What are everyone’s thoughts of waiting to obtain consent to perform procedures until the patient arrives to the actual procedure room or OR? Management is wanting us to increase the number of procedures (TEEs, cardioversions), but that’s forcing physicians to obtain consent after the patient has already been transported from their room down to the procedure room because they don’t have time to go see them on the floor to obtain consent there.
I see this as a form of coercion because the patient thinks it looks bad if they say no since resources were spent getting them there, but I can’t find anything online that says consent can’t take place in the procedure room itself. You would hope/think that the full consent process (purpose of procedure, risk/benefits, other options, etc) would take place prior to the day of, but some physicians’ documentation does not support that is happening (lack of updated H&Ps, no recent labs, no documentation of discussion with patient).
What are y’all’s thoughts?
Patient should not be in the OR without consent. This is an accident waiting to happen.
My current facility does consent in pre-op, they’re brought down and the surgeon and anesthesiologist talk to them there. Seems more convenient than sending the doctors up to the floor but still getting everything in order before actually going into the OR. They’re super strict that the patient doesn’t cross the line or start any nonessential meds until everything is set. Seems like common sense to me.
I prefer to consent while the scrub tech sharpens my 10 blades menacingly in the background
And the anesthesia tech is doing the same to my Miller blade
For our breast biopsies it was a firm hospital policy/procedure to get consent in an adjacent office outside the procedure room, with patient still dressed .
The hospital I do most of my work at won’t transport without a consent previously signed. I haven’t read anything about the exact location, but if patients admitted and on the floors they stay there until the consent is signed. Emergency procedures are a bit different, but in all cases I’m talking to the patient about the surgery before they get to the OR.
Let’s face it: there are different and sometimes competing interests/purposes when it comes to “obtaining consent”, right?
- ensuring the patient is making an informed decision about whether or not to proceed.
- ensuring the physician and institution are protected from legal risk.
It is the latter that drives most if not all of the policies and procedures around when and where the consents must be completed, and also most of the wording in the consent forms themselves.
But shame on those of us who fail to accomplish the former. “We don’t have time…” is an unacceptable excuse.
We have to draw a distinction between obtaining informed consent and signing bullshit paperwork that almost no-one reads.
No one should come to a procedure room without the physician talking to the patient and obtaining informed consent, if its not an emergency.
It doesn't matter at all imo where the forms are signed and lawyers and admin types made happy.
Exactly. For all my elective cases, I discuss all the b/r/a in clinic. On day of surgery, signing paper is just a formality. Same for inpatient, discussed the day before at least, unless an emergency.
Signing the papers mean jack. No different than the fact I have never made anyone sign AMA papers. Those don't mean jack either.
I don’t meet any of our direct-access colonoscopy patients until well after they’ve done the prep, which is arguably a much greater incentive to complete the procedure than being in an OR/procedure room.
Yeah I’m FM but we have this program where I am too. I order the colonoscopy and the colorectal department schedules and the patients done meet the actual doctor who will be doing the procedure until day of. I’ve never heard anyone complain.
But when you order the colonoscopy and commit them to prepping do you have a risks/benefits discussion with them? Especially if they’re average risk and qualify for stool based screening as well, they may change their mind when the risks are clearly explained to them. If you don’t, then (like the commenter’s point) having taken the prep already they might feel coerced into giving consent even if they do not feel comfortable or otherwise wouldn’t take the risk.
I work in a 3 hospital system and the variability between all 3 but the same system is wild. Some won’t let the patient go outside the OR without the consent. Some will let them INTO the OR.
In our group, we often discuss the procedure and verbally consent before the patient goes to the procedural area. But the actual consent is often signed just before the procedure as the performing physician may be different from the consenting physician.
The concern about coercion is very valid given the power differential in these situations as well.
Unfortunately, our current consent is a blanket consent including videography, allowing observers, use the tissue for research etc. Apparently, its a Leapfrog requirement. I was (and still remain) worried about the implications. Surprisingly, everyone has signed it without objections. We have a combination of educated urban + educated rural patients.
Somewhere in my post history is someone in r/legaladvice asking about this omni-consent and a bunch of people explaining how pervasive this has become regardless of how crazy it is. So it made at least one person mad enough to ask reddit, at least.
