| 2010-11-18 18:49:47 |
Marty Polovich |
Welcome to the ONS Hot Topics Chat. |
| 2010-11-18 18:59:44 |
Stephanie@ons. |
Welcome to the ONS Hot Topics chat. Tonight we will be discussing treatment consents with Marty Polovich. Please feel free to ask your questions to Marty. Welcome! |
| 2010-11-18 19:00:03 |
Marty Polovich |
Good evening, and welcome to the ONS Hot Topics Chat |
| 2010-11-18 19:00:14 |
Marty Polovich |
This is Marty Polovich |
| 2010-11-18 19:00:25 |
Marty Polovich |
I will facilitate the discussion |
| 2010-11-18 19:00:37 |
Marty Polovich |
I hope that you will participate |
| 2010-11-18 19:00:58 |
Marty Polovich |
Informed consent is most often considered a legal issue |
| 2010-11-18 19:01:12 |
Marty Polovich |
It is also a patients rights and ethical issue |
| 2010-11-18 19:01:32 |
Marty Polovich |
Let me stress that there is often a difference between legal and ethical issues |
| 2010-11-18 19:01:54 |
Marty Polovich |
Just because something is legal doesn't make it ethically right, and vice versa |
| 2010-11-18 19:02:24 |
Marty Polovich |
Because chemotherapy is given for the treatment of potentially life-threatening illness, it's both |
| 2010-11-18 19:03:00 |
Marty Polovich |
Not all settings where chemotherapy is given require a separate consent for chemo |
| 2010-11-18 19:03:12 |
Marty Polovich |
Does your setting have a chemo consent? |
| 2010-11-18 19:03:25 |
Madelinekilby |
we do |
| 2010-11-18 19:04:20 |
Marty Polovich |
OK, many states do not require a separate chemo consent |
| 2010-11-18 19:04:59 |
Mosera |
We have separate consents, as well. We are in the process of redesigning both. Other than the ASCO sample Consent to Chemotherapy and Chemotherapy Consent Use and Discussion Guide, do you have any other literary resources you recommend? |
| 2010-11-18 19:05:00 |
Marty Polovich |
But ONS and ASCO standards indicate that a consent is a requirement for best practice |
| 2010-11-18 19:05:29 |
Marty Polovich |
Those that you mention are some of the best that are "out there" |
| 2010-11-18 19:05:58 |
Marty Polovich |
The Chemotherapy SIG virtual community also has some sample consents |
| 2010-11-18 19:06:21 |
Mosera |
Excellent! I'll look into that. Thank you! |
| 2010-11-18 19:06:33 |
Marty Polovich |
It is important to consult with your Risk Management dept or legal dept. when designing consents |
| 2010-11-18 19:06:46 |
Marty Polovich |
They have to be on board before you implement |
| 2010-11-18 19:07:29 |
Mosera |
I agree. |
| 2010-11-18 19:07:55 |
Marty Polovich |
Lets' talk about what should be in a consent for chemotherapy |
| 2010-11-18 19:08:17 |
Marty Polovich |
First of all, it should say more than "consent for chemotherapy." |
| 2010-11-18 19:08:34 |
Marty Polovich |
I've seen consents that are not very specific |
| 2010-11-18 19:08:42 |
Stephanie@ons. |
Welcome to the chat dcafran! |
| 2010-11-18 19:09:21 |
Marty Polovich |
That is really not helpful to patients and provides no documentation of consent |
| 2010-11-18 19:09:39 |
Marty Polovich |
Informed consent is really two activities |
| 2010-11-18 19:09:55 |
Stephanie@ons. |
Welcome nursg! We are discussing chemotherapy consents. |
| 2010-11-18 19:09:59 |
Marty Polovich |
need to comprehend the treatment plan that’s the informed part |
| 2010-11-18 19:10:17 |
nursg |
Do you get a different consent each time the agents change? |
| 2010-11-18 19:10:45 |
Marty Polovich |
That is the best way to do it--because the patients need to discuss the risks of treatment |
| 2010-11-18 19:10:56 |
Marty Polovich |
If that treatment changes, so do the potential risks |
| 2010-11-18 19:11:15 |
Marty Polovich |
Patients need to indicate that they agree voluntarily to undergo treatment |
| 2010-11-18 19:11:37 |
Marty Polovich |
If that treatment changes, their agreement should also be re-addressed |
| 2010-11-18 19:11:44 |
Marty Polovich |
That's the "consent" part |
| 2010-11-18 19:12:19 |
Marty Polovich |
People can make informed decisions only if they understand information that will affect their decision |
| 2010-11-18 19:12:32 |
nursg |
