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Correspondence |

Informed Nondissent Rather Than Informed AssentResponse FREE TO VIEW

Alexander A. Kon, MD
Author and Funding Information

Affiliations: Pediatrics and Bioethics, University of California at Davis, Sacramento, CA,  Department of Medicine, University of Washington, Seattle WA,  Alexander M. Bickel Professor of Law, Yale University Law School, New Haven, CT

Correspondence to: Alexander A. Kon, MD, Pediatrics and Bioethics, University of California at Davis, 2516 Stockton Blvd, Sacramento, CA 95817; e-mail: aakon@ucdavis.edu



Chest. 2008;133(1):320-321. doi:10.1378/chest.07-2392
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I read with great interest the debate between Dr. Curtis and Professor Burt on one side, and Dr. Manthous on the other, regarding an “informed assent” approach for do-not-resuscitate (DNR) orders in some cases.14 As a pediatric intensivist, I have frequently cared for patients that I believed would not benefit from cardiopulmonary resuscitation (CPR). I have found that many parents agree that CPR would not be appropriate; however, they often express hesitation in bearing the burden of being the ultimate decision maker. This is certainly not always the case, but it does happen often. It has been my practice in such situations to do exactly what Dr. Curtis and Professor Burt advocate, and as a bioethicist I have taught this “method” to many critical care physicians, both pediatric and adult. I believe that such a model allows patients or surrogates to be active members in a shared decision-making process without burdening them with the guilt of “letting their loved-one die.”

I would, however, advocate a slightly different nomenclature. The term assent connotes an active agreement.5Indeed, in pediatrics we have taken the term assent to mean the active affirmation of a minor when he or she lacks the legal authority to provide consent.6 As such, I believe that what Dr. Curtis and Professor Burt are advocating is not assent.

When we provide information to patients or surrogates, and state that we will do “X” unless they object, what we are truly seeking is nondissent. What Dr. Curtis and Professor Burt propose, and what many of us do, is use an “informed nondissent” approach. Under such a model, the clinician makes a decision regarding the DNR status of the patient, and informs the family that unless they object the doctor will write a DNR order.

To be clear, such a system requires all the elements of informed consent with the sole exception of the active agreement of the patient or surrogate. Dr. Curtis, Professor Burt, and Dr. Manthous clearly articulate the necessity for open and clear communication, and the hazards of overestimating patient or surrogate comprehension. As Dr. Curtis and Professor Burt discuss, merely obtaining a signature on a piece of paper or a “yes” response does not ensure that such consent is informed. I myself have witnessed a physician obtain “informed consent” from a family, including having the father sign the consent form, without realizing that the family in fact comprehended only minimal English. The authors rightly explain that any method of shared decision making relies on excellent communication and sufficient comprehension regardless of whether one employs a consent or nondissent model. I do believe, however, that the term assent in such a context confuses the issue.

The author has no conflict of interest to disclose.

The authors have no conflicts of interest to declare.

Curtis, JR, Burt, RA (2007) Point: the ethics of unilateral “do not resuscitate” orders; the role of “informed assent.”Chest132,748-751. [PubMed] [CrossRef]
 
Manthous, CA Counterpoint: is it ethical to order “do not resuscitate” without patient consent?Chest2007;132,751-754. [PubMed]
 
Curtis, JR, Burt, RA Rebuttal from Dr. Curtis [letter].Chest2007;132,754-755
 
Manthous, C Rebuttal from Dr. Manthous [letter].Chest2007;132,755-756
 
Merriam-Webster OnLine. Available at: http://www.m-w.com/. Accessed September 26, 2007.
 
American Academy of Pediatrics, Committee on Bioethics.. Informed consent, parental permission, and assent in pediatric practice.Pediatrics1995;95,314-317. [PubMed]
 
To the Editor:

We appreciate the comments by Dr. Kon, and we agree with him that the clinical practice that he describes seems to be exactly what we recommend in our editorial.1 We also can understand why he might think “nondissent” describes that practice better than “assent” for the reasons he gives. However, we believe that nondissent conveys a more passive conception of the family’s role than we intend. We are trying to describe a subtle but important distinction between a family’s active decision to decide treatment issues and a family’s active decision to defer to physicians’ decision about treatment issues. In both cases, the family is informed and understands that it has a right to take the lead in deciding. To say that the family decides not to “dissent” suggests some expectation that the physicians’ decision has precedence unless the family actively objects. Our view is that the family’s right to decide should take precedence but that the family should be able to exercise that right by deferring to the physician. The virtue of the “informed assent” label is that we believe it more clearly expresses this right.

Having said that, we believe the difference between assent and nondissent is subtle. We prefer assent; but more importantly, we prefer the clinical practice that Dr. Kon describes as opposed to a practice that requires families to provide explicit informed consent and “make the decision” when it is their preference to defer these decisions to the physicians. Therefore, we agree with Dr. Kon on the truly consequential question.

Dr. Rady and colleagues raise an interesting issue about the Uniform Anatomical Gift Act. We do not believe this issue has direct relevance to the concept of informed assent that we promoted in our editorial.1 The new law, as we understand it, restricts the timing of treatment withdrawal regardless of the family’s wishes, whether expressed through the conventional understanding of “informed consent” or through the alternative possibility of “informed assent” that we would propose. However, we believe that it is extremely important that all laws, regulations, and policies governing the care of a potential organ donor should be consistent with and supportive of the highest possible quality of end-of-life care for dying patients and their families. Organ donation is a vitally important endeavor that provides the opportunity to save lives. Nonetheless, this benefit should not be obtained at the expense of high-quality end-of-life care for patients and their families.

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

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References

Curtis, JR, Burt, RA (2007) Point: the ethics of unilateral “do not resuscitate” orders; the role of “informed assent.”Chest132,748-751. [PubMed] [CrossRef]
 
Manthous, CA Counterpoint: is it ethical to order “do not resuscitate” without patient consent?Chest2007;132,751-754. [PubMed]
 
Curtis, JR, Burt, RA Rebuttal from Dr. Curtis [letter].Chest2007;132,754-755
 
Manthous, C Rebuttal from Dr. Manthous [letter].Chest2007;132,755-756
 
Merriam-Webster OnLine. Available at: http://www.m-w.com/. Accessed September 26, 2007.
 
American Academy of Pediatrics, Committee on Bioethics.. Informed consent, parental permission, and assent in pediatric practice.Pediatrics1995;95,314-317. [PubMed]
 
Curtis, JR, Burt, RA Point: the ethics of unilateral “do not resuscitate” orders; the role of “informed assent.”Chest2007;132,748-751. [PubMed] [CrossRef]
 
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