Informed Consent: Are You Informed About It?
The nursing world continues to be taken by storm by the case of Amanda Trujillo, and as stated in the American Journal of Nursing‘s blog (Off the Charts), at the heart of the controversy sits informed consent:
“…she was fired for, as she claims, just doing what she’s obligated to do as a nurse—specifically, providing informed consent to a patient about a surgical procedure.”
Trujillo left a comment on a blog further detailing that her termination was for going “out of scope.”
A conflict clearly exists. Are nurses actually obligated to provide informed consent for surgical procedures? Are we even supposed to?
I went spelunking for definitive answers regarding nursing practice and informed consent, and the most clear documentation I found is from AORN (the Association of Perioperative Registered Nurses). This makes sense because informed consent is generally involved with an operation, so these nurses need a deep understanding of their role and scope in this area. The document Key Concepts in Informed Consent for Perioperative Nurses is a worthwhile read for every RN because informed consent is a liability issue and the waters are clearly murky, as has been brought into the limelight by Amanda Trujillo.
The short answer is that it is NOT an RN’s obligation to provide informed consent. On the contrary,
“In case law, the intrusion of another health care provider (eg, perioperative nurse who attempts to answer a patient’s questions about a surgical procedure) into the physician-patient relationship is regarded as detrimental to the patient. Furthermore, a perioperative nurse who engages in this type of discussion with a surgical patient may be held accountable to a higher standard of practice…and may incur further liability.”
Seems Trujillo has incurred said liability.
But she points out that she was advocating for her patient, and few RNs would argue that this is clearly a nursing responsibility. What is our responsibility, then, regarding informed consent, specifically? Per the AORN article,
“Perioperative nurses may be held liable for lack of informed consent if they fail to recognize or identify inadequate disclosure for surgical consent or fail to report it promptly to the surgeon or nursing supervisor.”
I interpret this and the examples in the article to mean that an RN is responsible for ensuring that the patient’s understanding and expectations meet the surgeon’s description and for reporting discrepancies immediately (and—my addition—documenting thoroughly having done so). Reporting a discrepancy and attempting to rectify it by providing information look like a gray area, and nurses may feel tempted to be helpful by providing information themselves, but case law and nursing guidelines are actually extremely specific on this issue:
Nurses should not be educating patients about surgical procedures.
This goes against logic. Aren’t we patient advocates? Isn’t a huge part of our job to educate patients? In other areas, yes, but in the case of informed consent, our responsibilities are markedly different. We advocate in this area by ensuring the patient expects what the consent says he or she should expect and, if not, by letting the surgeon or another appropriate supervisor know. Period. This practice area needs to be highlighted to nursing students and practicing nurses because it is not well understood.
Correction, 2/15/12: Per personal communication with Amanda Trujillo, the issue was not about obtaining surgical consent; it was that the physician felt it was outside her scope of practice to educate the patient about hospice. Still, this issue is in the news in our field, and nurses need to understand our role in informed consent.
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