March 15, 2024 • 30 mins
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.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
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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
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Florence (00:00):
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
(00:49):
Episode 167 Consent.
To some extent, this episode isan extension of last week's
episode on personalised care.
They go together Sometimes.
As clinicians, I think we canget hung up on the idea of
(01:10):
consent as a single moment intime often where, in preparation
for surgery, we have adiscussion with someone about
the pros and cons of the surgerywe're about to undertake and
ask them to sign a completedconsent form.
Tomorrow morning I'mundertaking a caesarean list and
(01:38):
when the women are admitted,there's a series of tasks we
need to undertake before goingto theatre, and my task is
consent, the signing of aconsent form.
We will talk about if someoneis consented or not as if it was
(01:59):
a one-off action just prior totheatre on the day of surgery.
But when we stop to think aboutit, consent is a much bigger
issue, and it has become evenmore so in the wake of cases
(02:20):
such as Montgomery v Lanarkshire, which I've talked about in the
past.
So I'm not going to go intodetail here now, but the general
principle was that a full rangeof options should be offered to
people and that consent isgained over a period of time.
(02:43):
It's a series of conversations,not a single moment.
I've been thinking quite a lotabout consent recently because
in my maternity unit in myhospital we've recently
introduced e-consent, that's,electronic consent, which has
(03:08):
been interesting for me toreflect on how it's gone and
reflect on the consent processas part of that introduction.
E-consent definitely has manybenefits, but I've also
discovered a few disadvantagestoo, and it's just made me think
quite a lot more in depth aboutthe whole consent process, and
(03:34):
consent is something that wegive a lot more thought these
days.
For a start, there's a generalprinciple that the person taking
consent should be able to becompetent to do the procedure
they're consenting you for.
So we don't expect our GPtrainee colleagues who come and
(03:56):
work in obstetrics andgynecology to take consent.
They don't have sufficientin-depth clinical knowledge,
they're not able to perform thesurgery.
Therefore, it's deemed thatthey 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
(04:19):
consent for all sorts ofprocedures that I had no idea
how to do and in some cases,didn't really know all the
praise and cons, but it was themainstay of my job admit the
patient, plaque the patientthat's, take the history, do the
(04:40):
blood tests and investigationsready for surgery and take a
consent.
So in my time, I consentedpeople for abdominal aortic
aneurysm repair or resection ofbladder tumours All sorts of
procedures that were the generalmainstay of my house officer
(05:04):
days, but none of which I couldperform and none of which,
therefore, in this day and age,I would be expected to take
consent for.
As usual, researching thisepisode, I've had a little look
at the latest guidance andthere's some really useful GMC
(05:29):
general medical council guidanceon consent published in 2020,
so nice and up to date, and I'mnot going to regurgitate it all
here.
I will put a link in the shownotes.
Reading it made me realise thatactually, many of the
principles in which I believeand much of the work I do on
(05:53):
women's experience of maternitycare is laid down in policy.
It's just we're notimplementing it properly.
I'm going to pick out some ofthe highlights that really
struck me.
It talks about seven principlesof consent.
There's a whole paragraph onthe awareness of one's own
(06:15):
biases when one is describingdifferent treatment options, and
includes the use of language.
What language you're using andhow you use it may influence
decisions.
For me, that's a big issue.
I think in maternity wesometimes use quite risk based
(06:42):
language and frighten people andcan struggle to check our own
concerns whether they be medical, legal or perhaps bad cases
we've been involved in frominfluencing the way we talk
(07:02):
about things.
Often, when women come backwith decisions that they regret
in the past, they talk aboutbeing told their baby would die
if they didn't take the actionwe were asking them to.
Well, what were the chances?
Actually, probably very slim,but we didn't spell it out that
(07:23):
way.
We laid it on thick, and I dothink language has a massive
role to play in the way we talkto women in obstetrics and
gynecology and medicine morewidely, but particularly in
maternity, where a woman isgoing through a physiological
(07:47):
process and, yes, she maydevelop medical complications or
the baby may, but she mayactually be completely healthy,
going through a normal processthat her body is designed to do.
