Episode 167 Consent

This week follows directly on from Episode 166 Personalised care this time talking about the issue of consent. In this episode I reflect on the introduction of electronic consent in maternity care, scrutinizing its benefits and the unforeseen complexities it introduces. I discuss the  General Medical Council's 2020 guidance on consent, spotlighting the critical need for inclusive language and the eradication of personal bias.  I consider the need for antenatal education as a bedrock for preparing expectant mothers to navigate the decision-making labyrinth of labour, fostering an environment where every voice is heard and every choice is informed.

Together, we're building a more empathetic, patient-centred maternity service. And don't forget, your suggestions drive our discussions forward; reach out via TheObsPod on Twitter, Instagram, or email to share your thoughts on future topics.

Want to know more?
https://www.gmc-uk.org/-/media/documents/gmc-guidance-for-doctors---decision-making-and-consent-english_pdf-84191055.pdf
https://concentric.health/patients/

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
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Transcript

Florence: 0:00

Hello, my name is Florence. Welcome to the ObsPod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, anyone else that's interested, the ObsPod is for you.

Florence: 0:49

Episode 167 Consent. To some extent, this episode is an extension of last week's episode on personalised care. They go together Sometimes. As clinicians, I think we can get hung up on the idea of consent as a single moment in time often where, in preparation for surgery, we have a discussion with someone about the pros and cons of the surgery we're about to undertake and ask them to sign a completed consent form. Tomorrow morning I'm undertaking a caesarean list and when the women are admitted, there's a series of tasks we need to undertake before going to theatre, and my task is consent, the signing of a consent form. We will talk about if someone is consented or not as if it was a one-off action just prior to theatre on the day of surgery. But when we stop to think about it, consent is a much bigger issue, and it has become even more so in the wake of cases such as Montgomery v Lanarkshire, which I've talked about in the past. So I'm not going to go into detail here now, but the general principle was that a full range of options should be offered to people and that consent is gained over a period of time. It's a series of conversations, not a single moment. I've been thinking quite a lot about consent recently because in my maternity unit in my hospital we've recently introduced e-consent, that's, electronic consent, which has been interesting for me to reflect on how it's gone and reflect on the consent process as part of that introduction. E-consent definitely has many benefits, but I've also discovered a few disadvantages too, and it's just made me think quite a lot more in depth about the whole consent process, and consent is something that we give a lot more thought these days.

Florence: 3:40

For a start, there's a general principle that the person taking consent should be able to be competent to do the procedure they're consenting you for. So we don't expect our GP trainee colleagues who come and work in obstetrics and gynecology to take consent. They don't have sufficient in-depth clinical knowledge, they're not able to perform the surgery. Therefore, it's deemed that they shouldn't be able to take consent. But that wasn't always true. When I was a junior doctor, part of my job was to take consent for all sorts of procedures that I had no idea how to do and in some cases, didn't really know all the praise and cons, but it was the mainstay of my job admit the patient, plaque the patient that's, take the history, do the blood tests and investigations ready for surgery and take a consent. So in my time, I consented people for abdominal aortic aneurysm repair or resection of bladder tumours All sorts of procedures that were the general mainstay of my house officer days, but none of which I could perform and none of which, therefore, in this day and age, I would be expected to take consent for.

Florence: 5:18

As usual, researching this episode, I've had a little look at the latest guidance and there's some really useful GMC general medical council guidance on consent published in 2020, so nice and up to date, and I'm not going to regurgitate it all here. I will put a link in the show notes. Reading it made me realise that actually, many of the principles in which I believe and much of the work I do on women's experience of maternity care is laid down in policy. It's just we're not implementing it properly. I'm going to pick out some of the highlights that really struck me. It talks about seven principles of consent. There's a whole paragraph on the awareness of one's own biases when one is describing different treatment options, and includes the use of language.

Florence: 6:24

What language you're using and how you use it may influence decisions. For me, that's a big issue. I think in maternity we sometimes use quite risk based language and frighten people and can struggle to check our own concerns whether they be medical, legal or perhaps bad cases we've been involved in from influencing the way we talk about things. Often, when women come back with decisions that they regret in the past, they talk about being told their baby would die if they didn't take the action we were asking them to. Well, what were the chances? Actually, probably very slim, but we didn't spell it out that way. We laid it on thick, and I do think language has a massive role to play in the way we talk to women in obstetrics and gynecology and medicine more widely, but particularly in maternity, where a woman is going through a physiological process and, yes, she may develop medical complications or the baby may, but she may actually be completely healthy, going through a normal process that her body is designed to do. There's also a big section on what matters to the patient in this GMC consent guidance, and that's something I've spoken about before really trying to listen to and understand what matters to people, what's important to them, so to see it written down in a policy document from the GMC pretty powerful.

