Informed consent
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This presentation discusses some of the issues surrounding informed consent and childbirth
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Informed consent
- 1. Informed consent/ informed choice in maternity care Adjunct Associate Professor Belinda Maier Midwifery Advisor QH 2009-2013 Maier.Belinda@yahoo.com.au
- 2. Informed consent This term was first used in a 1957 medical malpractice case by Paul G. Gebhard
- 3. Don't endanger your baby by taking harmful medication!
- 4. Don’t be a martyr this is the 21st century!!
- 5. Who has the most invested in the baby?
- 6. Time to inform ?
- 7. Framing information Language of risk
- 8. Framing information Information as a way to ensure compliance
- 10. Dilemma of refusal Wide range Wide ranging effects
- 11. Some examples: water birth
- 12. homebirth
- 13. amniocentesis
- 14. induction
- 15. Management of third stage
- 16. What we can do better to promote Informed decision making by women?
- 17. Some final words… “Birth is as safe as life gets” Harriet Hartigan
Editor's Notes
- In the following presentation informed choice and informed consent in Maternity care will be discussed within evidence based and woman centred context. It will be argued that maternity care providers too often gain informed compliance based on limited, rushed or biased information sharing and assumptions about what informed choice and consent is. consent is only possible when there is a choice and respect for women’s right to informed refusal. This presentation will discuss current literature in relation to contemporary information sharing to enable informed choices and consent and also some of the challenges around informed refusal within the context of health care for all
- An informed consent can be said to have been given based upon a clear appreciation and understanding of the facts, implications, and future consequences of an action. In order to give informed consent, the individual concerned must have adequate reasoning faculties and be in possession of all relevant facts at the time consent is given. Impairments to reasoning and judgement which may make it impossible for someone to give informed consent include such factors as severe mental retardation, severe mental illness, intoxication, severe sleep deprivation, Alzheimer's disease, or being in a coma. This term was first used in a 1957 medical malpractice case by Paul G. Gebhard. Informed consent can be complex to evaluate, because neither expressions of consent, nor expressions of understanding of implications, necessarily mean that full adult consent was in fact given, nor that full comprehension of relevant issues is internally digested. Consent may be implied within the usual subtleties of human communication, rather than explicitly negotiated verbally or in writing. In some cases consent cannot legally be possible, even if the person protests he does indeed understand and wish. There are also structured instruments for evaluating capacity to give informed consent, although no ideal instrument presently exists
- For a woman, making informed decisions means learning and thinking about the best information available on maternity care, and then deciding what's right for herself and her baby. Key questions include: What are the possible choices? What does the best available research tell us about beneficial and harmful effects of each of these choices? What are her own needs and preferences and those of her partner (if she has one)? What choices are available and supported in her care setting and through her caregivers? If she wants an option that will not or may not be available, would she consider switching to a care setting or caregiver that does offer the preferred care? In every other area of medicine we are all treated as individuals. You have acid reflux, your neighbour has acid reflux: you are not necessarily prescribed a one size fits all prescription. Some are treated by diet; some by this drug; some by that drug.Why, why, why then in childbirth and pregnancy are women treated as if every single pregnancy is exactly the same. Every single time X complication arises, X procedure will treat it effectively. Why are doctors in maternity care ignoring evidence that disproves much of their routine practices???
