2004 to 2005 in the same practice,
analysing minor surgery. Within this audit, a total of 5 procedures had
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ecorded consent, and 45 had no recorded consent. This 2005-2006
audit on ‘Consent for minor surgery” examined this aspect of minor
surgery more intensively and found that there have been improvements,
as a total of 77 procedures had recorded consent, with 45 procedures
without.
Limitations
This study has several limitations. It investigates incision, injection and
excision in depth, although it does not include all minor surgery practices
such as cautery and cryotherapy, which would be beneficial for inclusion
in future audits. In addition, there were only three doctors analysed within
this audit and the lack of published literature surrounding audits in minor
surgery and specifically consent, left difficulties comparing one practice
with another and the estimation of local and national trends. This may not
be very symbolic of Northern Ireland’s trends or even Belfast’s. This audit
does not investigate each doctor separately although if it did it may allow
for specific weaknesses to be pinpointed and for unnecessary re-training
of some doctors, and may pin-point strengths in certain practice teaching
methods. It may also act as a means to deter doctors from forgetting to
record consent in the future as they would be aware of the audit and their
result within it. Of the procedures investigated every procedure within the
time period was analysed and recorded allowing for an accurate data
analysis. A potential limitation was the computer abilities of each doctor
and the possibility that written consent was taken but not recorded
correctly due to lack of time during each consult. Fortunately, the audit
specifies how consent should be documented if it is to be counted. This
should therefore be the only method for documentation of consent, and if
there are any differences between the practices of the doctors then these
could easily be rectified by a computer lesson. However, as this would
occur after the audit it leaves the possibility for consent to have been
taken but not recorded correctly and therefore not included in the results.
In addition the computer cannot record whether verbal informed consent
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was obtained but not documented. Furthermore, the circumstances of
the general practice surgery are ever changing and this must be
remembered, for instance the number of minor surgery procedures
carried out between the audit and re-audit had diminished greatly. The
decrease in frequency of the number of minor surgery procedures was
due to many contributing factors some of which included pressure on
appointments, the retirement of one of the doctors, and the replacement
doctor lacking the qualifications to perform minor surgery. However,
evidence suggests that it is cost-effective for minor surgery to be
performed in the general practice setting. [10]
Risks of Minor surgery
Minor surgery in the categories of exicison, incision and injection, all
have their complications. Each minor surgical procedure could result in
failure, a referral, further treatment, pain from the procedure to which
analgesia may be necessary, adverse effects, such as bleeding, infection
and depending on the site, difficulty with movement, working and
everyday activities. [11] Research on infection rates following minor
surgery in general practice appears to be very poor with most information
centred on hospital infection rates. However, research by Heal et al was
undertaken to investigate the incidence of and risk factors for surgical
site infections in a general practice in Australia. The randomised control
trial assessed 857 patients in which 74 acquired an infection. The
presence of diabetes or those undergoing excision of a non-melanocytic
skin cancer or excision from a lower limb correlated with a higher
incidence of infection post-minor surgery. This information should
encourage use of antibiotics prophylactically for high-risk patients. [10]
Another complication of minor surgery can be bleeding. However, a
number of studies have been carried out on the topic of whether
antiplatelet medication should be stopped prior to minor surgical
procedures. The French Society of Anaesthesiology and Intensive Care
published a statement saying that the consequences of withdrawing
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these medicines (which may include a myocardial infarction) can
outweigh the risks of any increased peri-operative bleeding, routine
antiplatelet withdrawal is not recommended and may even be harmful,
and should only be withdrawn if risks of bleeding are greater than the
cardiovascular risks of stopping. A number of studies show no proof of
an increase in bleeding complications during dermatological surgery and
agree that the risks of stopping antiplatelet medicines far outweigh the
risk of complications from withdrawal. [12] Another audit on 61 procedures
was carried out in a different practice in Australia, between April 2004
and November 2004. It looked at the success rate of steroid injection,
and complication rates of all procedures. In the results there were no
complications recorded for any procedure. [13] It is important to recognise
the potential risk factors for minor surgery and to realise the relative
frequency of each and this is equally as important when explaining to
patients. A recent MDU study of GP minor surgery settled claims
revealed that nearly two-thirds of cases arose from one of the following:
scarring, perforated ear drum, haemorrhage or haematoma, infection,
nerve damage and pain. This signifies the importance of gaining
consent, documenting in the notes that consent was obtained, that the
risks and effects have been explained and that the patient has consented
to it understanding this information. [10] With regards to minor surgery the
consent must be in written form and discussed in detail to ensure the
patients understanding and compliance with such procedures. [14]
Although, the existence of a written document does not ascertain
conclusive evidence that the patient has given adequately informed
consent but merely stipulates that a discussion took place and a
reminder to the doctor to give sufficient information. [15] Gaining informed
consent from mentally ill or intellectually disabled is a confusing situation.
