Ethical Concerns Regarding the Timing of Written Consent
Sean C. Wightman, Victoria Yin, Jacob S. Hershenhouse, Tsehay B. Abebe, Li Ding, Scott M. Atay, Takashi Harano, Anthony W. Kim, John N. Pagteilan, Abhineet Uppal, Baddr A. Shakhsheer
The Journal of Clinical Ethics, Winter 2024; 35(4)
Abstract
Objective
Thorough informed consent requires decision-making capacity, adequate information, lack of coercion, and an appropriate environment. Consent obtained in the preoperative area is hurried, limiting the quality of informed consent and the opportunity for patient reflection, characteristics inconsistent with patient-centered practice. The incidence of obtaining consent immediately prior to surgery is unknown.
Methods
Consecutive patients undergoing surgery at a single center between 1 June 2021 and 14 June 2021 were identified. Time between consent signature and operating room arrival time was measured. Three surgeons reviewed cases and categorized them as major or not major operations.
Results
78.7 percent (199/253) of patients arriving to the preoperative area the day of surgery signed written consent that day. 99.6 percent (248/249) of anesthesia consents were signed the day of surgery. Spanish as a primary language corelated significantly with consent signing on the day of surgery (p = .04). Race and distance traveled for surgery were not significantly associated with consent signing in the preoperative area. 79.3 percent (157/198) had consent signed within 90 minutes of arrival to the operating room. Among major outpatient cases, 77.8 percent (182/234) had consent signing in the preoperative area.
Conclusions
This demonstrates routine consent signing in the hurried preoperative setting, suggesting a potential source for improved informed consent. Additionally, language-based consenting disparities, specifically in Spanish, offer opportunity for improvement. The majority of consents were signed the day of surgery, in the preoperative area, and within 90 minutes prior to operating room start time. This offers an opportunity for improved patient-centered care.

Informed consent in assisted reproductive technology: Implications for pediatric clinicians
Mary E Graham, Shannon Blee, Rebecca D Pentz, Emily Roebuck, Alexander H Hoon Jr, Mara Black
Developmental Medicine & Child Neurology, 17 November 2024
Abstract
After conceiving through assisted reproductive technologies (ART), parents may present to their pediatrician with concerns related to their child’s neurodevelopment, including whether their child’s health may be related to their use of ART. Pediatricians may be unfamiliar with the ART process and what the families endured up to this point, resulting in difficulty counseling parents through these discussions. Before presentation to the pediatrician, parents have undergone extensive evaluation with reproductive endocrinologists. During counseling, the reproductive endocrinologist provides information on maternal and childhood risks associated with ART. However, in this rapidly evolving field, providing comprehensive, patient-centered, informed consent is increasingly complex and counseling patients properly can be challenging. When parents have gone through the proper informed consent process, and when the pediatrician has an understanding of what this process entails, care of the child can be optimized. In this review, we discuss the complexities of the prenatal informed consent process that parents navigate before presenting to pediatricians. We emphasize the importance of these discussions and highlight ethical principles, as well as emotional, medical, legal, and financial stressors that parents face during ART, with the belief that this understanding will improve the care that pediatricians subsequently provide.

Consent to advanced imaging in antenatal pulmonary embolism diagnostics: Prevalence, outcomes of nonconsent and opportunities to mitigate delayed diagnosis risk
David R Vinson, Madeline J Somers, Edward Qiao, Aidan R Campbell, Grace V Heringer, Cole J Florio, Lara Zekar, Cydney E Middleton, Sara T Woldemariam, Nachiketa Gupta, Luke S Poth, Mary E Reed, Nareg H Roubinian, Ali S Raja, Jeffrey D Sperling
Academic Emergency Medicine, 17 November 2024
Abstract
Background
Nonconsent to pulmonary vascular (or advanced) imaging for suspected pulmonary embolism (PE) in pregnancy can delay diagnosis and treatment, increasing risk of adverse outcomes. We sought to understand factors associated with consent and understand outcomes after nonconsent.
Methods
This retrospective cohort study was undertaken across 21 community hospitals from October 1, 2021, through March 31, 2023. We included gravid patients undergoing diagnostics for suspected PE who were recommended advanced imaging. The primary outcome was verbal consent to advanced imaging. Diagnostic settings were non-obstetric (99% emergency departments [EDs]) and obstetrics (labor and delivery and outpatient clinics). Using quasi-Poisson regression, we calculated adjusted relative risks (aRRs) of consenting with 95% confidence intervals (CIs). We also reported symptom resolution and delayed imaging at follow-up and 90-day PE outcomes.
Results
Imaging was recommended for 405 outpatients: median age was 30.5 years; 50% were in the third trimester. Evaluation was more common in non-obstetric (83%) than obstetric settings (17%). Overall, 314 (78%) agreed to imaging and 91 (22%) declined imaging. Consenting was more prevalent in obstetric settings compared with non-obstetric settings: 99% versus 73% (p < 0.001). When adjusted for demographic and clinical variables, including pretest probability, only obstetric setting was independently associated with consenting: aRR 1.26 (95% CI 1.09-1.44). Seventy-nine (87%) patients declining imaging had 30-day follow-up. Eight of 12 who reported persistent or worsening symptoms on follow-up were again recommended advanced imaging and consented. Imaging was negative. None who initially declined imaging were diagnosed with PE or died within 90 days.
Conclusions
One in five gravid patients suspected of PE declined advanced imaging, more commonly in non-obstetric (principally ED) settings than obstetric settings. Patients symptomatic on follow-up responded favorably to subsequent imaging recommendations without 90-day outcomes. Improving the communication and documentation of informed consent and securing close follow-up for non-consenters may mitigate risks of missed and delayed PE diagnosis.