There's also a big section onwhat matters to the patient in
(08:09):
this GMC consent guidance, andthat's something I've spoken
about before really trying tolisten to and understand what
matters to people, what'simportant to them, so to see it
written down in a policydocument from the GMC pretty
powerful.
(08:30):
Another interesting point isabout looking ahead to future
decisions, and this isparticularly relevant in
maternity care.
Often the decisions we'reasking people to make are very
time specific, very timeconstrained and particularly
(08:51):
intrapartum decisions.
Decisions during labour andbirth can be critical to take in
that moment.
Every minute of delay can besignificant in terms of the
outcome for mother or baby andwe need to ask ourselves are we
(09:16):
properly equipping women?
Are we really looking ahead tofuture decisions that people may
need to take in an instant?
And there's a project that'sbeen going on in conjunction
with the Royal Colleges and NHSEngland called I Decide, which
(09:38):
is about just that trying toevolve a new way of taking
decisions and talking to womenand couples about decisions they
need to make.
That incorporates an element ofhow urgent or not that decision
is.
It's been piloted in quite afew places and I'm really
(10:01):
looking forward to when it comesout.
The principles are the same Arewe looking ahead to future
decisions?
And I think we're starting to dothis a bit better in maternity
and this is where it fits inwith what I was discussing about
personalised care in my lastepisode, because when we're
(10:25):
taking decisions and helpingwomen think through the pros and
cons of different preferences,we are encompassing what future
decisions there may be.
For example, if a woman tellsme under no circumstances ever
would she consider an assistedvaginal birth, then I need to
(10:46):
explore why she feels that.
What's underpinning herdecision making?
Does she understand the prosand cons?
Is she aware of the high risksituation of a caesarean birth
at full dilatation in anemergency situation and the fact
(11:08):
that this has potentialnegative consequences for her
and her baby?
And actually, if under nocircumstances, would she be
willing to accept an assistedvaginal birth?
After I've gone through all theinformation and all the
different situations in whichthat might be required and the
(11:31):
different options she may haveat that moment in time, then it
may be that a planned caesareanbirth is the best choice for her
.
It also comes into it when I'mtalking to women about vaginal
birth after caesarean.
Part of the decision makingneeds to be not only the
(11:51):
comparison of a straightforwardphysiological vaginal birth or a
planned caesarean, but I alsoneed to discuss emergency
caesarean, scar rupture,assisted vaginal birth, perineal
tears, longer term consequencesfor future pregnancies and her
(12:15):
future health and future births.
There's a whole enormous set oftopics to encompass.
So, as I said, this GMC consentguidance equips us very well.
So what's the problem?
(12:36):
Why is it that we're strugglingwith the implementation?
Well, I think that's becauseyou've got to take into account
the environment within which weare actually working the
multiple conversations, theexchange of information, the use
(12:57):
of visual aids, written aids,consideration of language and
the whole way it is laid out.
If you are going to compressthat into a series of maybe 15
(13:18):
or 20 minute anti-natal clinicappointments or a brief
interaction on the labour ward,that is where the problem comes,
and this is what I came acrosswith the introduction of
e-consent.
I was suddenly giving peoplerather than a paper document on
(13:44):
which I'd written some pros andcons of caesarean and some
complications, and asking themto look at two pages of A4 and
sign it.
I was giving them an iPad andthey were scrolling through
enormous numbers of risks andbenefits, multiple pages of
(14:08):
information, and then asking ifthey were ready to consent and
sign it.
And I found some couples werecompletely overwhelmed by this
information.
And this was not their fault,this was our fault.
This was not designed to begiven to them immediately on the
day of surgery, but because wehad only just implemented it.
(14:33):
Yes, we'd had lots ofdiscussions in the anti-natal
clinic and we may have providedthe RCOG information leaflets to
them, but the actual readingand consideration of every
single risk, complication orconsequence was not something
(14:56):
that they'd necessarilyappreciated until it was starkly
laid out in front of them.
And indeed, often with the paperconsent form, I very rarely
found that people read it.
