The Intricacies of Informed Consent

Obtaining informed consent can seem burdensome, but it ensures that we are meeting the needs of our clients.
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Using the components of informed consent as a framework is just one way to ensure that we’re meeting the needs of our clients and the expectations of relationship-centered care.

The phrase “informed consent” is not necessarily something that is front-of-mind on a daily basis in an ambulatory equine practice. From a legal standpoint, informed consent is a tool that helps decrease the risk of malpractice. However, there are other ways to look at it, including as a tool to assess your degree of client communication and education.

The expectations clients have of their veterinarians have been changing over the past couple of decades. The paradigm of veterinarian-client relationships has shifted from a doctor-centric model, where the veterinarian did most of the talking and told the client lots of information, to a relationship-centered care model, where the focus is on the interaction between the veterinarian and the client. It’s a more team-based approach with a greater focus on client communication and education.

For equine veterinarians, this approach isn’t all that new. We see our clients often, and we have the opportunity to develop strong and long-lasting relationships with them. Clear and effective communication is key to relationship building. Along with this approach is the belief that the client is a valued team member.

In keeping with the idea that the client is a valued team member, it is important that he or she understands what is going on. This can be achieved through education. The end result is informed consent—not due to a desire to decrease malpractice risk, but stemming from a desire to have a knowledgeable team member that is better equipped to care for the horse, make decisions that are best for his or her situation, and adhere to your recommendations.

What Is Informed Consent?

We deal with matters of consent on a daily basis; virtually every diagnostic or treatment procedure we perform must be at the consent of the client. However, the intricacies of what constitutes informed consent are less commonly considered. The American Veterinary Medical Association defines informed consent as follows: “To the best of their ability and in a manner that would be understood by a reasonable person, veterinarians should inform animal owners or their authorized agents of the diagnostic and treatment options available. They should also provide an assessment of the risks and benefits of such choices, a prognosis, and a documented estimate of the fees expected for the provision of services. The owners or authorized agents should indicate that their questions have been answered to their satisfaction, the information received by them has been understood, and that they are consenting to the recommended treatments or procedures.”1

Let’s address each aspect of the definition to try to gain a thorough understanding of what needs to happen in order for the veterinarian to obtain informed consent.

Provide diagnostic and treatment options available, including fees, risks, benefits and prognosis: These components constitute the majority of the information that needs to be conveyed for informed consent. One of the most challenging facets of the above requirement is making the decision about which options are worth discussing or describing, and which are not. This is going to be different for each of us.

It is tempting to think that it’s also going to be different depending on the client’s situation, but this can be a murky area. If we start limiting the options provided to a client based on what we think is his or her actual or perceived financial status, or our beliefs about what the client will agree to, we diminish or take away the client’s ability to make an informed decision based on all the information. That being said, the depth of explanation and how it’s presented are going to be different for each of our clients.

One of the most straightforward ways to ascertain how much your client might want to know is to ask him or her. This saves you from guessing and involves the client in the conversation. Further, asking what the client already knows about a possible diagnostic or treatment option can give valuable insight into what information the client has and allow you to tailor your explanation to that person.

It might even save you some time! In the case of diagnostics, a brief explanation of the question you are hoping the test will answer, its potential to impact the horse’s health, how it will influence the ability to form a treatment plan, as well as any risks, should be included. Discussing treatment plans is more straightforward with the benefits, risks and prognosis described for each potential option.

Discussing associated costs or fees is a key component of informed consent, although it is often left out of the discussion. A companion animal study determined that 29% of appointments included a cost discussion.2 When this information is omitted, the risk of an unhappy client or one who cannot pay an invoice is increased.

It’s also important to recognize that presenting several options for care does not mean that you shouldn’t make a recommendation for what would be best for the horse. In fact, research has shown that making a clear recommendation for care impacts how likely the client is to follow through.3

Questions have been answered: This requirement can be difficult to assess. The most straightforward way to determine whether the client’s questions have been answered is to ask. There is value to be had in using an open-ended question to do so. How often are you asked whether you have any questions by a physician or pharmacist? It has become almost as perfunctory as asking how someone is when you see that person.

Using an open-ended question indicates that you are accepting of the client’s questions and are seeking to actively involve him or her in dialogue about that horse. This is in contrast to closed-ended questions, where there is risk of the client perceiving that the question was being asked out of obligation or to fulfill a requirement.

Given this, there is a significant difference in the type of response you are likely to receive, with open-ended questions resulting in richer answers. Asking open-ended questions is also more in line with the spirit of partnership and teamwork befitting relationship-centered care.

Information received has been understood: Similar to ascertaining whether the client’s questions have been answered, it can be difficult to determine whether he or she has understood the information received. This is challenging, because we understand what we are trying to get across to our clients. We set out with the goal of being understood, and we do our best to convey information in a way that we believe our clients will understand.

However, rarely do we know whether we were successful.

As with the other components of informed consent, the best way to determine whether our explanations have been comprehended is to ask clients to share with us their understanding of what we’ve said. It can feel intrusive or unkind to “test” our clients by asking them to repeat what they’ve just been told. However, ensuring that they have fully grasped the information you’ve presented is quite beneficial.

Consenting to recommended treatment or procedure: This is generally the most clear-cut component, usually with a “yes” or “no” answer. Unfortunately, there are still some gray areas. Consider a client that says “Well, I guess I have to” or who tearfully states “Do what you have to do.” Are those appropriate “yes” consent statements? Do those kind of statements represent the response of someone who is comfortable with the decision, or who feels like he or she has been presented all the options and has made a knowledgeable choice?

Clients who are feeling pressured, emotionally charged or unduly influenced might consent to a procedure or plan, but could later regret it. These types of situations can be avoided by investing the time and energy into the earlier aspects of informed consent, so that by the time the final decision is made, there is no question in the mind of the client that he or she understands what’s going on and has made an informed decision.

Take-Home Message

Working through the process of obtaining informed consent can appear burdensome—lots of information needs to be exchanged and checks completed to ensure that information was understood.

However, many of us strive to fulfill the components of informed consent as we work with our clients for the health of their horses, just not purposefully. Using the components of informed consent as a framework is just one way to ensure that we’re meeting the needs of our clients and the expectations of relationship-centered care.

References

1. “Owner Consent in Veterinary Medicine.” American Veterinary Medical Association website. www.avma.org/KB/Policies/Pages/Owner-Consent-in-Veterinary-Medicine.aspx. Accessed on October 1, 2016.

2. Coe, J.B.; Adams, C.L.; Bonnett, B.N. Prevalence and nature of cost discussions during clinical appointments in companion animal practice. J Am Vet Med Assoc 2009;234(11):1418-1424.

3. Kanji, N.; Coe, J.B; Adams, C.L., et al. Effect of veterinarian-client-patient interactions on client adherence to dentistry and surgery recommendations in companion-animal practice. J Am Vet Med Assoc 2012;240(4):427-436.