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Informed Consent: The Nurse's Role

Tuesday April 1, 2003
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You answer the EMS phone and you hear that a 35-year-old woman and her 6-year-old daughter are being flown in after a severe automobile collision. The mother has an obvious fracture of the left femur and is unconscious. The flight nurse says the pediatric patient has no bowel sounds with guarding and rigidity to the abdomen. You can hear the young girl screaming in pain, and the crew is having trouble maintaining her blood pressure.
After arrival, your assessment concurs with that of the transport team, and the trauma surgeon talks about taking your pediatric patient to surgery. Her mother is arousable but is not coherent. The surgeon tells you to do whatever you can to locate someone to give consent. What does that mean to you?
What Is Consent?
In most states, the RN does not explain the fundamentals of consent. The physician conducting the surgery will usually explain these elements in a language others can understand. It is the nurse's duty to witness the signature on the form.
The physician must first find the appropriate person to give consent. Contacting the mother or father is the first step. If the parents are not reachable, another guardian or relative is needed. Once the family is located, the physician must determine they have the capacity to understand what they are being told. They must be able to make a decision based upon their morals and beliefs.
The physician must explain to the family the following (these may vary slightly from state to state) -
What is the surgery and why does the child need it? In our example, if the mother were awake and alert, she would be told which type of abdominal surgery her daughter would be having. She would most likely be told her daughter's condition is unstable and that she is bleeding from somewhere in her abdomen. The daughter could die if the bleeding isn't stopped.
What should the outcome be and what could go wrong? She would be told the goal of surgery is to stop the bleeding and stabilize all vital signs. The physician would discuss the major risks associated with abdominal surgery. But the physician is not required by law to tell the mother everything that could go wrong. He or she must only explain what a reasonable person needs to know to make an informed decision. For example, there is always a chance of infection. The physician may not specifically mention infection, but it is considered an inherent risk and therefore part of the procedure.
Are there any alternatives and what are their effects? The physician may not say anything about alternatives in this case because in emergent situations, there may not be any alternatives that apply.
Beyond the Physician's Role
The family has a responsibility to understand all the information they are given. If they don't, they must ask questions. For example, the family is told hemorrhaging is a risk, but they don't understand hemorrhaging means uncontrolled bleeding and don't ask for clarification. Suppose your patient dies from this complication. The family would have a difficult time attempting a lawsuit based solely on not being properly informed.
Your role as an RN is to witness the signature of the family. Also, as a patient advocate, you must encourage the family to ask the physician if they have questions or don't understand what they have been told.
"While obtaining informed consent is the legal responsibility of the physician, some patients and families may be more comfortable discussing their concerns with a registered nurse," says Beth Zorn, RN, BSN, LNCC, a legal nurse consultant for Faraci & Lange in Rochester, NY. "It is important for the nurse to advocate for the patient in this situation by documenting the patient's concerns in the record, discussing issues with the patient that can be addressed by a nurse, or referring the patient back to the physician for further discussion when appropriate."
Knowing the elements of consent and the importance of being a patient advocate, you desperately try to reach the 6-year-old girl's father at home and at work. You leave a message at home and are told he has just left the office. The mother is still disoriented and cannot give you any helpful information.
No Consent
When a pediatric patient is involved, every effort is made to contact the family. In emergent situations such as this, the responsibility to make a decision lies on the treating physician. He or she is allowed to proceed with the surgery on two conditions (this may vary slightly in some states) -
The surgery is a life-or-death situation
The physician must obtain the opinion of another licensed practitioner in that state, if at all possible

You explain to the physician that you can't reach any family members. In anticipation, he has already contacted another pediatric surgeon and is ready to proceed. When you return to the department, the patient's father has arrived and is with his wife. You join the ED physician and explain what has happened and offer encouragement.
Encouraging families to gain a better understanding and ask questions is perhaps our most important role in informed consent. Clearly knowing the part we play and how we can empower others makes us better nurses. By offering our knowledge, encouraging guidance, and bestowing compassion, we remain vital members of a team.