This used to be normal for us about 15 years ago. Then the hospital lawyers came down on it and said it can be considered that consent was obtained “under duress”
So we all stopped
I see the point you’re making, but where does it stop? Is it coercion to get consent after an IV is in? After they give a urine sample? After they’re NPO and have arrived that morning and taken a spot on the OR schedule? The patient would feel most free to change their mind in a clinic visit days before a procedure, but that costs time and decreases how many patients we can care for.
For surgery, I wouldn’t take them back to the OR unless everything, including consent, is squared away (apart from emergencies). But we do consents for procedures like cardioversions and endo procedures in the room. The patients seem to like it and it makes the day streamlined. It’s not like we had many patients cancelling under our old system. And as an added benefit, it allowed us to have the same nurse do pre, intra, and post procedure care. There’s no handoffs and the patients feel like they have someone dedicated to them throughout the entire visit.
As long as they receive the paperwork prior to- I assume they wouldn't have time to read it carefully in the OR with everyone waiting
They have the same amount of time. We’re waiting either way. It’s a welcoming environment and we don’t rush them.
You wouldn't feel rushed with a bunch of people staring at you waiting to start? The whole point of obtaining consent in the room was to make the process quicker- you don't think the patient will pick up on the impatience? I know I would feel awkward and rushed in that position. What happens if they're already in the OR and they say they don't consent to observers/video recordings/etc? Edit- never mind, my mistake. I see you said you wouldn't do this for surgeries. So this is more a general comment regarding the practice of getting consent in the OR, not directed at you.
There are only two people, plus the nurse who has already been with them through the pre operative process. The GI doc is in the corner typing his notes from the previous case. I welcome them and ask them my pre operative questions from my chair. I discuss the plan and give them multiple opportunities to ask any questions. After the sign my consent the GI doc does his consent while I’m back in my corner preparing meds. I understand if you’re skeptical of the process, but our patients love it as much as we do. We aren’t doing it just to save time, we’re also doing it so that we can spend that saved time on important issues when the patient has questions or when I discover anesthetic concerns. Our patients aren’t shy in their critical reviews when they are unhappy with their care, but I haven’t seen any complaints about feeling rushed. I have had patients complain about our typical pre OR system, as a parade of people bouncing in and out of the room asking the same question leads patients to feel that we aren’t organized and communicating.
Consent in the procedure room is technically legal, but it is ethically weak. The patient is already transported, stressed, and feels obligated to proceed. True informed consent requires time, privacy, and freedom to decline. Rushing it undermines autonomy and exposes everyone to risk.
Sometimes for logistical purposes they may physically sign the paper in the room (very rare) but we always have the conversation about the procedure well before then
I am seeing this done more frequently now in the context of patients with multi-drug resistant organism precautions. So as to not expose the patient to multiple rooms in the hospital unnecessarily, like the pre-procedural holding area. Both for logistical reasons (having to deep clean those areas afterwards, delaying ability to care for other patients) and to minimize risk of disease spread to other immunocompromised patients in the same space.
For an inpatient case? Yeah the team should probably go to the bedside and get it. How that can be optimized is subject for discussion. The person performing the procedure should be able to obtain the consent during the initial consultation. The paperwork should be left for the patient to think about and sign when they feel comfortable. The nurse or whoever can take possession of the signed consent form and notify whoever needs to be notified to add the case on the board I don’t think you need to make the Physician stand there until the patient signs a piece of paper I don’t think they need to make the Physician physically bring the paper to the bedside. If verbal consent can be obtained, a signed piece of paper can be obtained after the fact.
As a G.I. doing open access endoscopy, me obtaining consent on the day of did not really make sense. The patient has usually already taken the preparation. They kind of consent the procedure in the primary care office. I have yet to hear the story about someone who took the prep, learned about the procedure from the G.I. on the morning of the procedure and decided not to go forward with it. I imagine if they had reservations, they would not have agreed in the primary care doctor’s office or picked up the prescription for the prep or taken it.
EP here. We do all of our consents in the pre holding area. The only time we'd ever get consent my the lab is if we have to change something last minute.
I feel like conversations and consents should happen away from the lab/or
We conduct the entirety of our outpatient visits and procedures in our procedure room. I don’t see an ethical quandary with doing this, although these are not surgeries and all discussion takes place fully clothed with patients who traveled here for this reason
Are we practicing in the same country? I assume this is US. At least for inpatients my experience has always been that I go talk to the patient first about the surgery, then I put in a consent order and floor RN will prepare the paperwork to have the patient sign. Then they get transported to the Pre-Op on the designated times.
