Chapter 01 — Conducting a Surgical Consultation and Obtaining Informed Consent

The first consultation shapes everything that follows. It determines how well the patient understands the plan, how much they trust the team, how closely they follow instructions, and how they later judge the result. It is also where consent begins. Consent is a process of shared decision-making that starts with the first conversation in the outpatient clinic and continues until the patient leaves the hospital. It is not a signature collected shortly before the operation.

1.1 A structure for the consultation

A consistent structure helps the clinician stay organized and helps the patient follow. Figure 1.1 shows the five stages used throughout this book. They are summarized here and described in more detail in the sections that follow.

Prepare. Review the history, examination findings, imaging, and medicine list before the patient enters the room. If the patient does not speak the clinician’s language fluently, book a qualified interpreter in advance.

Open. Ask what the patient already understands and what worries them most (Section 1.2).

Explain. Describe the diagnosis, the proposed operation, the alternatives, and the likely course if no treatment is given (Sections 1.3 and 1.4).

Discuss risks. Cover the common, expected effects of the operation and the uncommon or rare risks that are serious or that matter to this patient (Section 1.5).

Check and document. Confirm understanding with teach-back, invite questions, give written information, allow time to decide, and record the discussion (Sections 1.6 to 1.8).

[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]

Figure 1.1. The five stages of a surgical consultation.

1.2 Opening: let the patient speak first

Patients usually arrive with an agenda of their own: a specific fear, a question rehearsed in the waiting room, or something a relative or a website has told them. In an analysis of recorded clinical encounters, clinicians asked about the patient’s agenda in only about one-third of visits, and when they did, they interrupted after a median of 11 seconds [1]. Concerns that are not raised at the start tend to surface at the end, when there is no time left to address them.

A short, open question at the start takes less than a minute and often changes what the rest of the consultation needs to cover.

Many patients fear something specific: cancer, a stoma, a long scar, time off work, or being unable to fast or pray. Name the fear and say when you will address it: “You mentioned a bag on the tummy. I will come back to that in a moment, because it is important.” A patient who is waiting for the answer to one question rarely hears anything else.

1.3 Explaining in plain language

Patients cannot judge a decision they cannot understand. Plain language is not simplification for its own sake. It means choosing words the patient will recognize and briefly explaining any term that cannot be avoided. Use everyday words, use the same word for the same thing throughout, and state the most important point first. Table 1.1 gives examples.

Table 1.1. Plain-language explanations of common surgical terms.

Explain one topic at a time. Give a small amount of information, check that it has been understood, and then move on; this is sometimes called “chunk and check.” Pause after important or upsetting information, and let the patient’s next question guide you. A simple sketch of the anatomy and the planned incisions is often worth several minutes of description, and the patient can take it home.

Analogies are useful if they are accurate. Describing the gallbladder as a small storage pouch beside the liver, for example, helps patients understand why it can be removed without stopping the production of bile. Check that an analogy does not create a false belief, such as the idea that a removed organ will “grow back.”

1.4 Informed consent as shared decision-making

Valid consent requires that the patient has capacity, is given adequate information, and decides voluntarily. The standard for what counts as adequate information has moved from what a responsible body of doctors would disclose to what the patient would want to know. In Montgomery v Lanarkshire Health Board (2015), the UK Supreme Court held that a doctor must take reasonable care to ensure that the patient is aware of any material risks of the recommended treatment and of any reasonable alternatives. A risk is material if a reasonable person in the patient’s position would be likely to attach significance to it, or if the doctor is, or should reasonably be, aware that this particular patient would do so [2]. Professional guidance in the United Kingdom reflects this approach [3].

Shared decision-making turns this legal standard into a conversation. One practical model describes three steps (Figure 1.2): team talk, in which the clinician makes clear that there is a choice to be made together; option talk, in which the options, including doing nothing, are compared; and decision talk, in which the patient’s preferences are explored and a decision is reached [6].

[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]

Figure 1.2. Shared decision-making in three steps, adapted from the three-talk model.

In practice, a consent discussion should cover:

• The diagnosis, and the nature and purpose of the proposed operation, including what it is expected to achieve.

• Reasonable alternatives, including non-operative treatment, and the likely course if nothing is done.

• Common and expected effects, including pain, scarring, and the length of recovery.

• Uncommon or rare risks that are serious, or that would matter particularly to this patient.

• What will happen if the operation cannot be completed as planned, for example conversion from keyhole to open surgery or the need for a stoma.

• Who will perform the operation, including the involvement of trainees under supervision [3].

• Any additional procedures that may become necessary during the operation, and any that the patient does not want carried out without further discussion.

“This patient” is the key phrase. A thyroid operation carries a small risk of voice change. For most patients this is a rare complication, but for a teacher, a singer, or an imam who relies on their voice it may be decisive. A hernia repair in a manual worker needs a frank discussion of time off work. The same operation requires different disclosure for different patients, so ask about occupation, hobbies, and priorities before deciding what to emphasize.

1.5 Communicating risk

Patients and clinicians interpret words such as “rare” and “small risk” very differently. Numbers expressed as natural frequencies (“3 out of 100 patients”) are easier to understand than percentages or relative risks, and they let the patient picture both those who are affected and those who are not [7]. Use the same denominator when comparing risks, and give absolute figures rather than relative ones. A simple icon array, a grid of 100 figures with the affected ones shaded, helps patients who find numbers difficult.

