When consenting for a procedure, wherever there is a risk of death – no matter how small – would you always mention this risk?

Doctors often have to make difficult judgment calls about how much information to give to patients around sensitive issues such as death and cancer.

In 2015, the case of Montgomery v Lanarkshire Health Board changed the law on informed consent, meaning doctors would now be expected to explain to patients all the “material risks” – that is, those that the patient would be likely to attach significance to – of a proposed treatment.

The D word

A recent survey of nearly 400 Medical Protection members[1] asked whether the risk of death – no matter how small – should always be mentioned as part of the consent process. While 30% of respondents said they “strongly agreed”, a notable 29% did not agree.

Further explanations from respondents broadly fell into two camps:

• “To not do so cannot in my view represent informed consent. All material risks must be explained – this is now the legal default.”

   

• “There is virtually no procedure with no risk. When the risk is minimal, discussing it is likely to cause the patient more distress than any risks of not mentioning it.”

Doctors have said that the main reason they don’t always mention “cancer” when discussing running tests is that they don’t want to upset their patient – they shield them from the truth in order to protect them. The concern being, that if the patient knows what the test is for, they may become anxious and concerned about what could be found, or they might refuse to have the test altogether. Complaints are sometimes made against doctors for upsetting patients by mentioning the word “cancer”, so some doctors prefer to be less specific until the results of the test are known.

So what should you tell them?

It is challenging to have difficult conversations with patients, especially when there’s not much time available. Knowing how much information to share can vary based on individual circumstances. The GMC advises doctors to think about:

• the patient’s needs, wishes and priorities
• the patient’s knowledge and understanding of their condition, prognosis and the treatment options
• the nature of the condition
• the complexity of the treatment
• the nature and level of risk associated with the investigation or treatment.

A doctor should never make assumptions about what information a patient might want or need, their knowledge and understanding of what is being proposed, or any other factors a patient might consider to be significant.

A patient has a right to know about their diagnosis and prognosis and any uncertainties including further investigations. A doctor should inform them of all the treatment options, including the option not to have any treatment. They should be told what the purpose of any proposed investigation or treatment is, what it will involve and any potential benefits, risks and burdens.

A useful question to ask the patient is ‘Is there anything that you are worried about?’ as it may prompt the patient to discuss specific concerns (which could include the fact that they are worried about the possibility of cancer, which in turn could lead into a discussion about the investigation and management options).

Most importantly, doctors should answer any questions the patient may have, honestly and as fully as they can.

When might doctors not share information with their patients?

Information should not be withheld, even if a relative, partner or friend of the patient has asked you to do so, unless you believe the disclosure could cause the patient serious harm. The GMC says: “In this context ‘serious harm’ means more than that the patient might become upset or decide to refuse treatment.”

Remember that if you withhold information from the patient you must document your reason for doing so, and be prepared to explain and justify your decision. The GMC adds: “You should regularly review your decision, and consider whether you could give information to the patient later, without causing them serious harm.”

If a patient is adamant that they do not want to know about their condition or treatment in detail, you should try to find out why. If they insist they do not want to know, then you should respect their wishes, however, they still need to be informed sufficiently to give their consent for any proposed investigation or treatment.

On the record

It is crucial that you clearly record when a patient has declined to be informed about their condition or treatment – detailing their reasons why and the discussions you have had with them.

Make sure the patient knows they can change their mind and access the additional information at any time. You should also regularly review your decision and check if the situation has changed.

Further information

GMC, Consent: patients and doctors making decisions together, Part 2: Making decisions about investigations and treatment (2008)