Page 15 - 2022 Risk Basics - Surgical Practice

SVMIC Risk Basics: Surgical Practice

Most often in cases we reviewed, the only documentation

associated with the consent process was a boilerplate hospital
surgical consent form which did not reflect the details of the

discussion during which surgeons outlined the risks. This

made it difficult for the defense to argue that the particular
surgical complication had been explained to, and was

understood by, the patient prior to the procedure. Remember,
it is the discussion that takes place between the physician and

the patient (or patient’s legal representative) that constitutes

the basis for the consent to be informed. The consent form that
is signed by the patient or representative is merely evidence

memorializing that the discussion took place, and the
patient/representative understood the information discussed.

CASE STUDY

A case in point involved a 62-year-old male with a history
of cervical spine fusion and congestive heart failure who

presented to the emergency room after having a bloody
bowel movement followed by a fainting episode at home.

The emergency room examination found left-lower

quadrant tenderness with guarding, so a GI consult was
obtained, and a colonoscopy was performed. A colon

lesion was identified, and an endoscopic biopsy showed

adenocarcinoma, resulting in the patient’s referral to a
surgeon. The patient was seen in the surgeon’s office by

his advanced practice registered nurse, who provided the
patient with a generic consent form to authorize only that

the surgeon would perform “a procedure”. The patient

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