Florence: 8:30

Another interesting point is about looking ahead to future decisions, and this is particularly relevant in maternity care. Often the decisions we're asking people to make are very time specific, very time constrained and particularly intrapartum decisions. Decisions during labour and birth can be critical to take in that moment. Every minute of delay can be significant in terms of the outcome for mother or baby and we need to ask ourselves are we properly equipping women? Are we really looking ahead to future decisions that people may need to take in an instant? And there's a project that's been going on in conjunction with the Royal Colleges and NHS England called I Decide, which is about just that trying to evolve a new way of taking decisions and talking to women and couples about decisions they need to make. That incorporates an element of how urgent or not that decision is. It's been piloted in quite a few places and I'm really looking forward to when it comes out. The principles are the same Are we looking ahead to future decisions?

Florence: 10:10

And I think we're starting to do this a bit better in maternity and this is where it fits in with what I was discussing about personalised care in my last episode, because when we're taking decisions and helping women think through the pros and cons of different preferences, we are encompassing what future decisions there may be. For example, if a woman tells me under no circumstances ever would she consider an assisted vaginal birth, then I need to explore why she feels that. What's underpinning her decision making? Does she understand the pros and cons? Is she aware of the high risk situation of a caesarean birth at full dilatation in an emergency situation and the fact that this has potential negative consequences for her and her baby? And actually, if under no circumstances, would she be willing to accept an assisted vaginal birth? After I've gone through all the information and all the different situations in which that might be required and the different options she may have at that moment in time, then it may be that a planned caesarean birth is the best choice for her.

Florence: 11:42

It also comes into it when I'm talking to women about vaginal birth after caesarean. Part of the decision making needs to be not only the comparison of a straightforward physiological vaginal birth or a planned caesarean, but I also need to discuss emergency caesarean, scar rupture, assisted vaginal birth, perineal tears, longer term consequences for future pregnancies and her future health and future births. There's a whole enormous set of topics to encompass. So, as I said, this GMC consent guidance equips us very well. So what's the problem? Why is it that we're struggling with the implementation? Well, I think that's because you've got to take into account the environment within which we are actually working the multiple conversations, the exchange of information, the use of visual aids, written aids, consideration of language and the whole way it is laid out. If you are going to compress that into a series of maybe 15 or 20 minute anti-natal clinic appointments or a brief interaction on the labour ward, that is where the problem comes, and this is what I came across with the introduction of e-consent.

Florence: 13:37

I was suddenly giving people rather than a paper document on which I'd written some pros and cons of caesarean and some complications, and asking them to look at two pages of A4 and sign it. I was giving them an iPad and they were scrolling through enormous numbers of risks and benefits, multiple pages of information, and then asking if they were ready to consent and sign it. And I found some couples were completely overwhelmed by this information. And this was not their fault, this was our fault. This was not designed to be given to them immediately on the day of surgery, but because we had only just implemented it. Yes, we'd had lots of discussions in the anti-natal clinic and we may have provided the RCOG information leaflets to them, but the actual reading and consideration of every single risk, complication or consequence was not something that they'd necessarily appreciated until it was starkly laid out in front of them.

Florence: 15:04

And indeed, often with the paper consent form, I very rarely found that people read it. I would outline things, I would give them the paperwork, I would explain that it goes through what I've just discussed with you. I'd ask people if they had any questions and I would suggest they read it and sign. And most of the time I'd say probably 95% of the time people would just sign it. They wouldn't read it at all. And in some ways that's great. You know, that shows they trust me, but in other ways. It's not great because then the consent, the whole process, is just kind of lip service, isn't it? It's a tick box.

Florence: 15:52

So the next step with e-consent is to be able to have those conversations in the clinic and then send people information to read and absorb before they're admitted for surgery. And this is where we've currently got to in the hospital I work at, and I find it great to be able to have a conversation in the anti-natal clinic and then I can tell the woman. I'm going to send you all the information so that you can go away and think about it, read it up, what you will be asked to sign or counter sign on the day that you have your baby. But I'm going to give it to you now and you can come back in a few weeks time and tell me if that's what you want to do, or you can come back on the day of surgery and ask further questions. It gives women weeks to go away and think about their decision and the opportunity to ask questions on multiple occasions, which is obviously infinitely preferable, but I do still find the whole process quite difficult.

Florence: 17:06

I don't want to be paternalistic and suggest that some women don't want all the information or don't need all the information. But there is a paragraph in the GMC consent document which talks about just that whether there may be information that you expect is going to distress or cause significant anxiety for the patient that you're talking to and what you might do about that, and whether or not it's appropriate to exclude some information. And I think that's quite an uncomfortable thought, excluding information. But I definitely find with some of the women that I care for who have mental health conditions, I can have a conversation with them about. I want you to make a well informed decision. There's a multitude of information I can give you. In what depth do you want me to talk about things and do you want the most common things or do you want absolutely everything and what may or may not provoke your anxiety? And would it be helpful to have all the information and dip into it when you want it? Or actually do you want me to not necessarily give you absolutely everything?

