Informed consent is more than a box ticking exercise – it is a necessity that takes time, consideration and skill to be achieved properly
For any person-centred care system to be effective, both service users and healthcare professionals must take an active role in decision making.
Medical paternalism can have catastrophic implications – as shown earlier this year, by the unanimous decision handed down by the Supreme Court in the Montgomery v Lanarkshire Health Board case, which resulted in new case law on patient consent, and the plaintiff receiving £5.25 million in compensation.
While the case was by no means the first time the principles of person-centred care had been violated, its nature and the events that followed it serve as an important learning resource for healthcare professionals at all levels: to understand the consequences of not acknowledging or adhering to the principles of person-centred care.
In brief: Nadine Montgomery, a diabetic mother, who gave birth by vaginal delivery, experienced a complicated labour which was caused by shoulder dystocia (when the baby’s head has been born, but one of their shoulders becomes stuck). Resulting in her son experiencing oxygen deprivation, and consequently being born with Cerebral Palsy. Shoulder dystocia is acknowledged as having a risk of 9-10% in diabetic mothers – particularly those of small stature – however, the mother involved had argued that she had not been told of the significant risks surrounding her son’s birth, and the implications of having a natural birth, versus a caesarean. As a result of her appeal against Bellshill Maternity Hospital, Lanarkshire, and the subsequent judgement, Mrs Montgomery received significant compensation. Both the case and its impact have come to be seen as a healthcare milestone and a potential turning point in the physician-patient relationship.
Following the judgement, doctors must now ensure that patients are aware of the “material risks” involved in any proposed treatment, and of reasonable alternatives. Previously doctors followed the “Bolam test”, which asked whether a doctor’s conduct would be supported by a responsible body or medical opinion. Though that test will still apply to other areas of medical negligence, it will no longer do so for the issue of consent.
Within the Montgomery judgement no less than five key person-centred care principles were violated – patient information, choice and respect for patient values, safety, involvement and communication – showing both the role each plays in the care process and how they work in unison. The high profile nature of the judgement, and consequent events, put the issue of decision making and service user autonomy, firmly under the spotlight and into the consciousness of healthcare professionals at all levels.
But how are we going to embed good practice around consent more firmly in our healthcare system? According to this week’s 2015 NHS National Maternity Survey findings, only 72% of women responded that they felt they were “always” involved enough in decision about their care, during labour and birth – down 7% on 2013 results. This result shows that in maternity care specifically, involvement and decision making remain an area in need of urgent improvement.
As outlined in the judgement itself, service user consent amounts to much more than a signature at the end of a promptly filed form, and actually takes a lot of time, consideration and skill to be done properly. Getting it right starts with acknowledging that person-centred care is the only way to effectively provide quality treatment, and subsequently taking responsibility for providing it, by building and driving a culture that enables it.
Like anything viewed with hindsight, learning from and changing behaviours based on past events and experiences allows a tragedy to become an opportunity and for a negative situation to have a positive outcome. If used and understood in the right way, Nadine Montgomery experiencing such a preventable tragedy could result in other expectant mothers never having to.
We will all at one time or another be healthcare patients or the friends and family of people who are, and when that time comes we will all trust our physicians to inform, communicate with and take care of us during that time. But for many people, including Nadine Montgomery and apparently some maternity service users, it’s a confidence that is not always met at present.