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CHAPTER 10: INFORMED CONSENT

Informed consent is the process by which the physician communicates relevant and accurate information to the patient and his or her family members prior to carrying out a procedure. It is not a one-way communication, but rather a time where the questions and concerns of the patient and family members can also be addressed.

The neurosurgeon can be expected to obtain informed consent from the patient before proceeding with any form of treatment. During a brain surgery patient’s investigation and treatment process, other procedures that a patient may encounter requiring informed consent include, but are not limited to, cerebral angiography, LP, and placement of an EVD, lumbar drain or CSF shunt. Additionally, the patient or his or her family members may be asked to enroll in a relevant clinical trial or study. This, too, requires informed consent to be obtained.

Informed consent should of course include an honest and candid discussion of the risks and expected benefits of the procedure, and a description of the planned procedure. At the end of this discussion, one should be able to clearly weigh in one’s mind whether the procedure’s benefits outweigh its risks, which is the usual expectation. Another topic that should be discussed in a comprehensive informed consent is any appropriate alternative(s) to the proposed procedure. For example, observation of the lesion versus surgery or, where appropriate, biopsy of a lesion versus an attempt at its complete removal or resection, and so forth. Informed consent should also include mention of a team approach. Assisting the attending surgeon may be a neurosurgeon-in-training, that is, a neurosurgical “Resident”, “Chief Resident” or “Registrar”, or a “Fellow”. Finally, informed consent for neurosurgery should include a question by the doctor regarding the patient’s “advance directives” (AD). That is, does the patient have a Living Will or other written directive that informs the health care team and family members alike regarding the patient’s wishes should he or she at some point become unable to communicate those wishes? The physician should document all of the above, in addition to the procedure he or she has been given permission to carry out, including which side of the head. A final statement regarding the fact that the patient and his or her family members agree to the above and wish to proceed with the discussed procedure should also be documented.

In summary, a comprehensive informed consent includes a discussion of the following elements:

Benefits of the procedure
Risks of the procedure
Overview of the planned procedure
Alternatives to the procedure
Team approach
Advance directives
The anticipated type, side and date of the procedure
The desire to proceed as discussed

Note that there are certain situations where a patient cannot provide informed consent. For example, a minor, not of legal adult age, which is typically 18 years. Here the parents should be able to provide informed consent. Alternatively, a patient may have some form of significant cognitive or mental impairment, that is, he or she may be confused, comatose, demented, or significantly mentally challenged. The hospital facility should have guidelines regarding how to obtain consent in these special circumstances, and regarding how to provide care deemed medically necessary and in the best interests of the patient. In a life-threatening emergency such as a hospital receiving a comatose ruptured aneurysm or herniating patient upon whom medical personnel need to carry out a potentially life-saving procedure but are unable to contact the patient’s family members and have no AD, the best interests of the patient should be the only consideration. In such a circumstance, two or more physicians may fulfill the requirements for emergency consent, and generally proceed to do what they were trained to do: heal the sick and save lives.