Editor’s note: Academic Emergency Medicine is the official journal of the Society for Academic Emergency Medicine.

Clinical staff attitudes towards opt-out consent for blood-borne virus screening in emergency departments in England
Esther G Blakey, Cassandra E L Fairhead, Alison J Rodger, Fiona M Burns, Lucie Ralph, David R Chadwick
HIV Medicine, 13 November 2024
Abstract
Objective
Opt-out screening for blood-borne viruses (BBVs) in emergency departments (EDs) has been established in areas with a high prevalence of HIV diagnoses in England. This multi-site study explored the attitudes of healthcare workers (HCWs) towards BBV screening in EDs post-implementation.
Design
This was a cross-sectional electronic survey of HCWs.
Methods
Between November 2023 and February 2024, HCWs across 33 EDs in England participating in opt-out BBV screening were invited to complete a survey about the feasibility and acceptability of screening, including the opt-out consent process. Factors independently associated with acceptability of opt-out screening were identified using multivariable logistic regression. Free-text responses were analysed thematically.
Results
Responses from 610 HCWs in 19 EDs were provided: 50.4% were nurses, 43.1% doctors, and 6.5% other healthcare professionals. Acceptability of the screening programme and opt-out consent was high (90.3% and 77.7%, respectively), with some variation between EDs. Acceptability of opt-out consent was greater among doctors than among other HCWs, and among HCWs who proactively discussed screening further with patients who opted out. However, 50.8% of HCWs felt that patients should be verbally reminded at blood draw, and 44.3% of HCWs wanted more training in discussing opt-out screening with patients. Free-text answers suggested changes to test-ordering systems, including simple integration of tick boxes to document whether patients opted out and to block repeated testing.
Conclusions
There was substantial support from ED HCWs for routine opt-out ED BBV screening, including opt-out consent. Key areas suggested for improvement included changes to test-ordering systems and additional training for HCWs. Frequent preference for verbal reminders at the point of blood draw suggests continued HIV testing exceptionalism.

Improving the Consent Process for Superficial Abscesses Through Pre-printed Consent Forms
Sima Patel, Ceri Gillett
Cureus, 11 November 2024; 16(11)
Abstract
Introduction
Informed consent is essential to ensure that patients are appropriately educated about proposed procedures, including associated risks and potential benefits, to make a valid decision. Incision and drainage of an abscess is a common procedure performed by various healthcare professionals. Inconsistent practices in the consent process can lead to misunderstandings among the patient and have financial and legal complications for both the clinician and the hospital. This study aims to improve the consent process for the incision and drainage of a superficial abscess via the implementation of pre-printed consent forms.
Method
We conducted a retrospective, single-centre study to evaluate existing consent forms, found in patients’ notes, for the incision and drainage of superficial abscesses. The goal was to assess these forms for standardisation, ultimately developing a pre-printed consent form suitable for use by a diverse range of healthcare professionals.
Results
This study revealed significant inconsistencies in consent documentation. While 20 out of 22 (91%) consent forms included infection as a documented risk, only 11 out of 22 (50%) mentioned COVID-19 as a potential risk. The study found that 22 of our 22 (100%) consent forms were documented in black ink. Providing patients with copies of the consent forms can enhance their understanding by allowing them to review the information at home. Eight out of 22 (36%) patients were offered a copy, and 13 out of 22 consent forms (59%) were noted to have abbreviations, both of which may limit understanding and comprehension of the procedure. After implementing a pre-printed consent form, 14 clinicians surveyed (100%) reported that the forms were effective, with 12 out of 14 (86%) indicating they would use these pre-printed forms in their future practice.
Conclusion
The identified variations and inconsistencies in the consent process prompted the creation of a standardised pre-printed consent form. Feedback on this form has been positive, indicating its potential to transform the consent process. The sample size was small, so early results are positive; however, further ongoing work would be required to draw a more definitive conclusion.

Interventions and strategies for enhancing the consent process in neurosurgery. A systematic review of the literature
Review Article
Ashraf Elmahdi, David Smith
British Journal of Neurosurgery, 3 November 2024
Abstract
Background
The informed consent process in neurosurgery aims to support patient autonomy and provide comprehensive information for decision-making. However, gaps in communication and understanding between patients and surgeons persist, that need to be addressed. This systematic review examined the interventions and strategies which to enhance the process of consent in neurosurgery.
Methods
A comprehensive search of databases and relevant sources to identify relevant studies for inclusion. Systematic review of prospective and retrospective studies that assess the effect of interventions which improve the consent process. Data collection and analysis involved independent reviewers assessing eligibility, study quality, and risk of bias. Findings from the included studies were used to write the review.
Main results
The reviewed identified seven studies notably revealed an educational and interactive consent process involving strategies like booklets, videos, multiple interviews, and interactive websites showed improvements in patient knowledge. Recall of risks decreased over time, and factors like age, education, and timing of consent influenced recall.
Authors’ conclusions
To maximise informed consent, neurosurgeons should consider various strategies. Tailoring communication-based on patient’s health literacy and treatment knowledge, involving their support system, and using a bullet-point consent form is essential. Utilising multiple modalities like verbal, static, and dynamic visuals improve information retention. Creative and memorable visual aids enhance comprehension. Allowing time for questions and team approach is superior.