The only time consent is done in Pre-Op is when a floor RN forgets to do it, and any pre-op RN will not hesitate to report that floor RN.
Consent obtained in the procedure room is technically valid but ethically flawed. The patient is already transported, vulnerable, and feels pressure to proceed. True informed consent requires time, privacy, and the freedom to decline without consequence. Rushing it undermines autonomy and increases risk.
We have precedent in austria that non-emergency procedures need to be consented to with „appropriate“ time before. For most non-immediately addressed fractures that is at least 24 hours, for elective arthroplasty, we have seen rulings from 72 h to a week beforehand being not appropriate.
The whole concept is flawed in my opinion anyway. How is a patient with no medical training at all supposed to ever be able to fully comprehend an operation and its consequences? Most (even doctors) wildly misinterpret statistics if complications, it feels like like half lacks the attention span to follow more than 2 minutes of interaction.
I‘m not saying consent isn’t important to obtain, but the way it’s supposed to happen according to the law is a fairytale
Idk if there’s an ethical issue at hand but what this does is open up the surgeon and hospital to legal action. Consent could be displayed as coerced, last minute, or even not obtained as an accident. Not sure how anyone can think about the risks and benefits when 15 people are standing around waiting for them to sign. At least that’s what my lawyer will say to the jury. What hospital is this?
For inpatient procedures that are done in a procedure suite (instead of bedside on the floor/ICU) I am often talking to the patient about the procedure when I make the decision to do it, usually on the initial consult or when I'm rounding if something has changed. I discuss the details of the procedure, the indications/risks/benefits etc. As far as I'm concerned, this is the actual informed consent that matters morally/ethically. I do typically document that I had this discussion and the patient is agreeable to move forward in my note that day. I don't think documenting it in your progress notes is strictly necessary since you're going to be signing a consent that has all that in it, but it's how I prefer to do things.
Sometimes the person doing the procedure is not the person who had the discussion, but again that's why there's a pre-op meeting to ensure everything is adequately discussed.
The actual signed consent is much less important to me and falls under the umbrella of 'red tape'. Frustratingly, my facility (more specifically the endoscopy suite staff) 'have a policy' (that no one can produce for me) that consent has to be done the day of the procedure, and anything from before the day of the procedure is not valid. So they get their formal consent signed usually in the pre-op holding area. My signature is the only one required to get the patient moved into the room since the signature pad in the pre-op bays is usually broken and the nurses won't let me use their fancy lil ipads, so the RN collects the patient signature after mine is done, though that almost always happens in pre-op as well.
I don't think consenting in the OR is illegal, but the ethics are weak, both for the reasons you identified and also because they may have already gotten some midaz or something before I get to the room.
The inpatient pulmonary procedure team is also the pulmonary consult team, so if I'm doing a procedure on a patient in the endo suite then I'm generally not rounding on them that day & I'll see them in pre-op. With the volume of consults plus procedures we have there's not really any other way to do it and still be able to run the service. I will say that for inpatients, a new H&P pre-op is not needed and I don't do one, they have an admitting H&P from the hospitalist and also my consult note.
For outpatient procedures I review the procedure with the patient when I call to schedule them. The fellow who calls them to schedule is pretty much never the fellow that does the procedure, but they get a formal consent and sign it the day of the procedure in pre-op, plus a (usually garbage/templated) H&P. Same deal, no H&P+Consent, no going into the room.
It strikes me as bad taste to consent in the OR, but I can't imagine this is illegal.
Consent at time of decision for procedure, not in the OR. Also, nurses shouldn’t be getting consent (which I see some colleagues try to bully them into), that is the person doing the procedure’s job.
Don’t worry, we know better to not do the consenting :)
As a surgeon I think this is a terrible idea.
Consent is not signing the form. Consent is the process by which the surgeon explains the risk and benefits and the patient has time to think about it and make a decision.
I try to consent people the day before if it all possible. That gives them overnight to think about things, come up with questions to ask me etc.
This is not consent. You are correct, this is coercion.
The concept of the contract must be upheld holds water until any ol person, even with the credibility of a felon, whines about it.