Informed consent, Kenya’s most ignored patient right

I met Sarah in 2013 at the ante-natal clinic when she was expecting her third baby at 31 years of age. I must admit that I had difficulty wrapping my head around the fact that she had a surgical scar on her abdomen resulting from a surgery two years back; and despite having signed on the dotted line, she had no idea what the surgery was about.

Several times, as doctors who are required to perform emergency caesarean sections, we have ended up with poor outcomes because of delay in obtaining consent for the surgery. The patient is not allowed by her social circumstances to consent to the surgery as consensus must be sought from the spouse, parents, siblings and even the in-laws. In the process we end up losing a baby, having severe haemorrhage or even loss of the mother’s life.

The most socially restrictive challenges to the patient accessing the care they need happen in matters to do with contraceptive use. Many women will take up contraceptives when they get married and hence the importance of partner participation. It is sad to see the woman cede her right to choose a preferred method because the spouse does not approve of it.

Ill health is a point of extreme vulnerability for all of us. When your life is at stake, it is very easy to go along with any treatment option offered, if only to stay alive or be rid of the pain. For this reason, health care providers tend to have the upper hand in influencing decisions, which may inadvertently be abused even with the best of intentions.

In my view, after patient confidentiality, informed consent is the second most important patient right. Yet only a handful of patients in Kenya even know about it.

It is enshrined in the Patient Rights Charter yet it is poorly appreciated. Informed consent is built upon seven key tenets that cannot be divorced from each other:

1. Patient’s role: the doctor is obligated to help the patient understand his/her role in the decision-making process, so as to ensure the patient is a partner in their care process;

2. The treatment option: the patient must understand his/her condition, having been appropriately explained in a language he/she understands, and the logical process that leads to the planned treatment, its process and expected duration of care;

3. Other treatment alternatives: all other treatment alternatives must be fully explored and understood, including those that may not be available locally available and understanding the option of no treatment;

4. Risks and benefits: the doctor has to elaborate the well known risks that may arise as a result of the treatment and the sought after benefits; and comparing them to the risks and benefits of the alternative treatment options;

5. The unexpected: the patient must be prepared well for the unexpected eventualities that may arise in the course of treatment;

6. Patient fitness: the patient must be considered mentally and physically fit to process and understand the information provided, without undue influence from drugs or excruciating pain or unconscious state; and

7. Choice: with all the aforementioned tenets considered, then the patient is fully informed and capable of making an informed choice/preference in their care plan.

Putting this into perspective goes to demonstrate just how many patients go through medical care without really having consented to it.

For consent to be valid, the patient must be fit to give it, adult (over 18 years), having understood their condition, the treatment, the options, risks and benefits, the unexpected issues, and willingly and knowingly taken their preferred choice of treatment.

In the event that the patient is unfit to give consent, either by mental incapacity or by being in unconscious state, then there is need for a next of kin to take up this role. This person is commonly listed in the patient record and assumes authority to make medical decisions for the patient. Therefore it is important to always ensure that whoever is listed as your next of kin is someone you trust to take such weighty decisions for you.

When dealing with children, the matter of informed consent does not apply by virtue of their age. The parents/guardians are authorised to approve the treatment choice. However, their decisions must always be in the best interest of the minor, otherwise they shall be overruled by a court of law.

This can get complicated when dealing with, for instance, the health of an infant born to a teenage mother who isn’t an adult herself yet. Our laws then may require strengthening in defining the role of emancipated minors in this case.

SPECIAL CIRCUMSTANCES

In special circumstances, however, exception may be made where the risk to life, limb or sight is imminent and the patient is unable to give consent and a next of kin cannot be located. In this case, at least two doctors must agree to the life-saving procedure and should state in writing that they have taken up the responsibility of consenting on behalf of the patient, in the best interest of the patient.

In the case that the patient’s condition is not an emergency, then the court should appoint a custodian to take the decision of behalf of the patient.

Voluntary presence of a patient in a hospital implies consent to care but not to every procedure available. Verbal consent must be sought for physical examination and uncomplicated procedures such as collection of laboratory specimens, insertion of medical devices such as IV lines and catheters, and performance of pelvic examination.

Surgical interventions, exposure to diagnostic and treatment radiation, insertion of medical devices that alter body function and other complex interventions must have a written and signed consent.

As a patient, when you find yourself in need of medical intervention, kindly ensure you have given a valid informed consent. It is important to remember that you have a right to seek a second opinion before taking a decision.

You are also entitled to the best possible care within the confines of the treatment options you consent to, even if you decline what is regarded as the best option of care.

Dr Bosire is an obstetrician/gynaecologist in private practice in Nairobi.

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1. Patient’s role: the doctor is obligated to help the patient understand his/her role in the decision-making process, so as to ensure the patient is a partner in their care process;

2. The treatment option: the patient must understand his/her condition, having been appropriately explained in a language he/she understands, and the logical process that leads to the planned treatment, its process and expected duration of care;

3. Other treatment alternatives: all other treatment alternatives must be fully explored and understood, including those that may not be available locally available and understanding the option of no treatment;

4. Risks and benefits: the doctor has to elaborate the well known risks that may arise as a result of the treatment and the sought after benefits; and comparing them to the risks and benefits of the alternative treatment options;

5. The unexpected: the patient must be prepared well for the unexpected eventualities that may arise in the course of treatment;

6. Patient fitness: the patient must be considered mentally and physically fit to process and understand the information provided, without undue influence from drugs or excruciating pain or unconscious state; and

7. Choice: with all the aforementioned tenets considered, then the patient is fully informed and capable of making an informed choice/preference in their care plan.