I would outline things, I wouldgive them the paperwork, I
(15:17):
would explain that it goesthrough what I've just discussed
with you.
I'd ask people if they had anyquestions and I would suggest
they read it and sign.
And most of the time I'd sayprobably 95% of the time people
would just sign it.
They wouldn't read it at all.
And in some ways that's great.
(15:37):
You know, that shows they trustme, but in other ways.
It's not great because then theconsent, the whole process, is
just kind of lip service, isn'tit?
It's a tick box.
So the next step with e-consentis to be able to have those
conversations in the clinic andthen send people information to
(16:00):
read and absorb before they'readmitted for surgery.
And this is where we'vecurrently got to in the hospital
I work at, and I find it greatto be able to have a
conversation in the anti-natalclinic and then I can tell the
(16:21):
woman.
I'm going to send you all theinformation so that you can go
away and think about it, read itup, what you will be asked to
sign or counter sign on the daythat you have your baby.
But I'm going to give it to younow and you can come back in a
few weeks time and tell me ifthat's what you want to do, or
(16:42):
you can come back on the day ofsurgery and ask further
questions.
It gives women weeks to go awayand think about their decision
and the opportunity to askquestions on multiple occasions,
which is obviously infinitelypreferable, but I do still find
(17:03):
the whole process quitedifficult.
I don't want to be paternalisticand suggest that some women
don't want all the informationor don't need all the
information.
But there is a paragraph in theGMC consent document which
talks about just that whetherthere may be information that
(17:25):
you expect is going to distressor cause significant anxiety for
the patient that you're talkingto and what you might do about
that, and whether or not it'sappropriate to exclude some
information.
And I think that's quite anuncomfortable thought, excluding
(17:46):
information.
But I definitely find with someof the women that I care for
who have mental healthconditions, I can have a
conversation with them about.
I want you to make a wellinformed decision.
There's a multitude ofinformation I can give you.
(18:07):
In what depth do you want me totalk about things and do you
want the most common things ordo you want absolutely
everything and what may or maynot provoke your anxiety?
And would it be helpful to haveall the information and dip
(18:31):
into it when you want it?
Or actually do you want me tonot necessarily give you
absolutely everything?
And in my experience this isusually initiated by the woman.
I'll start talking to her aboutpros and cons and possible
(18:53):
complications and, led by her,she will say actually, please
don't tell me anymore.
I don't want to know any morethan this.
I'm comfortable with mydecision, having had this level
of information.
And I take her lead, I take herdirection.
(19:16):
Sometimes she may ask me todiscuss it with her partner and
then her partner can talk to herabout it at a later point.
But if she tells me, please, Idon't want you to go through
everything all over again.
Perhaps she's been through itmultiple times or actually I've
(19:37):
done a lot of reading, I've donea lot of thinking.
I don't want you to outlineevery minute possible detail
then.
Fair enough, that's her choice.
Another aspect of consent I findvery interesting is this idea
of written or verbal consent.
I find it really weird thatGoing to theatre so moving from
(20:04):
one room on the delivery suiteto another room on the delivery
suite, means that I need awritten piece of paper, and part
of this is the surgicalchecklist.
One needs a consent form andit's part of the check that the
person has agreed to theprocedure that's going to be
(20:24):
undertaken.
And I guess that's much moreimportant in surgery where
someone's having a generalanaesthetic, that you're very
clear what their wishes arebefore they're unconscious.
But I find it strange that if Ido an assisted vaginal birth in
(20:44):
the room, verbal consent issatisfactory and if I go to
theatre I need written consentfor that and I'm not advocating
we should have written consentfor the room.
I'm just pondering what is thedifference and whether it's just
(21:07):
one of those that's how we'vealways done it or that's how
Medico legally it's been seen.
I find it interesting, and inthe GMC document it talks about
written and verbal consent andit also talks about non-verbal
consent and whether or notsomeone is indicating through
(21:32):
their body language that they'rewilling to undergo something.
But they talk about consent foreverything, from the beginning
of an examination and they talkabout the assumption that most
people have come to a medicalprofessional for some advice and
(21:56):
potentially examination andinvestigation and therefore one
presumes some consent from thefact that the person has turned
up in the first place.