This book groups material risks into three bands to keep consent checklists consistent (Table 1.2). The bands are a teaching convention. They do not replace the formal frequency categories used in medicine information leaflets.

Table 1.2. Risk bands used in the consent checklists of this book. The figures are illustrative only.

Wherever possible, quote figures from your own unit’s audit data or from current published series, and state the source if asked. The example numbers in Table 1.2 must not be used as real data. Present both sides: tell the patient how many will do well as well as how many will have a complication (“97 out of 100 have no wound problem; about 3 develop an infection”), and describe the expected benefits of the operation with the same care as the risks.

1.6 Checking understanding: teach-back

Teach-back checks whether the clinician has explained something clearly; it does not test the patient. The patient is asked to describe the plan in their own words. If the account is incomplete or wrong, the clinician explains again in a different way and checks again (Figure 1.3). In a study of patients with diabetes and limited health literacy, those whose physicians used this “closing the loop” approach were more likely to have good blood glucose control [8].

[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]

Figure 1.3. The teach-back cycle.

The way the request is phrased matters. It should make clear that the clinician is checking their own explanation. Limit teach-back to the two or three things the patient must remember, such as the operation planned, the most important preparation instruction, and the warning signs that need urgent help. Testing every detail turns the method into an examination.

Nurses can use the same method when teaching wound care, medicine schedules, or stoma care. For practical skills, ask the patient to demonstrate the skill, not only to describe it.

1.7 Inviting and answering questions

Questions are not interruptions. They show the clinician what the patient has understood, what they fear, and what will decide whether they go ahead. Invite them early and more than once, and phrase the invitation so that questions are expected: “What questions do you have so far?” works better than “Any questions?”, which invites the answer “No.”

Some patients find it hard to ask. A short list of suggested questions, given in the waiting area or sent with the appointment letter, helps them prepare. Question prompt lists increase the number of questions patients ask, usually without a substantial increase in consultation length [9]. In a trial using simulated patients, asking three questions (What are my options? What are the possible benefits and harms of those options? How likely are these to happen to me?) led doctors to give more information about options, benefits, and harms, and to involve the patient more in the decision [10]. Appendix B contains a prompt list that can be copied for patients.

Some questions are difficult because they touch on fear, on the surgeon’s own experience, or on trust. They deserve calm, direct answers. Table 1.3 suggests an approach to the questions surgeons find hardest; the figures in square brackets must be replaced with real data.

Table 1.3. Answering difficult questions: suggested approach and example words.

When the answer is bad news, for example a malignant result at follow-up, use a structured approach such as SPIKES: prepare the setting, find out what the patient already knows, ask how much they want to know, give the information in small pieces, respond to the patient’s emotion, and agree a plan and the next contact [11]. Book enough time, offer to include a family member, and do not give such news by telephone unless the patient has asked for it.

1.8 Documenting the discussion

A consent form records that a discussion took place. It does not replace the discussion. Clinical notes should show what was actually said, so that another clinician can see what the patient was told and how they responded. Table 1.4 lists what to record.

Table 1.4. What to record after a consent discussion.

1.9 Family, interpreters, and cultural context

In many communities, relatives attend consultations and take part in decisions. This can be a real support to the patient, but it carries the risk that the patient’s own wishes are not heard. Ask the patient, preferably before the family comes in, whom they would like to involve and how much they want shared with others. Where the law requires the patient’s own consent, confirm it with the patient directly.

Family members should not act as interpreters for consent discussions. They may omit or soften information, and the patient may not feel free to ask questions. Use a qualified interpreter or a bilingual clinician with appropriate language competence, and record who interpreted.

Respect for patient preferences includes requests for a chaperone or an examiner of the same sex, and questions about fasting, prayer, modesty, and travel around the operation. These are not side issues. They affect whether the patient can follow the plan, and they are best addressed during the consultation; the timing of elective surgery around Ramadan, for example, should be agreed in clinic, not discovered on the day. Avoid assumptions based on religion or nationality, and ask instead.

1.10 Capacity, time, and special situations

• Capacity. A patient has capacity if they can understand the relevant information, retain it long enough to decide, weigh it, and communicate a choice. Capacity is specific to the decision and to the time. If it is in doubt, assess it and document the assessment.

• Children and young people. Consent is normally given by a parent or guardian, but the child should be involved in the discussion and asked for their agreement at a level suited to their age (see Chapter 25).

• Emergencies. When the patient cannot consent and treatment cannot wait, act in the patient’s best interests, follow local law and policy, and document the reasons.

• Time to decide. For elective operations, give written information in advance and allow time to consider it. Consent for a major elective operation should be discussed in clinic and confirmed, not first obtained, on the day of surgery.

• Withdrawing consent. Tell the patient that they may change their mind at any point, including on the day of surgery.

1.11 Common pitfalls

• Treating the signature on the form as a substitute for the conversation.

• Listing every possible risk without saying which matter most. Too much information is as unhelpful as too little.

• Asking “Any questions?” only at the end of a long explanation, instead of inviting questions early and more than once.

• Using jargon or abbreviations, and then repeating the same words when they were not understood.

• Leaving out non-operative treatment, even when it is not the recommended option.

• Delegating the consent discussion to someone who cannot answer the patient’s questions about the operation.

• Assuming what a patient wants because of their age, religion, or nationality, instead of asking.