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Correspondence |

Informed Assent and Medical EducationResponseResponse FREE TO VIEW

Christopher Dale, MD
Author and Funding Information

Affiliations: Providence Portland Medical Center, Portland, OR,  Yale University Law School, New Haven, CT,  University of Washington, Seattle, WA,  Bridgeport Hospital, Bridgeport, CT

Correspondence to: Christopher Dale, MD, Providence Portland Medical Center, 5050 NE Hoyt, Ste 540, Portland, OR 97219; e-mail: dalecr@gmail.com



Chest. 2008;133(4):1051-1052. doi:10.1378/chest.07-2635
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As someone who graduated from internal medicine residency just several months ago, I wondered as I read the Point-Counterpoint articles12 between Drs. Curtis and Burt and Dr. Manthous if I could apply the principal of “informed assent” to my own practice in the hospital and ICU. As I reflect on my recent medical training I clearly recall, for example, a number of patients with end-stage COPD for whom I thought intubation was futile. Based on my informed consent discussion however, several chose intubation. From this group of severely ill patients who I thought would not be able to be extubated, a few were. A couple of the extubated patients who I thought would not survive to hospital discharge did survive.

I wonder how informed assent fits into medical education, where residents, fellows, and new attendings do not yet necessarily have the perspective and experience to say if an intervention is truly futile or “highly unlikely to result in meaningful survival.”3 Is there a place in informed assent for this uncertainty about futility? Among those with decades of experience, what error rate in prognostication is acceptable?

Additionally, how does one teach and model informed assent given some degree of uncertainty? One can model traditional informed consent, which lends itself well to a frank discussion about risks, benefits, and the unknown. But it would seem that the “knowing” perspective of informed assent and the inexperience of residents and fellows might be irreconcilable.

The author has no conflict of interest to disclose.

The authors have no conflicts of interest to disclose.

The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Curtis, JR, Burt, RA (2007) Point: the ethics of unilateral “do not resuscitate” orders.Chest132,748-751. [PubMed] [CrossRef]
 
Manthous, CA Counterpoint: is it ethical to order “do not resuscitate” without patient consent?Chest2007;132,751-754. [PubMed]
 
American Thoracic Society.. Withholding and withdrawing life-sustaining therapy.Ann Intern Med1991;115,478-485. [PubMed]
 
To the Editor:

Dr. Dale raises two important issues concerning “informed assent”: the difficulties of prognostication, and the importance of teaching and modeling appropriate communication with patients and family members regarding medical decision making. His comments imply that these difficulties are less pronounced in interactions based on “informed consent” than in the application of our concept of informed assent.1 However, although problems of prognostic certainty and of medical training are indeed considerable, these problems are no different for informed consent than for informed assent.

According to both concepts, physicians are obliged to provide full information about the risks and benefits of treatments and convey specific recommendations about the medically proposed course. According to both concepts, moreover, a fully informed patient or family surrogate is always entitled to make an affirmative choice to accept physicians’ recommendations. The crucial difference in our concept of informed assent is that physicians should explicitly inform the patient or family that they are entitled to accept those recommendations. In highlighting this option, physicians convey their willingness to relieve the patient or family of unwanted burdens of making difficult decisions regarding a therapy, especially decisions about withholding or withdrawing a therapy very unlikely to provide benefit.

We believe that physicians should emphasize this option only when they have concluded that the treatment at issue is very unlikely to provide benefit to the patient. If there is a high level of uncertainty about whether the treatment is likely to be beneficial, a physician should be reluctant to offer this option of informed assent. In this circumstance, the physician instead should make clear to the patient or family that there is no clear “medical” justification for deciding one way or the other, but that the risk/benefit calculation depends on value judgments that are unique to each patient. As Dr. Dale suggests, it is often difficult for physicians to distinguish between circumstances of high and low therapeutic uncertainty. But physicians are obliged to assess the level of uncertainty in every case and inform the patient or family surrogate accordingly, whether they are seeking informed consent or highlighting the option of informed assent.

Dr. Dale states that “traditional informed consent lends itself well to a frank discussion about risks, benefits and the unknown.” Our concept of informed assent equally requires that physicians engage in this frank discussion. Perhaps Dr. Dale is concerned that explicitly informing patients or family that they are entitled to defer to physicians’ judgment increases the likelihood that patients or family will mistakenly conclude that they are obliged to defer. It is, of course, easy to respond to this concern by insisting that physicians explicitly inform the patient or family that they are entitled but not obliged to defer. Unfortunately, there is often a profound difference between saying something to a patient and ensuring that the patient understands what is being said. Medical training must equip physicians with skills to facilitate understanding. The risks of misunderstanding and the skills required for physicians to avert misunderstanding are equally important whether the issue with patients and families is informed consent or informed assent. Otherwise, informed consent becomes nothing more than a signature on a piece of paper. The educational challenges are considerable, but the necessary skill sets are no different for the implementation of either concept.