Our consent is long and states that the treatment may or may not work etc. and the patient does not get a copy and most do not read the three paragraphs. All pts get pt education for each agent prior to treatment. |
| 2010-11-18 19:13:01 |
Marty Polovich |
Consents for chemo are necessarily long |
| 2010-11-18 19:13:14 |
Marty Polovich |
There is a lot to document |
| 2010-11-18 19:13:32 |
Marty Polovich |
The education is an essential part of the consent process. |
| 2010-11-18 19:13:37 |
nursg |
Does ONS have a template form that can be used? |
| 2010-11-18 19:14:04 |
Marty Polovich |
ONS does not have a consent template, but ASCO does on their website |
| 2010-11-18 19:14:28 |
nursg |
I have seen that one. |
| 2010-11-18 19:14:53 |
Marty Polovich |
I like the ASCO template because there is also a discussion guide |
| 2010-11-18 19:15:57 |
Marty Polovich |
Not all information about treatment needs to be in the consent, but that information that may affect a patient's decision to undergo treatment |
| 2010-11-18 19:16:12 |
nursg |
Would it stand up in court? |
| 2010-11-18 19:16:51 |
Marty Polovich |
Actually, any consent can be "broken" in court |
| 2010-11-18 19:17:07 |
Marty Polovich |
The process is the most important thing |
| 2010-11-18 19:17:13 |
nursg |
One more question - there is a place for witness on our form, should it be a family member or a nursing staff along with the physician's signature? |
| 2010-11-18 19:17:58 |
Marty Polovich |
A witness can be anyone, but an employee (nurse) is better than a family member. |
| 2010-11-18 19:18:08 |
Marty Polovich |
The physician should also sign |
| 2010-11-18 19:18:15 |
Marty Polovich |
They are responsible ultimately |
| 2010-11-18 19:19:08 |
Marty Polovich |
Risks, benefits, alternatives and voluntariness are the main elements of consent |
| 2010-11-18 19:19:30 |
Marty Polovich |
The hard part with cancer treatment is the uncertainty |
| 2010-11-18 19:19:41 |
Marty Polovich |
Often treatment does not work |
| 2010-11-18 19:19:55 |
Marty Polovich |
Or the side effects vary a lot from patient to patients |
| 2010-11-18 19:20:20 |
Marty Polovich |
And patients have a hard time understanding the medical jargon that we often use |
| 2010-11-18 19:21:11 |
nursg |
Our physician talks to the patient about the chemo and side effects, we then give written material and give the patient a chance to ask questions, then sign the consent for treatment. These are questions I have had for along time and you have answered them. Thank you. |
| 2010-11-18 19:21:39 |
mosera |
Regarding the witnesses, we wonder if we should have at least one witness be a non-employee, in case someone feels that all the witnesses (e.g., nurse and physician) have an conflict of interest. What are your thoughts? |
| 2010-11-18 19:21:41 |
Marty Polovich |
Patients also must be told if the treatment is time-sensitive and the consequences of not undergoing treatment |
| 2010-11-18 19:21:59 |
Marty Polovich |
Re witnesses |
| 2010-11-18 19:22:13 |
Marty Polovich |
The organization should decide who is an appropriate witness |
| 2010-11-18 19:22:31 |
Marty Polovich |
But it's often seen as a witness to the signature ONLY , not the consent |
| 2010-11-18 19:22:49 |
Marty Polovich |
And a written form is not always done |
| 2010-11-18 19:23:14 |
Marty Polovich |
The process is most important--the discussion where the patient is informed, and that the patient agrees to treatment |
| 2010-11-18 19:23:28 |
Marty Polovich |
That can be documented in a physician dictated note |
| 2010-11-18 19:23:44 |
Marty Polovich |
But, it must include all of the required elements |
| 2010-11-18 19:23:59 |
Marty Polovich |
We developed a dictation template for chemo consent |
| 2010-11-18 19:24:18 |
Marty Polovich |
When the MD dictates the discussion, it helps them remember to include all the info |
| 2010-11-18 19:25:09 |
Marty Polovich |
The Joint Commission lists the elements of consent in their chapter on patients rights |
| 2010-11-18 19:25:47 |
Marty Polovich |
We audited charts in our practice for compliance and found that some did really well, and others did not |
| 2010-11-18 19:26:06 |
Marty Polovich |
