Wouter Leclercq

A review of surgical informed consent: Past, present, and future. A quest to help patients make better decisions 29 2 Informed consent is often given by the patient during a preoperative consult with a consultant, a resident, or a specialized nurse. The information associated with a surgical procedure can be exchanged verbally, in writing, by video, or by computer technology. In this respect, large differences exist between countries. The US demands a patient signature, whereas a note in the patient chart is sufficient in the UK. In the Netherlands, doctors are not strictly required to obtain written consent. 26 Preconditions As a routine, the patient’s competence is only ‘‘checked’’ in a general sense and deemed appropriate if communication with a patient is ‘‘normal’’. 27 Only if the patient is officially ‘‘incompetent’’ will a legally appointed surrogate decision maker or an other representative in accordance with the law be allowed to decide for the patient. 27 However, a normal intelligence per se does not necessarily mean that a patient is really competent. Recently, Appelbaum 28 reviewed the literature on patient competence. A group of patients with known cognitive disease and patients with cancer demonstrated variable outcomes on competence tests. Lower scores were found in people of older age and limited education. The number of ‘‘incompetent’’ patients was higher than expected. Surprisingly, the doctor’s ability to differentiate between competent and incompetent was not better than throwing a dice. 28 On the other hand, even patients who are objectively deemed competent may be ignorant. They frequently do not know the process of SIC and do not know their rights, which results in wrong beliefs. 29,30 Only 40% of the patients think that the IC paper confirms their wishes. 29 Interestingly, they usually do not feel the need for more information and their actual knowledge of the benefits and risks involved remains poor. 31-35 In contrast, when asked what information they would like to have, they indicate that they would like more information than they actually receive. 36 Several misconceptions also exist with respect to voluntariness. One study reveals that 46% of patients in the study were under the impression that the major goal of an IC is to protect the hospital from litigation. In addition, 68% of the patients were convinced that the IC process gives the doctor control of what is going to happen. 29 Information elements Literature on patient education is extensive and is usually focused on informing patients in a general sense. On the other hand, studies on information in relation to the IC process are scarce. Results consistently demonstrate that neither doctors nor patients are well prepared for all elements of the IC process. 19,20,30,37-42 Residents are frequently ‘‘in charge’’ of the IC process but do not know what to tell a patient and do not perform well in