Florence: 18:42

And in my experience this is usually initiated by the woman. I'll start talking to her about pros and cons and possible complications and, led by her, she will say actually, please don't tell me anymore. I don't want to know any more than this. I'm comfortable with my decision, having had this level of information. And I take her lead, I take her direction. Sometimes she may ask me to discuss it with her partner and then her partner can talk to her about it at a later point. But if she tells me, please, I don't want you to go through everything all over again. Perhaps she's been through it multiple times or actually I've done a lot of reading, I've done a lot of thinking. I don't want you to outline every minute possible detail then. Fair enough, that's her choice.

Florence: 19:50

Another aspect of consent I find very interesting is this idea of written or verbal consent. I find it really weird that Going to theatre so moving from one room on the delivery suite to another room on the delivery suite, means that I need a written piece of paper, and part of this is the surgical checklist. One needs a consent form and it's part of the check that the person has agreed to the procedure that's going to be undertaken. And I guess that's much more important in surgery where someone's having a general anaesthetic, that you're very clear what their wishes are before they're unconscious. But I find it strange that if I do an assisted vaginal birth in the room, verbal consent is satisfactory and if I go to theatre I need written consent for that and I'm not advocating we should have written consent for the room. I'm just pondering what is the difference and whether it's just one of those that's how we've always done it or that's how Medico legally it's been seen.

Florence: 21:14

I find it interesting, and in the GMC document it talks about written and verbal consent and it also talks about non-verbal consent and whether or not someone is indicating through their body language that they're willing to undergo something. But they talk about consent for everything, from the beginning of an examination and they talk about the assumption that most people have come to a medical professional for some advice and potentially examination and investigation and therefore one presumes some consent from the fact that the person has turned up in the first place. But each interaction, each examination requiring consent, and certainly when I go on the ward round, I ask the midwife to ask the woman if it's okay if we come in, warn her in advance. Certainly before I touch her I will ask would you mind if I feel your baby or can I take your blood pressure? Every interaction you are asking for consent, but in a much less formalised way.

Florence: 22:41

The final issue, which I'm not going to go into in great depth here is what if someone is unable to consent, so they lack capacity, and that's a whole separate topic and something that I have experienced. In an emergency situation, someone is unconscious you're allowed to act in someone's best interest and do whatever is deemed necessary to attempt to save their life. But I also have had some situations with women with mental health issues where they lack capacity and we've had to very carefully assess their capacity with the help of psychiatric experts and then have a best interest, meeting with an advocate for the woman and to consider from her behaviour, from her interactions, from what we know about her, from her family and from the advocate, what efforts have we made to try and explain information, what efforts have we made to try and understand whether she can retain and give us back information from the way she's talking and behaving, what do we think she wants and what's in her best interest, and that's a whole, very complex situation which I'm not going to delve into here but is something to consider. We're very fortunate that in maternity care, far and away the majority of people we care for are able to consent. They do have capacity, and it's much more difficult for other clinicians in other specialties who perhaps more regularly come across people who have perhaps lost their capacity and ability to be able to consent. So that's a slight whistle stop tour.

Florence: 25:08

What's my zesty bit? I think it is go away. Read that GMC guidance. It's quite interesting. But also think about that antenatal period. How much time we have in the antenatal period. Yes, it's time limited. We've got eight months pretty much by the time the woman's booked, if we're lucky, in which to impart a lot of information. But we need to use that time wisely to give her the right information for making those future decisions. And I think that antenatal education, which has been really axed over the years, is really lacking within the health service, really needs to come back in if we're going to really prepare people for those future decisions.

Florence: 26:11

And I think if you're a pregnant woman listening to this, if we're bombarding you with information, understand part of it is we're trying to give you the knowledge and help you think through those future decisions and try and do as much as you can during pregnancy to prepare for the decisions you might be asked to make around pregnancy care, labour and birth and also the early care of your baby. But equally, be aware we are human and that we may have our own biases, and be aware when we're using the language that isn't helpful and help check us. I've learned a lot over the years from people saying to me actually, risk is a much less helpful word. Why not use chance? And I've definitely modified and changed my language as a result. So when someone is using really difficult language, I know it's a big ask to ask you to give us feedback in the moment when you're trying to get your head around what we're saying, but if you can't in the moment, then try and give us that feedback later or to another member of staff that you are able to perhaps talk to, because that's the way we're going to learn.

Florence: 27:40

I very much hope you found this episode of the ObsPod interesting. If you have, it'd be fantastic If you could subscribe, rate and review on whatever platform you find your podcast, as well as recommending the ObsPod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalog from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved, on that rare occasion when it's been absolutely necessary.

Florence: 28:39

If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes, where I've attached some links. If you want to get in touch to suggest topics for future episodes, you can find me at the ObsPod, on Twitter and Instagram, and you can email me at TheObsPod at gmailcom. Finally, it's very important to me to keep the ObsPod free and accessible to as many people as possible, but it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and by chance, you do have a tiny bit to spare, you can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation, but if you'd like to contribute, you now can. Thank you for listening.