- Pregnant women comply with, rather than choose, mode of birth Competing demands and time pressures on health professionals ensure that pregnant women comply with, rather than choose, how they want to give birth. Stapleton and colleagues (p 639) observed 886 antenatal consultations and interviewed 383 pregnant women in Wales and found that health professionals often did not discuss the contents of the widely used leaflet Informed Choice. Women's trust in health professionals meant that they complied with professionally defined choices and rarely asked questions or made alternative requests. Fear of litigation, power hierarchies and technology limited the choices available. A randomised cluster trial by O'Cathain and colleagues (p 643) also found that Informed Choice was not effective in promoting informed choice of women using maternity services. There was no difference in the proportion of women in the intervention and control group who reported they exercised informed choice. However, women in the intervention group were more satisfied with the information they received, even though only three quarters of them reported actually being given a leaflet (the intervention). The article investigates and evaluates, from a feminist perspective, the issues of informed choice and first obstetric ultrasound examinations, and reveals that it is impossible for an expectant mother to achieve this due to the medical environment and culture of hospitals. The study also indicates that the social pressure of having a scan, and obtaining a photograph as part of the pregnancy package, contributes to the external pressures on women, leading to their adoption of compliant behavior patterns. Vulnerability of First-Time Expectant Mothers During Ultrasound Scans: An Evaluation of the External Pressures That Influence the Process of Informed Choic
- "You can always present information so they select the treatment you want them to"—A study of nephrologists revealed that doctors used information to influence patients' treatment choices.18 Presenting "logically equivalent" information in different ways has a substantial effect on treatment preferences.19 w19 For example, relative risk is more persuasive than absolute risk.6 Enabling patients to understand risks is crucial before considering different treatment options. Yet risk is a complex phenomenon that many patients (and doctors) find difficult to understand. Common errors include compression bias (the tendency to overestimate small risks and underestimate large ones), miscalibration bias (overestimation of the level and accuracy of one's knowledge), availability bias (overestimation of notorious risks20), and optimism-pessimism bias (the tendency of patients to believe that they are at less risk of an adverse outcome than people similar to them14). Patients may understand different methods of presenting risk to varying extents. Numerical information is often poorly understood,6 w20 so doctors may need to determine how to present risk in a way that is helpful for an individual patient, or at least be able to present it in different ways. Differences in education and experience may also affect patients' understanding of risk; methods of increasing comprehension among people with poor literacy and numeracy will be essential.21 Individualised risk information—that is, based on each patient's clinical characteristics—is available for only a few conditions, such as the Framingham equation for stroke or cardiovascular disease.w21 Even this information is probabilistic in nature and requires skilful communication. Furthermore, there may be ambiguity associated with the language of risk. Doctors and patient may have different perceptions of what is "low risk," "unlikely," or "rare."6 w22 There may also be variation in acceptability of risk, so doctors need to ascertain the degree of risk that a patient is comfortable with to ensure discussion is relevant. In addition, people's conceptions of a condition and its implications may vary.6
- Pregnancy and birth have been conceptualized as medically problematic, with all pregnant women considered at risk and in need of medical monitoring. Universal application of risk scoring and surveillance as preemptive strategies in an effort to reduce risk is now standard obstetric practice. Labeling women “high risk” can result in more unnecessary interventions and have negative psychologic sequelae. When perceived pregnancy risk is out of proportion to the real risk, and when risk management procedures are applied to all women with benefit for only a few, the use of technology in caring for pregnant women becomes normalized. A learned reliance on technology can diminish women's own authoritative knowledge of pregnancy and birth. This may also have the unintended consequence of contributing to birth fear, a phenomena becoming more widely recognized. Health care provider-patient communication about pregnancy risk can be presented in a manner that encourages informed compliance rather than informed choice. Evidence-based risk assessment is essential to providing optimal prenatal care. Using tools such as the Paling Palette can help health care providers present balanced and readily understood information about risk. Risk Assessment and Risk Distortion: Finding the BalanceJournal of Midwifery & Women's Health, Volume 54, Issue 3, Pages 191-200R. Jordan, P. Murphy
- Informed refusal is a medico-legal concept whereby a person can be said to have given refusal to an intervention based upon an understanding of the facts and of the implications of not following a recommended diagnostic or therapeutic action.[1][2]. Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse.[3]
- There is evidence that women who refuse cesarean sections and have been forced to have one have all successfully sued and that outcomes have not been as dire as predicted. There are many tragic cases we could discuss but for this presentation we wont only to say that in Australia the unborn baby has no legal rights therefore it is not possible to gain consent over the mothers rigths to perform a ceasrean.
- Use stories
- There are no sureties in life…