But each interaction, eachexamination requiring consent,
and certainly when I go on theward round, I ask the midwife to
(22:16):
ask the woman if it's okay ifwe come in, warn her in advance.
Certainly before I touch her Iwill ask would you mind if I
feel your baby or can I takeyour blood pressure?
Every interaction you areasking for consent, but in a
(22:37):
much less formalised way.
The final issue, which I'm notgoing to go into in great depth
here is what if someone isunable to consent, so they lack
capacity, and that's a wholeseparate topic and something
(22:57):
that I have experienced.
In an emergency situation,someone is unconscious you're
allowed to act in someone's bestinterest and do whatever is
deemed necessary to attempt tosave their life.
But I also have had somesituations with women with
(23:20):
mental health issues where theylack capacity and we've had to
very carefully assess theircapacity with the help of
psychiatric experts and thenhave a best interest, meeting
(23:42):
with an advocate for the womanand to consider from her
behaviour, from her interactions, from what we know about her,
from her family and from theadvocate, what efforts have we
(24:02):
made to try and explaininformation, what efforts have
we made to try and understandwhether she can retain and give
us back information from the wayshe's talking and behaving,
what do we think she wants andwhat's in her best interest, and
(24:23):
that's a whole, very complexsituation which I'm not going to
delve into here but issomething to consider.
We're very fortunate that inmaternity care, far and away the
majority of people we care forare able to consent.
They do have capacity, and it'smuch more difficult for other
(24:49):
clinicians in other specialtieswho perhaps more regularly come
across people who have perhapslost their capacity and ability
to be able to consent.
So that's a slight whistle stoptour.
What's my zesty bit?
I think it is go away.
(25:14):
Read that GMC guidance.
It's quite interesting.
But also think about thatantenatal period.
How much time we have in theantenatal period.
Yes, it's time limited.
We've got eight months prettymuch by the time the woman's
booked, if we're lucky, in whichto impart a lot of information.
(25:38):
But we need to use that timewisely to give her the right
information for making thosefuture decisions.
And I think that antenataleducation, which has been really
axed over the years, is reallylacking within the health
(26:03):
service, really needs to comeback in if we're going to really
prepare people for those futuredecisions.
And I think if you're a pregnantwoman listening to this, if
we're bombarding you withinformation, understand part of
it is we're trying to give youthe knowledge and help you think
(26:23):
through those future decisionsand try and do as much as you
can during pregnancy to preparefor the decisions you might be
asked to make around pregnancycare, labour and birth and also
the early care of your baby.
But equally, be aware we arehuman and that we may have our
(26:48):
own biases, and be aware whenwe're using the language that
isn't helpful and help check us.
I've learned a lot over theyears from people saying to me
actually, risk is a much lesshelpful word.
Why not use chance?
And I've definitely modifiedand changed my language as a
(27:12):
result.
So when someone is using reallydifficult language, I know it's
a big ask to ask you to give usfeedback in the moment when
you're trying to get your headaround what we're saying, but if
you can't in the moment, thentry and give us that feedback
later or to another member ofstaff that you are able to
(27:35):
perhaps talk to, because that'sthe way we're going to learn.
I very much hope you found thisepisode of the ObsPod
interesting.
If you have, it'd be fantasticIf you could subscribe, rate and
review on whatever platform youfind your podcast, as well as
(27:57):
recommending the ObsPod toanyone you think might find it
interesting.
There's also tons of episodesto explore in my back catalog
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
(28:19):
very seriously and take greatcare not to use any patient
identifiable information unlessI have expressly asked the
permission of the personinvolved, on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
(28:44):
the subject a little more deeply, don't forget to take a look at
the programme notes, where I'veattached some links.
If you want to get in touch tosuggest topics for future
episodes, you can find me at theObsPod, on Twitter and
Instagram, and you can email meat TheObsPod at gmailcom.
(29:09):
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(29:31):
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Thank you for listening.
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife.