References
Curtis, JR, Burt, RA Point: the ethics of unilateral “do not resuscitate” orders; the role of “informed assent.”Chest2007;132,748-751discussion 55–56. [PubMed] [CrossRef]
 

In this world nothing is certain but death and taxes Benjamin Franklin1

Thanks to Dr. Dale for distilling our debate: “Is there a place in informed assent for this uncertainty about futility?” Drs. Curtis and Burt2 assert that informed assent “should not be offered when clinicians are uncertain about the possibility of success or when the clinicians’ convictions about withholding or withdrawing treatment are based on their value judgments about the patient’s resulting quality of life.” For me, this requisite limits the utility of their construct. Knowledge and experience may increase the likelihood that one’s “certainty” approximates truth. In many cases, I know with near certainty that the withholding/withdrawal of life-prolonging therapies will lead to death. For example, the extubation of a patient with severe ARDS who requires 100% inspired oxygen to breathing room air will almost certainly end with the death of the patient. Some incontrovertible common-sense rules of physiology apply (eg, cells, organs, patients die without sufficient oxygen). However, likely outcomes associated with providing treatments to patients with complex diseases are seldom certain, especially early in the course of treatment. As a trial of therapy proceeds, the patient either does or does not rally. Meanwhile, I learn more about the patient’s predilections regarding invasive medical therapies, and the quality of life and death the patient might find acceptable. Time and the acquisition of more information reduces, but usually does not eliminate, uncertainty (both mine and that of surrogate decision makers). Accordingly, I rarely reach certainty, to practice informed assent rather than informed consent.

I am, however, certain that other clinicians are more certain than I. (I am not sure whether this is a strength or weakness.) I contend that interclinician and intraclinician variability of how we process uncertainty potentially renders arbitrary the Curtis-Burt litmus test for informed assent. Two equally knowledgeable and seasoned clinicians might reach different conclusions (one certain, the other uncertain) based simply on their differing comfort with (and definitions of) certainty. Misapplied informed assent also carries the risk of adding to already-existing health-care disparities.3 Because I am uncomfortable with even modest uncertainty, I most frequently seek informed consent for the withdrawal/withholding of life-sustaining therapies. Perhaps my discomfort with uncertainty unnecessarily “burdens” surrogates while unburdening me. But I agree with Curtis and Burt2 that unilateral decision making, regarding therapies that demarcate life and death, requires certitude. At this juncture of medicine and metaphysics, informed consent insulates the patient’s autonomy from my arrogance and fallibility.4

References
Franklin B. “In this world nothing is certain but death and taxes”: brainy quotes. Available at: http://www.brainyquote.com/ quotes/authors/b/benjamin_franklin.html. Accessed March 5, 2008.
 
Curtis, RJ, Burt, RA Point: the ethics of unilateral “do not resuscitate” orders; the role of “informed assent.”Chest2007;132,748-751. [PubMed] [CrossRef]
 
Satcher, D, Pamies, RJ. Multicultural medicine and health disparities. 2006; McGraw Hill. New York, NY:.
 
Manthous, CA A concussive clinical coincidence.Chest2003;125,1593-1594
 

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References

Curtis, JR, Burt, RA (2007) Point: the ethics of unilateral “do not resuscitate” orders.Chest132,748-751. [PubMed] [CrossRef]
 
Manthous, CA Counterpoint: is it ethical to order “do not resuscitate” without patient consent?Chest2007;132,751-754. [PubMed]
 
American Thoracic Society.. Withholding and withdrawing life-sustaining therapy.Ann Intern Med1991;115,478-485. [PubMed]
 
Curtis, JR, Burt, RA Point: the ethics of unilateral “do not resuscitate” orders; the role of “informed assent.”Chest2007;132,748-751discussion 55–56. [PubMed] [CrossRef]
 
Franklin B. “In this world nothing is certain but death and taxes”: brainy quotes. Available at: http://www.brainyquote.com/ quotes/authors/b/benjamin_franklin.html. Accessed March 5, 2008.
 
Curtis, RJ, Burt, RA Point: the ethics of unilateral “do not resuscitate” orders; the role of “informed assent.”Chest2007;132,748-751. [PubMed] [CrossRef]
 
Satcher, D, Pamies, RJ. Multicultural medicine and health disparities. 2006; McGraw Hill. New York, NY:.
 
Manthous, CA A concussive clinical coincidence.Chest2003;125,1593-1594
 
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