In general, where intellectually disabled patients have attained the age of
18 and are not institutionalised, doctors should not proceed with any
treatment, unless consent from the patient themselves has been
obtained, applying generally, also to institutionalised patients. Under
most legislation for the treatment of mentally disabled, consent of a
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parent or a legal guardian must be obtained before a procedure can be
preformed. [14]
Ethical Issues
Medical ethics is a generic term for the various ways of understanding
and examining moral life. Some approaches are normative, others are
non-normative. Normative ethics is a form of inquiry that attempts to
answer a question. Non-normative ethics has two types, firstly
descriptive which is the factual investigation of moral conduct and beliefs.
The second is meta-ethics involving analysis of language, concepts and
methods of reasoning in ethics. These are grouped together as nonnormative
because they determine what is factually and conceptually the
case, not ethically what should be the case. [16] The belief that some
knowledge should be shared with the patient is well established and
safeguarded by legal codes. However, it is reasonable to suggest that
doctors still significantly control what information is made available to
patients and others involved. This creates two problems, firstly, the
knowledge which the doctor has and what they chose to do with it is
crucial in the decision making by the patient, and secondly, making moral
decisions is a process which demands factual knowledge of the patient’s
condition by the patient. [17] With regards to obtaining consent for minor
surgery the doctor should present the medical facts accurately to the
patient and strive to protect the patient’s autonomy where possible. [16, 18]
Legally a doctor is free to choose who they will care for, but once they
have undertaken a case the doctor becomes legally liable for the
consequences of their own negligence. [14, 18] A duty of care arises once a
doctor undertakes the care of a patient. All doctors have an obligation to
keep abreast and be informed of technical advances, new techniques
and therapy appropriate to the field of medicine in which they practise or
profess special skills. A doctor can be negligent in many ways including
negligent advice or failure to warn about the risks of a surgical
procedure, such as minor surgery. [14] In many situations, it is uncertain,
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as to whether a customary standard exists for the communication of
medical information. The majority of professionals could offer the same
inadequate level of information or have total discretion to determine the
scope of disclosure, or possibly not know what information is in the best
interests of their patients. [16] Within Health Centre X however, there is a
standard protocol for written consent for minor surgery, the problem lies,
with whether the doctor remembers the protocol, whether they then
disclose the adequate information that is in their patients best interests.
In 2001, a BMA working party report concluded that the whole process of
obtaining patient consent would need to be thoroughly re-assessed.
Greater emphasis was needed to be placed on the initial explanation
given to the patient, with provision for continuing opportunity for
discussion in order that the patient could raise any concerns and/or
questions. The Department of Health tried to deal with this situation by
publishing booklets dealing with consent in specific situations, leaflets for
patients, and an implementation guide which included model consent
policy and forms. [19] This audit highlights the importance of up-to-date
medical records. For instance, on some occasions consent may have
been obtained but not documented correctly onto the computer. The
medical records originally began as ‘aide memoires’ for treating doctors,
however nowadays, under the influence of factors such as Freedom of
Information legislation, concepts of openness and accountability, quality
assurance, involvement of patients more closely in understanding their
illnesses and being falsely informed before decisions are taken about
treatment has lead to greater importance of the accuracy and objectivity
of the medical record. The importance of keeping the medical records at
a high standard help maintain the standard of patient care, for instance,
like in Health Centre X, where patients see different doctors; in after
hours services and where the only communication between the locum
and the treating doctor is in writing. [14] The principle of non-maleficence
asserts an obligation, on the doctor, not to inflict harm onto others. Harm
is difficult to classify but can be viewed as setbacks to physical or
psychological interests, such as health and survival. [16] Acquiring valid
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consent from each patient allows the patient to prepare mentally, know
what to expect and why they require the said treatment, allowing for an
informed decision to accept or refuse treatment, in view of their own
subjective idea of what harm or injury entails. When a patient is under
the care of a doctor they should be treated autonomously, without harm
and the treatment offered should contribute to their welfare. This is
known as ‘beneficence’. This involves the doctor taking positive steps to
help their patients. [16] In relation to the audit, if a doctor is seeking
informed consent from a patient it should clearly state the aims and
benefits of the treatment as well as the risks, therefore reinforcing the
positive steps which the doctor is making. The concept of justice usually
includes the terms fairness, entitlement and what is deserved.
Distributive justice refers to the distribution of all rights and
responsibilities in society. Several principles of justice appear within
morality and merit acceptance. One is formal, the rest material. Virtually
all accounts of justice in health care hold that delivery programs and
services designed to assist persons of a certain class, such as poor or
elderly, should be available to all that social class. Is it unjust to deny
access to equally needy persons outside that social class? Material
principles specify the relevant characteristics for equal treatment
because they identify the substantive properties for distribution, such as
need. Most societies invoke several of the material principles in framing
public policy, appealing to different principles in different spheres and
contexts. This allows for the fair distribution of treatment across social
classes according to need, effort, contribution, merit, free-market
exchanges and allows each person an equal share. This is relevant to
the audit in that informed consent should be obtained from everyone or
their guardian where possible, and treatment should be equally
distributed according to these principles. [16] Ethically, the importance of
gaining informed valid consent from each patient or someone
responsible for the patient encompasses many issues. These issues
involve many fundamental ethical principles of a doctor, demonstrating
the importance of gaining and recording informed consent accurately.
