Getting the message across

Many patients struggle to understand even basic information - so how can you be sure they have given informed consent?

AFTER years of training, it is no surprise that doctors will often use medical jargon, common clinical expressions and instructions in their everyday working life. So much so that it can be easy to forget the difficulty many patients experience in understanding exactly what their doctor is telling them – even at a basic level.

This mismatch in communication raises serious implications for doctors who rely on patient understanding to obtain informed consent for proposed treatments and procedures.

The notion of shared decision-making between doctor and patient has become central to modern medical practice, but this so-called low “health literacy” presents a major barrier. The term has been coined to describe “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”

Research carried out in 2012 by London South Bank University found a startling 43 per cent of people aged 16 to 65 in England are unable to “eff ectively understand and use” basic health information. The figure rose to 61 per cent when the information also required maths skills.

A quick search of MDDUS case fi les throws up dozens of examples of how a lack of valid informed consent factors in clinical negligence claims. Often, a complaint is made by a patient who had failed to grasp the potential risks of a particular procedure which has then resulted in a poor outcome. It is not uncommon for patients in such cases to comment that, had they fully understood the implications of the proposed treatment, they would not have agreed to it.

Complicating matters is the fact that many doctors may not be aware when a patient does not understand what is being explained to them.

Low health literacy is not just a problem for patients with limited education or reading ability but can also be found in individuals who may be highly literate in other areas but have diffi culty understanding medical terminology and jargon. Patients may be embarrassed to admit their lack of understanding and sometimes matters can be further complicated by anxiety or confusion associated with pain or drug treatments.

Struggling patients may feel it is impolite to question their doctor or ask for more information.

The RCGP published a report in June 2014, Health Literacy, which suggests “many people engaging both across primary and secondary care may simply not have the assumed levels of healthcare literacy that empowers them to manage their conditions.”

It cites research suggesting that “patients typically retain around half of the information they receive in a consultation, and only half of what they do retain is generally correct.”

The report goes on to acknowledge the implications on the consenting process, saying: “Low health literacy is a barrier to participating in shared decision-making. This includes the process of informed consent for medical and surgical procedures.

“Patients must be given enough time and understandable information to fully appreciate the implications of their consent.” The report emphasises the importance of good communication skills and for doctors to “tailor information to patient skills as well as clinical need.”

General Medical Council (GMC) guidance echoes the RCGP advice by encouraging doctors to share information in a way the patient can make sense of, using written materials, visual or other aids where necessary. The regulator states: “Before accepting a patient’s consent, you must consider whether they have been given the information they want or need, and how well they understand the details and implications of what is proposed. This is more important than how their consent is expressed or recorded.”

The RCGP says GPs are ideally placed to work with patients and patient advocates to identify barriers in the system and create solutions to assist those with low health literacy. They recommend a “universal precautions” approach to communication by speaking clearly and avoiding jargon with all patients rather than only when health literacy is obviously low.

Joanne Curran is an associate editor of GPST

 

Below are some useful points to consider to help ensure patients give informed, valid consent:

  • Make no assumptions about what a patient may want or need to know.
  • Use clear, simple and consistent language when discussing risks with patients.
  • Speak slowly and avoid complex terminology or medical jargon.
  • Use common analogies – e.g. a patient might better understand a joint problem if compared with a hinge.
  • Just because a patient is being agreeable do not assume he or she understands what you are explaining or shares your perception of that information.
  • Ask patients to put the information in their own words to check comprehension.
  • Consider using patient information leafl ets, advocacy services, expert patient programmes or support groups for people with specifi c conditions but do not assume patients will have read a hand-out or information sheet.
  • Go over hand-outs or other written aids with the patient and circle important points.
  • Involve other healthcare staff who may have more time, experience and resources to inform the patient.
  • Try to foster an open atmosphere where questions are welcome.
  • Remember that too much information can be as unhelpful as too little.
  • Remember that a patient’s ability to process and retain information can be aff ected by factors such as anxiety, pain or the eff ects of clinical medication.
  • Be mindful of questions of capacity in seeking patient consent.