Essential to Good Patient Care
By John Murphy
Decades ago when most new PT grads weren't even thinking of career options, patients put complete trust in their health care providers. There was no bother about informed consent; consent was implicit in the practitioner/patient relationship. But physical therapists' patients today question the authority of the health care practitioner (along with questioning all types of authority).
Beginning a few decades ago, the rights of the patient were recognized and along with that, patients demanded to be informed about treatment and even given choices of what treatment they could receive.
Society no longer places health care professionals on as high a pedestal as they used to, related Jonathan M. Cooperman, JD, MS, PT, who is on the APTA's Judicial Committee as well as clinical services manager of the Rehabilitation and Health Center, Akron, OH.
Cooperman has noticed a distinct generation gap in the patients he sees. Those about the age of 70 and older don't question his judgment. Very often they respond, "Whatever you want" or "Whatever you think is best" when he describes their treatment.
"They grew up in an era where the physician or health care practitioner held complete power over them and they were willing participants, probably to a fault," Cooperman told ADVANCE. But for the most part, that era ended in the 1970s when the Supreme Court recognized that patients have the right to be informed of their treatment and to give their permission for it, he related.
Consent as Habit
Most physical therapists have been very good about obtaining informed consent, Cooperman added. They normally do it in the course of just talking to the patient.
Right before his examination, for example, Cooperman would say to the patient something like, "Ms. Smith, with your permission, I'm going to look at your neck. I'll be testing your reflexes, looking at the range of motion of your neck and testing the strength of the muscles around your arms, shoulders, hands and fingers. Is that OK?"
Cooperman explained that he makes such a litany numerous times a day, as anyone in his practice could testify. Informed consent takes only a few moments, but there are a few key ingredients to it.
The APTA's Code of Ethics says nothing more than "physical therapists shall obtain a patient's informed consent before treatment." But case law and standards of practice have hammered out several common requirements for it. For most health providers, the basic elements of informed consent are about the same, explained Kathy Lewis, JD, MA, PT.
Those elements include explaining to the patient the diagnosis as well as explaining the recommended procedures and the possible benefits and risks those procedures have. The health provider should also describe the alternatives to the recommended procedures, as well as explain the likely outcome if the patient opts to forgo any of the treatment options.
Those elements assure that patients not only voice their permission, but that the permission is the result of an informed choice. If the patient is not given information, then it's not informed consent, reasoned Lewis, who is the regional chair for the physical therapy program at Texas Tech University Health Sciences Center, Amarillo, TX.
Lewis related how one of her students in her administration class explained how the student was required to obtain a patient's informed consent while on an affiliation. The student was told not to bother explaining all the procedures and alternatives, but to simply ask for the patients' "informed" consent. That may be consent but it wouldn't hold up in court as informed consent, Lewis figured.
In the case where the patient is not competent or able to provide consent--like a minor or a patient with limited mental capacity--then a parent or guardian can stand in to provide consent, explained Cooperman. When a guardian is not available, as in a nursing home, he never assumes the patient cannot understand, but explains his procedures anyway.
Depending on the procedure being performed, informed consent becomes more important the more involved the procedure is, Cooperman observed. For example, he said, if the physician is doing a high-risk procedure such as surgery, the patient is given an express informed consent form--a detailed written document that lists the risks, prognosis and probability of injury.
In physical therapy, informed consent for everyday procedures is often oral, and can even be implied. But express written informed consent could be requested when the therapist will be performing a potentially risky procedure like cervical manipulation, Cooperman noted.
In addition, a therapist who treats patients who have postpartum and gynecologic problems would give the patient a detailed written consent form if the treatment involves manual techniques around the genital area.
Some patients may also see a potential risk around high-tech therapy equipment, Lewis explained, and therefore therapists may want to be more careful about obtaining informed consent when therapy involves such technology.
But written consent is no guarantee of avoiding legal troubles, she added. If the process you're using ain't broke, don't fix it, Lewis quipped.
She elaborated that if a facility is having no problems by verbally explaining procedures and documenting that, then switching to written consent is not immediately called for.
She foresaw how a facility might begin to treat a higher risk patient population or already be involved in legal action that would prompt a desire for formalized consent.
But for most facilities, Lewis warned to examine the risks of moving to written consent forms.
Written forms do not necessarily simplify matters, and can make things even more complicated. "Once you put something in writing for the patient to read and sign, then you have to be much more careful about your verbiage," said Lewis.
There can't be a standard form for every patient, she added, so most have to be written specifically for each one. "Having a process where the patient reads and signs a form is not an automatic cure to save time and prevent all risks of liability."
In the managed care environment, therapists are required to save time. Lewis noted that informed consent doesn't have to be squeezed out because of the time crunch. Rather, clinicians can weave the informed consent into other parts of the treatment session, like explaining the procedures they are about to do while they are observing the patient.
Part of Education
Cooperman reasoned that informed consent is even more pertinent in the managed care environment. In managed care, therapists require that patients take more responsibility for their own treatment.
Part of getting them to do that is educating them, and part of that explanation ought to be informing them and obtaining their consent.
Essentially, informed consent is not just a legal requirement but good patient practice, Cooperman explained. After all, the theory behind informed consent is to empower patients and give them choices in their care.
He said that he personally has never had a problem with informed consent and never needed a patient to sign a form other than a general consent form when they first step into the facility. The reason for this success, he explained, was that he and his colleagues go to great lengths to educate patients about their problems and their treatment.
"I think the most important point to the whole issue of informed consent is just talking to your patients and explaining to them why you're going to be doing what you're doing," said Cooperman, "so that the patient not only understands but becomes an active participant in therapy."
John Murphy was formerly on staff at ADVANCE.