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Conclusion
With the ever changing world of medicine fundamental rules exist to
protect the patient and the doctor, such as consent. Consent is not
merely signing a sheet; it involves taking the time to communicate to your
patient the importance of the treatment, the options available, the
prognosis, the reasons to and not to have the treatment and the risks
and adverse effects of the treatment. The patient should only consent to
a treatment when all areas have been covered. Consent is not only there
to protect the patient but also to protect the doctor and to remind them of
the risks, treatment options and importance of the patients opinion.
Consent if correctly obtained can act as a legal document to demonstrate
prior consultations and prove false allegations. It also reinforces some
important ethical principles such as patients’ autonomy, non-maleficence,
beneficence and justice. In brief, after the audit from April 2005 to April
2006 Health Centre X’s record of documenting consent for minor
surgery, incision, excision and injection, was in need of much
improvement. Recommendations where then implemented and
underwent a re-audit from January to April 2007 which demonstrated a
vast improvement, especially with regards to excision and injection
gaining 100% of patients consent. Incisions in particular will need further
developments and with continuous monitoring and education standards
should improve across each type of minor surgery skill.
References
[1] Mazur DJ. Influence of the law on risk and informed consent. BMJ
2003; 327: 731-734.
[2] Shanner L. Informed consent and inadequate medical information.
The Lancet 1995; 346: 251.
[3] Clegg-Lamptey JNA, Hodasi WM. An audit of aspects of informed
consent and pain relief in surgical units of Korle Bu Teaching Hospital.
Ghana Medical Journal 2005; 39(2): 63-67
127

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubm
edid=17299545 (Accessed 14 May 2007)
[4] British Medical Association. Minor surgery- Specification for a directed
enhanced service. http://www.bma.org.uk/ap.nsf/content/dessurgery
(Accessed 11 Dec 2006)
[5] Practice Consent Policy.
[6] Primary Care Trusts NHS. Primary Care Minor Surgery Consent
Form.
http://www.natpact.nhs.uk/uploads/DEFINING%ZODES%20minor%20su
rgery%20-%20consent.doc (Accessed 15 May 2007)
[7] General Medical Council. Seeking Patients’ consent: the ethical
considerations 1998 http://www.gmcuk.org/guidance/current/library/consent.asp
(Accessed on 11 Dec 2006)
[8] BMJ news. Consent and records remain major factors in minor
surgery claims. BMJ 1997; 314: 1849
http://www.bmj.com/cgi/content/full/314/7098/1849/b (Accessed 15 May
2007)
[9] Syse A. Norway: valid (as opposed to informed) consent. The Lancet
2000; 356 (9238): 1347-1348.
[10] Heal C, Buettner P, Browning S. Risk factors for wound infection
after minor surgery in general practice. The Medical Journal of Australia
2006; 185(5): 255-258
http://www.mja.com.au/public/issues/185_05_040906/hea10211_fm.html
(Accessed 01 Aug 2007)
[11] Lee R. Consent for minor surgery. MDU 2007 http://www.themdu.com/search/hidden_article.asp?articleid=1104&articletitle=cons
(Accessed 01 May 2007)
[12] Pevreal W. Is it necessary to stop clopidogrel, dipyridamole or low
dose aspirin prior to minor surgery? UKMI
www.nelm.nhs.uk/Documents/N27.1%20Antiplatelets%20and%20Minor
%20Surgery.doc?id=563677 (Accessed 01 Aug 2007)
[13] Preest GA. Minor Surgery Audit November 2004.
http://pencoedmedical.co.uk/pencoedmedical/Minor%20Surgery%20Audi
128

t%20November%202004.doc (Accessed 01 Aug 2007)
[14] Plueckhahn VD, Breen KJ, Cordner SM. Law and ethics in medicine
for doctors in Victoria. 1994:105-112.
[15] Gattellari M, Butow PN, Tattersail MHN. Informed consent: what did
the doctor say? The Lancet 1999; 353: 1713.
[16] Beauchamp TL, Childress JF. Principles of biomedical ethics, 5 th
edition. 2001.
[17] Mitchell KR, Lovat TJ. Bioethics for medical and health professionals
1991.
[18] Council on Ethical and Judicial Affairs. Code of Medical Ethics.
2000-2001.
[19] English V, Romano-Critchley G, Sheather J, Sommerville A. Medical
Ethics today the BMA’s handbook of ethics and law. 2004.
129