Maybe birth fascinates you, oryou're simply curious about what
exactly an obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
(00:49):
Episode 167 Consent.
To some extent, this episode isan extension of last week's
episode on personalised care.
They go together Sometimes.
As clinicians, I think we canget hung up on the idea of
(01:10):
consent as a single moment intime often where, in preparation
for surgery, we have adiscussion with someone about
the pros and cons of the surgerywe're about to undertake and
ask them to sign a completedconsent form.
Tomorrow morning I'mundertaking a caesarean list and
(01:38):
when the women are admitted,there's a series of tasks we
need to undertake before goingto theatre, and my task is
consent, the signing of aconsent form.
We will talk about if someoneis consented or not as if it was
(01:59):
a one-off action just prior totheatre on the day of surgery.
But when we stop to think aboutit, consent is a much bigger
issue, and it has become evenmore so in the wake of cases
(02:20):
such as Montgomery v Lanarkshire, which I've talked about in the
past.
So I'm not going to go intodetail here now, but the general
principle was that a full rangeof options should be offered to
people and that consent isgained over a period of time.
(02:43):
It's a series of conversations,not a single moment.
I've been thinking quite a lotabout consent recently because
in my maternity unit in myhospital we've recently
introduced e-consent, that's,electronic consent, which has
(03:08):
been interesting for me toreflect on how it's gone and
reflect on the consent processas part of that introduction.
E-consent definitely has manybenefits, but I've also
discovered a few disadvantagestoo, and it's just made me think
quite a lot more in depth aboutthe whole consent process, and
(03:34):
consent is something that wegive a lot more thought these
days.
For a start, there's a generalprinciple that the person taking
consent should be able to becompetent to do the procedure
they're consenting you for.
So we don't expect our GPtrainee colleagues who come and
(03:56):
work in obstetrics andgynecology to take consent.
They don't have sufficientin-depth clinical knowledge,
they're not able to perform thesurgery.
Therefore, it's deemed thatthey 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
(04:19):
consent for all sorts ofprocedures that I had no idea
how to do and in some cases,didn't really know all the
praise and cons, but it was themainstay of my job admit the
patient, plaque the patientthat's, take the history, do the
(04:40):
blood tests and investigationsready for surgery and take a
consent.
So in my time, I consentedpeople for abdominal aortic
aneurysm repair or resection ofbladder tumours All sorts of
procedures that were the generalmainstay of my house officer
(05:04):
days, but none of which I couldperform and none of which,
therefore, in this day and age,I would be expected to take
consent for.
As usual, researching thisepisode, I've had a little look
at the latest guidance andthere's some really useful GMC
(05:29):
general medical council guidanceon consent published in 2020,
so nice and up to date, and I'mnot going to regurgitate it all
here.
I will put a link in the shownotes.
Reading it made me realise thatactually, many of the
principles in which I believeand much of the work I do on
(05:53):
women's experience of maternitycare is laid down in policy.
It's just we're notimplementing it properly.
I'm going to pick out some ofthe highlights that really
struck me.
It talks about seven principlesof consent.
There's a whole paragraph onthe awareness of one's own
(06:15):
biases when one is describingdifferent treatment options, and
includes the use of language.
What language you're using andhow you use it may influence
decisions.
For me, that's a big issue.
I think in maternity wesometimes use quite risk based
(06:42):
language and frighten people andcan struggle to check our own
concerns whether they be medical, legal or perhaps bad cases
we've been involved in frominfluencing the way we talk
(07:02):
about things.
Often, when women come backwith decisions that they regret
in the past, they talk aboutbeing told their baby would die
if they didn't take the actionwe were asking them to.
Well, what were the chances?
Actually, probably very slim,but we didn't spell it out that
(07:23):
way.
We laid it on thick, and I dothink language has a massive
role to play in the way we talkto women in obstetrics and
gynecology and medicine morewidely, but particularly in
maternity, where a woman isgoing through a physiological
(07:47):
process and, yes, she maydevelop medical complications or
the baby may, but she mayactually be completely healthy,
going through a normal processthat her body is designed to do.
