By Mark Crawford
HOW IMPORTANT IS GETTING INFORMED CONSENT FROM YOUR PATIENTS? Is it essential to the ethics and standards of your practice?
According to the National Board of Chiropractic Examiners’ (NBCE) Practice Analysis of Chiropractic 2015,1 a survey of chiropractic physicians showed that most believe that not obtaining written informed consent to treatment from patients is a significant risk (2.6 out of 4). Yet, they also ranked obtaining written informed consent as only 10 out of 20 for importance.
Clearly, it’s not high on the list of operational mandates.
Although there are no firm statistics on the percentage of doctors of chiropractic (DCs) who practice informed consent, Stephen M. Perle, DC, professor of clinical sciences at the University of Bridgeport in Connecticut, believes the numbers are low.
“I think that few do informed consent, and of those, probably not many do an adequate job,” says Dr. Perle. “When I’ve lectured on this topic, people seem to want a ‘perfect informed consent form,’ thus believing that informed consent is a paper, when it is actually a process.”
William J. Lauretti, DC, associate professor of chiropractic clinical sciences at New York Chiropractic College in Seneca Falls, agrees. “I served as a consultant for an insurance company several years ago, where I reviewed treatment records for more than 10,000 chiropractic visits,” he states. “Many of those DCs did a poor job of performing and documenting a thorough informed-consent process.”
A Lot on the Line
Informed consent is the process by which DCs disclose information about medical treatments to patients, prior to providing care. This information includes type of treatment, potential benefits and risks, and alternative treatment options. Dr. Perle offers the following mnemonic device – PARQ – for remembering the informed consent process:
PROCEDURES – explain the procedures being offered.
ALTERNATIVE – talk about alternative treatments that could be performed, including no treatment at all.
RISKS – discuss the material risks such as possible side effects and complications from the recommended procedures, as well as alternative procedures.
QUESTIONS – answer all patient questions.
When a DC initially agrees to provide treatment to a patient, “there is an imbalance of information about the proposed treatment – the practitioner has more information than the patient,” writes Melissa Winter-bottom, in her recent article, “Informed Consent for Chiropractic Care: Comparing Patients’ Perceptions to the Legal Perspective” in Manual Therapy.2 “This imbalance may compromise the patient’s right to self-determination. Informed consent is intended to allow both parties to enter into dialogue and reach agreement as equals, thereby enhancing autonomous decision-making for the patient.”
Perhaps more important than fulfilling legal criteria, informed consent enhances patient education. “It clarifies the patient’s perceived ideas about risk related to treatment and the competence of the provider, which improves overall provider-patient communication and rapport,” adds Leanne N. Cupon, DC, owner of Chiropractic Ortho and Rehab Center in Cumming, Ga.
Dr. Lauretti agrees.
“Many patients get negative messages about chiropractic care from friends, family, their personal medical physicians or from reading articles on the Internet,” he says. “Sitting down with a patient and thoroughly discussing the treatment plan in understandable terms, including potential benefits, risks and alternative treatments, is a great opportunity to build a bond of trust. If more DCs saw it this way, instead of as a chore or awkward conversation, informed consent would be done better and more consistently.”
The biggest risk of not getting written informed consent is litigation – often the result of lack of trust between the patient and the chiropractor. In a typical malpractice case, a common claim is that the doctor has somehow violated a standard of practice or a duty to a patient. “A doctor who does something that harms a patient and did everything right but didn’t inform the patient of the possible side effect can lose a malpractice case solely because of no or improper consent,” says Dr. Perle.
Dr. Lauretti has served as an expert witness in about a dozen cases involving malpractice accusations where he reviewed records. “More than half of them could have been dismissed or easily won if the DC had documented an adequate informed consent process,” says Dr. Lauretti. “An insufficient informed consent isn’t usually the sole deciding factor in a malpractice case, but it can make it far more difficult for DCs to defend themselves.”
Informed consent is a simple process that doesn’t take too long, improves patient care and doctor-patient relationships and protects the DC from litigation. With those upsides, why doesn’t every chiropractor do it?
“It can be perceived as time-consuming,” says Dr. Cupon. “The provider’s own perceptions about risks – including preconceived assumptions and misconceptions – also come into play. Sometimes it is limited knowledge about the informed consent process. Ego can most certainly play a role.”
For many DCs, the lack of knowledge about the informed consent process actually starts in chiropractic colleges and universities, where it is either not taught or is underemphasized. DCs may also believe there are no potential risks with chiropractic care, especially when compared with many procedures done in an MD’s office where patients often receive minimal information on informed consent. DCs may find talking to patients about risks and alternatives awkward and difficult, partly because they feel high-quality prospective data about risks are limited due to a lack of surveillance and reporting. As a result, “chiropractors often omit serious risks from the disclosure discussion, potentially compromising patient autonomy when seeking chiropractic care,” writes Winterbottom.
Chiropractic physicians must look at informed content as an opportunity, not a nuisance. It is time well spent building trust with the patient. It is also important to remember that informed consent is a process, not just a piece of paper that a patient signs. “I have heard of cases where patients signed standard forms, but it was still judged that the informed consent wasn’t sufficient because the patient didn’t really understand and there was no opportunity to have questions answered,” says Dr. Lauretti.
Winterbottom also indicates that patients perceive informed consent as a process rather than a static event, making it an ideal opportunity to “educate chiropractic patients about the risks associated with treatment while satisfying the legal requirements of informed consent,” she says.
For example, during the informed consent process a DC could educate a patient about potential red flags or symptoms that could be a serious concern. “If you’re treating a patient with a potential herniated disc in the lumbar spine,” says Dr. Lauretti, the conversation could go something like this:
“Joe, you have a mild herniated disc in your low back. At this point, I think it’s mild enough to treat conservatively. However, sometimes these things can get worse. The things to look out for are signs that the nerve going out of your spine and into your legs is being damaged. Those signs of nerve damage might include true weakness in your legs or feet, like dragging your feet when you walk because of weakness, or true loss of feeling in your legs or feet, like if you stick yourself with a pin and can’t even feel it. One other thing to look out for is that the nerves can be damaged in the spinal cord itself, which can lead to bowel or bladder incontinence or an inability to urinate. If any of those things begin to happen, you need to let me know immediately, okay?”
The bottom line for DCs and informed consent?
“Just do it,” advises Dr. Cupon. “It’s an important part of the provider-patient relationship. It balances ‘power’ by allowing the patient to receive all the necessary information in detail in order to make a truly informed decision, which leads to better patient compliance.”
Finally, if all chiropractic physicians took informed consent seriously, it would elevate the overall credibility of the chiropractic profession among other medical professions, as well as the general public. “It’s interesting that many of our critics from outside the profession choose to focus on the supposed risks of what we do,” says Dr. Lauretti. “I think if the profession could respond with evidence that we are making a major effort toward developing and enforcing a patient-centered, safety-conscious culture within the profession, it would go a long way toward disarming even our most strident critics.”
2) Winterbottom M, et al. Informed consent for chiropractic care: Comparing patients’ perceptions to the legal perspective. Manual Ther. June 2015;20(3):463-468.
Mark Crawford is a contributing writer.