ISD II – Ethics/Humanities/Health Law

Discussion Cases – Consent

Case 1: Joe Green is a clinical clerk who is in the middle of his Orthopedics rotation. He is paged to come to the floor by one of the nurses, Ms. Harvey. She says she needs him to get Mrs. Squires’ consent form signed before she can be taken to the O.R. for her total hip replacement. Joe met Mrs. Squires yesterday evening, when he did her admission history and physical. She is a pleasant 70 year old woman, who has had osteoarthritis involving her right hip for several years. Otherwise, she is in quite good health, and is only on one medication for high blood pressure. Joe assisted in a total hip replacement by Dr. Sharp, the staffperson, last week, and during his General Surgery rotation he had a lecture on surgical risks.

What, if any, are the consent issues here?

What should Joe do in this situation?

Case 2: Jenny is a clinical clerk who is considering applying to residency programs in Orthopedics. She is in the Orthopedic clinic this afternoon along with several other learners (a resident, an intern, another clerk and a first year medical student who is shadowing Dr. Power, the staffperson).

Dr. Power calls Jenny and Tom, the other clerk, into an examination room where all of the other trainees are already present. He motions to the frail elderly lady lying on the examination table and says, “This is Mrs. Clarke. She has an interesting finding. You two, examine her right knee and tell me what you think. Let’s see what you’ve been learning since you’ve been here.”

Tom goes first and examines Mrs. Clarke’s knee. She does not say anything, but winces in obvious pain as he palpates her knee, and bends and straightens it. Tom says, “I’m not sure what I was supposed to feel”. “Okay, your turn”, says Dr. Power to Jenny.

What, if any, are the consent issues here?

What should Jenny do in this situation?

Case 3: Mr. B. has a stricture seen on barium enema, which is suspected by clinical history to be malignant. Although initially very reluctant, informed consent is eventually obtained for a colonoscopy and biopsies by Dr. X. Mr. B. is very anxious before the procedure and is given medication to sedate him. Partway through the procedure, Mr. B. cries out, “Stop, it hurts. I’ve changed my mind.” Dr. X. replies, “I’m almost done here – just bear with me a little bit longer.”

Has the patient withdrawn consent at this time?

How should Dr. X. proceed?

Case 4: Tom is an 80 year-old man with diabetes, renal insufficiency, hypertension, coronary artery disease and severe peripheral vascular disease.

Two years ago, Tom had a left above the knee amputation. For the last three months, Tom has had an infection in the right lower extremity. Two weeks ago, he was admitted to hospital concerning this infection. At this time, a right below the knee amputation was recommended to him (since other treatment options had failed). Tom refused, saying that he had already lost a leg and saw no reason to live without any legs. Tom was discharged with a prescription for oral antibiotics although he was advised that this was not the optimal treatment.

Today, he was admitted to the hospital with a right lower extremity infection and sepsis. He was extremely confused and unable to communicate clearly. The orthopaedic surgeon brought in to consult on his case recommended that a right below the knee amputation be carried out. When his prior refusal of this procedure was brought up, the physician who discharged Tom the last time was consulted. He indicated that their conversation prior to discharge had concerned what the optimal way of treating the infection was, not the choice between amputation and death. The consulting surgeon is now of the opinion that Tom faces a real risk of dying if the amputation is not performed soon. Tom has no living relatives, nor a designated substitute decision maker, nor has he prepared an Advance Health Directive.

What factors need to be considered here in deciding what to do?

What should happen to Tom?