There's also a big section onwhat matters to the patient in
(08:09):
this GMC consent guidance, andthat's something I've spoken
about before really trying tolisten to and understand what
matters to people, what'simportant to them, so to see it
written down in a policydocument from the GMC pretty
powerful.
(08:30):
Another interesting point isabout looking ahead to future
decisions, and this isparticularly relevant in
maternity care.
Often the decisions we'reasking people to make are very
time specific, very timeconstrained and particularly
(08:51):
intrapartum decisions.
Decisions during labour andbirth can be critical to take in
that moment.
Every minute of delay can besignificant in terms of the
outcome for mother or baby andwe need to ask ourselves are we
(09:16):
properly equipping women?
Are we really looking ahead tofuture decisions that people may
need to take in an instant?
And there's a project that'sbeen going on in conjunction
with the Royal Colleges and NHSEngland called I Decide, which
(09:38):
is about just that trying toevolve a new way of taking
decisions and talking to womenand couples about decisions they
need to make.
That incorporates an element ofhow urgent or not that decision
is.
It's been piloted in quite afew places and I'm really
(10:01):
looking forward to when it comesout.
The principles are the same Arewe looking ahead to future
decisions?
And I think we're starting to dothis a bit better in maternity
and this is where it fits inwith what I was discussing about
personalised care in my lastepisode, because when we're
(10:25):
taking decisions and helpingwomen think through the pros and
cons of different preferences,we are encompassing what future
decisions there may be.
For example, if a woman tellsme under no circumstances ever
would she consider an assistedvaginal birth, then I need to
(10:46):
explore why she feels that.
What's underpinning herdecision making?
Does she understand the prosand cons?
Is she aware of the high risksituation of a caesarean birth
at full dilatation in anemergency situation and the fact
(11:08):
that this has potentialnegative consequences for her
and her baby?
And actually, if under nocircumstances, would she be
willing to accept an assistedvaginal birth?
After I've gone through all theinformation and all the
different situations in whichthat might be required and the
(11:31):
different options she may haveat that moment in time, then it
may be that a planned caesareanbirth is the best choice for her
.
It also comes into it when I'mtalking to women about vaginal
birth after caesarean.
Part of the decision makingneeds to be not only the
(11:51):
comparison of a straightforwardphysiological vaginal birth or a
planned caesarean, but I alsoneed to discuss emergency
caesarean, scar rupture,assisted vaginal birth, perineal
tears, longer term consequencesfor future pregnancies and her
(12:15):
future health and future births.
There's a whole enormous set oftopics to encompass.
So, as I said, this GMC consentguidance equips us very well.
So what's the problem?
(12:36):
Why is it that we're strugglingwith the implementation?
Well, I think that's becauseyou've got to take into account
the environment within which weare actually working the
multiple conversations, theexchange of information, the use
(12:57):
of visual aids, written aids,consideration of language and
the whole way it is laid out.
If you are going to compressthat into a series of maybe 15
(13:18):
or 20 minute anti-natal clinicappointments or a brief
interaction on the labour ward,that is where the problem comes,
and this is what I came acrosswith the introduction of
e-consent.
I was suddenly giving peoplerather than a paper document on
(13:44):
which I'd written some pros andcons of caesarean and some
complications, and asking themto look at two pages of A4 and
sign it.
I was giving them an iPad andthey were scrolling through
enormous numbers of risks andbenefits, multiple pages of
(14:08):
information, and then asking ifthey were ready to consent and
sign it.
And I found some couples werecompletely overwhelmed by this
information.
And this was not their fault,this was our fault.
This was not designed to begiven to them immediately on the
day of surgery, but because wehad only just implemented it.
(14:33):
Yes, we'd had lots ofdiscussions in the anti-natal
clinic and we may have providedthe RCOG information leaflets to
them, but the actual readingand consideration of every
single risk, complication orconsequence was not something
(14:56):
that they'd necessarilyappreciated until it was starkly
laid out in front of them.
And indeed, often with the paperconsent form, I very rarely
found that people read it.
I would outline things, I wouldgive them the paperwork, I
(15:17):
would explain that it goesthrough what I've just discussed
with you.
