Abstract
Informed consent is at the heart of the modern practice of medicine, but what do we mean by informed consent and how do we achieve it? The issue of informed consent is particularly important where, as with hormone replacement therapy (HRT), the therapy proposed is aimed at symptom amelioration and there is complex discussion about the risk benefit profile.
Recent debate over HRT, and its effect on cardiovascular disease and ovarian or breast cancer, has led authors to remind clinicians that there is no ‘one-size-fits-all approach’ when it comes to menopause symptoms or treatments. This is never more evident than when a clinician seeks to ensure that a patient has sufficient information to make an informed decision.
What is informed consent?
While the UK does not prescribe to the legal doctrine of informed consent, recent decisions of the courts have moved closer to this principle. Doctors, as well as complying with the legal minimums, are required also to have cognizance of the General Medical Council (GMC) guidance when considering the amount of information that a patient will need in order to make their decision. When discussing risks of a treatment the GMC advises:
You should do your best to understand the patient's views and preferences about any proposed investigation or treatment, and the adverse outcomes they are most concerned about. You must not make assumptions about a patient's understanding of risk or the importance they attach to different outcomes. You should discuss these issues with your patient.
You must tell patients if an investigation or treatment might result in a serious adverse outcome, even if the likelihood is very small. You should also tell patients about less serious side effects or complications if they occur frequently, and explain what the patient should do if they experience any of them.
This guidance deliberately places the patient's views at the centre of the consultation rather than regarding it as acceptable for the doctor to decide what the patient should know.
How is informed consent achieved?
The patient-centred model of consent requires you to work in partnership with your patients, and the GMC summarizes what you can do to achieve this:
listen to patients and respect their views about their health discuss with patients what their diagnosis, prognosis, treatment and care involve share with patients the information they want or need in order to make decisions maximize patients' opportunities, and their ability, to make decisions for themselves respect patients' decisions
The question of starting HRT requires doctors to tackle the challenge of communicating a set of risks to a patient that many in the medical profession are still grappling with themselves. This is on the background of the inherent difficulties that may be encountered when discussing risk as a concept, in a busy clinical setting. Here, the GMC suggests that the doctor may be assisted by other members of the team and by resources, such as patient information leaflets, advocacy services, expert patient programmes or support groups for people with specific conditions.