I'd ask people if they had anyquestions and I would suggest
they read it and sign.
And most of the time I'd sayprobably 95% of the time people
would just sign it.
They wouldn't read it at all.
And in some ways that's great.
(15:37):
You know, that shows they trustme, but in other ways.
It's not great because then theconsent, the whole process, is
just kind of lip service, isn'tit?
It's a tick box.
So the next step with e-consentis to be able to have those
conversations in the clinic andthen send people information to
(16:00):
read and absorb before they'readmitted for surgery.
And this is where we'vecurrently got to in the hospital
I work at, and I find it greatto be able to have a
conversation in the anti-natalclinic and then I can tell the
(16:21):
woman.
I'm going to send you all theinformation so that you can go
away and think about it, read itup, what you will be asked to
sign or counter sign on the daythat you have your baby.
But I'm going to give it to younow and you can come back in a
few weeks time and tell me ifthat's what you want to do, or
(16:42):
you can come back on the day ofsurgery and ask further
questions.
It gives women weeks to go awayand think about their decision
and the opportunity to askquestions on multiple occasions,
which is obviously infinitelypreferable, but I do still find
(17:03):
the whole process quitedifficult.
I don't want to be paternalisticand suggest that some women
don't want all the informationor don't need all the
information.
But there is a paragraph in theGMC consent document which
talks about just that whetherthere may be information that
(17:25):
you expect is going to distressor cause significant anxiety for
the patient that you're talkingto and what you might do about
that, and whether or not it'sappropriate to exclude some
information.
And I think that's quite anuncomfortable thought, excluding
(17:46):
information.
But I definitely find with someof the women that I care for
who have mental healthconditions, I can have a
conversation with them about.
I want you to make a wellinformed decision.
There's a multitude ofinformation I can give you.
(18:07):
In what depth do you want me totalk about things and do you
want the most common things ordo you want absolutely
everything and what may or maynot provoke your anxiety?
And would it be helpful to haveall the information and dip
(18:31):
into it when you want it?
Or actually do you want me tonot necessarily give you
absolutely everything?
And in my experience this isusually initiated by the woman.
I'll start talking to her aboutpros and cons and possible
(18:53):
complications and, led by her,she will say actually, please
don't tell me anymore.
I don't want to know any morethan this.
I'm comfortable with mydecision, having had this level
of information.
And I take her lead, I take herdirection.
(19:16):
Sometimes she may ask me todiscuss it with her partner and
then her partner can talk to herabout it at a later point.
But if she tells me, please, Idon't want you to go through
everything all over again.
Perhaps she's been through itmultiple times or actually I've
(19:37):
done a lot of reading, I've donea lot of thinking.
I don't want you to outlineevery minute possible detail
then.
Fair enough, that's her choice.
Another aspect of consent I findvery interesting is this idea
of written or verbal consent.
I find it really weird thatGoing to theatre so moving from
(20:04):
one room on the delivery suiteto another room on the delivery
suite, means that I need awritten piece of paper, and part
of this is the surgicalchecklist.
One needs a consent form andit's part of the check that the
person has agreed to theprocedure that's going to be
(20:24):
undertaken.
And I guess that's much moreimportant in surgery where
someone's having a generalanaesthetic, that you're very
clear what their wishes arebefore they're unconscious.
But I find it strange that if Ido an assisted vaginal birth in
(20:44):
the room, verbal consent issatisfactory and if I go to
theatre I need written consentfor that and I'm not advocating
we should have written consentfor the room.
I'm just pondering what is thedifference and whether it's just
(21:07):
one of those that's how we'vealways done it or that's how
Medico legally it's been seen.
I find it interesting, and inthe GMC document it talks about
written and verbal consent andit also talks about non-verbal
consent and whether or notsomeone is indicating through
(21:32):
their body language that they'rewilling to undergo something.
But they talk about consent foreverything, from the beginning
of an examination and they talkabout the assumption that most
people have come to a medicalprofessional for some advice and
(21:56):
potentially examination andinvestigation and therefore one
presumes some consent from thefact that the person has turned
up in the first place.
But each interaction, eachexamination requiring consent,
and certainly when I go on theward round, I ask the midwife to
(22:16):
ask the woman if it's okay ifwe come in, warn her in advance.
Certainly before I touch her Iwill ask would you mind if I
feel your baby or can I takeyour blood pressure?
Every interaction you areasking for consent, but in a
(22:37):
much less formalised way.
The final issue, which I'm notgoing to go into in great depth
here is what if someone isunable to consent, so they lack
capacity, and that's a wholeseparate topic and something
(22:57):
that I have experienced.
In an emergency situation,someone is unconscious you're
allowed to act in someone's bestinterest and do whatever is
deemed necessary to attempt tosave their life.
But I also have had somesituations with women with
(23:20):
mental health issues where theylack capacity and we've had to
very carefully assess theircapacity with the help of
psychiatric experts and thenhave a best interest, meeting
(23:42):
with an advocate for the womanand to consider from her
behaviour, from her interactions, from what we know about her,
from her family and from theadvocate, what efforts have we
(24:02):
made to try and explaininformation, what efforts have
we made to try and understandwhether she can retain and give
us back information from the wayshe's talking and behaving,
what do we think she wants andwhat's in her best interest, and
(24:23):
that's a whole, very complexsituation which I'm not going to
delve into here but issomething to consider.
We're very fortunate that inmaternity care, far and away the
majority of people we care forare able to consent.
They do have capacity, and it'smuch more difficult for other
(24:49):
clinicians in other specialtieswho perhaps more regularly come
across people who have perhapslost their capacity and ability
to be able to consent.
So that's a slight whistle stoptour.
What's my zesty bit?
I think it is go away.
(25:14):
Read that GMC guidance.
It's quite interesting.
But also think about thatantenatal period.
How much time we have in theantenatal period.
Yes, it's time limited.
We've got eight months prettymuch by the time the woman's
booked, if we're lucky, in whichto impart a lot of information.
(25:38):
But we need to use that timewisely to give her the right
information for making thosefuture decisions.
And I think that antenataleducation, which has been really
axed over the years, is reallylacking within the health
(26:03):
service, really needs to comeback in if we're going to really
prepare people for those futuredecisions.
And I think if you're a pregnantwoman listening to this, if
we're bombarding you withinformation, understand part of
it is we're trying to give youthe knowledge and help you think
(26:23):
through those future decisionsand try and do as much as you
can during pregnancy to preparefor the decisions you might be
asked to make around pregnancycare, labour and birth and also
the early care of your baby.
But equally, be aware we arehuman and that we may have our
(26:48):
own biases, and be aware whenwe're using the language that
isn't helpful and help check us.
I've learned a lot over theyears from people saying to me
actually, risk is a much lesshelpful word.
Why not use chance?
And I've definitely modifiedand changed my language as a
(27:12):
result.
So when someone is using reallydifficult language, I know it's
a big ask to ask you to give usfeedback in the moment when
you're trying to get your headaround what we're saying, but if
you can't in the moment, thentry and give us that feedback
later or to another member ofstaff that you are able to
(27:35):
perhaps talk to, because that'sthe way we're going to learn.
I very much hope you found thisepisode of the ObsPod
interesting.
If you have, it'd be fantasticIf you could subscribe, rate and
review on whatever platform youfind your podcast, as well as
(27:57):
recommending the ObsPod toanyone you think might find it
interesting.
There's also tons of episodesto explore in my back catalog
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
(28:19):
very seriously and take greatcare not to use any patient
identifiable information unlessI have expressly asked the
permission of the personinvolved, on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
(28:44):
the subject a little more deeply, don't forget to take a look at
the programme notes, where I'veattached some links.
If you want to get in touch tosuggest topics for future
episodes, you can find me at theObsPod, on Twitter and
Instagram, and you can email meat TheObsPod at gmailcom.
(29:09):
Finally, it's very important tome to keep the ObsPod free and
accessible to as many people aspossible, but it does cost me a
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and by chance, you do
(29:31):
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it freevia 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.
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