The sites that had a written consent did the best—consistency |
| 2010-11-18 19:26:48 |
Marty Polovich |
You also have to consider the literacy of the patients and aim for low reading level |
| 2010-11-18 19:27:06 |
Marty Polovich |
Standard approaches require fairly high literacy |
| 2010-11-18 19:27:21 |
Marty Polovich |
Written consent forms are usually quite difficult to understand by the non-healthcare professional.. |
| 2010-11-18 19:28:05 |
Marty Polovich |
They satisfy the legal requirement for consent, |
| 2010-11-18 19:28:21 |
Marty Polovich |
they are rarely helpful in explaining the planned treatment or encouraging questions |
| 2010-11-18 19:28:39 |
Marty Polovich |
Invite patients to be actively involved in the process |
| 2010-11-18 19:28:48 |
mosera |
Do you feel the consent form should address the impact of missed treatments (alluding to no-shows)? I ask because so few of our patients really understand that they may be compromising their outcome if they don't receive treatment due to the fact that they "didn't feel like coming in" several times. |
| 2010-11-18 19:29:38 |
Marty Polovich |
I think it is very important to include that information in the discussion. It is difficult to put that into language in a form |
| 2010-11-18 19:30:16 |
Marty Polovich |
We're aiming for understanding--and that needs a lot of explanation |
| 2010-11-18 19:30:30 |
dcafran@optonline.net |
Should specific side effects be listed or should a consent simply state that written information was given regarding potential side effects? |
| 2010-11-18 19:31:03 |
Marty Polovich |
If you have a consent form, it should include specific side effects of treatment |
| 2010-11-18 19:31:19 |
Marty Polovich |
Many people have patients sign an education ofrm |
| 2010-11-18 19:31:21 |
Marty Polovich |
form |
| 2010-11-18 19:31:25 |
Marty Polovich |
That's different |
| 2010-11-18 19:32:23 |
Marty Polovich |
That may be appropriate, depending on your setting. If the MD dictates consent, for instance |
| 2010-11-18 19:32:57 |
Marty Polovich |
I had a patient with an extravasation injury who said he would not have agreed to treatment if he knew that could happen |
| 2010-11-18 19:33:23 |
Marty Polovich |
He had teaching about vesicant extravasation, but it was not documented |
| 2010-11-18 19:33:35 |
dcafran@optonline.net |
I can understand that with a vesicant, however if we listed every possible side effect consent would be pages long. |
| 2010-11-18 19:34:01 |
Marty Polovich |
So any consent can be problematic "legally" |
| 2010-11-18 19:34:26 |
dcafran@optonline.net |
So if it was documented that education was given regarding extravasation that would suffice? |
| 2010-11-18 19:35:00 |
Marty Polovich |
In part. |
| 2010-11-18 19:35:21 |
Marty Polovich |
You need to decide what is right for your facility and patients |
| 2010-11-18 19:35:40 |
Marty Polovich |
There should be documentation somewhere about what the treatment IS |
| 2010-11-18 19:35:47 |
Marty Polovich |
The main risks (side effects) |
| 2010-11-18 19:35:55 |
Marty Polovich |
And that the patient agrees |
| 2010-11-18 19:36:08 |
Marty Polovich |
The level of detail varies a lot, |
| 2010-11-18 19:36:36 |
Marty Polovich |
I've seen statements like "The side effects of treatment have been explained to me" |
| 2010-11-18 19:37:28 |
dcafran@optonline.net |
Would you consider it acceptable to given written info using a web site like chemocare as I find it uses lay terms for easy understanding. And I will highlight key elements. |
| 2010-11-18 19:37:52 |
Marty Polovich |
A little more detail might be helpful, but the process is most important--that the patient indicates understanding and has had an opportunity to have questions answered |
| 2010-11-18 19:38:11 |
Marty Polovich |
Chemocare is great for teaching |
| 2010-11-18 19:38:32 |
Marty Polovich |
It provides information about treatment in very patient-friendly language |
| 2010-11-18 19:38:51 |
Marty Polovich |
Teaching is important when obtaining consent |
| 2010-11-18 19:39:41 |
Marty Polovich |
But the consent process is bigger than that--patient has to indicate agreeing to treatment |
| 2010-11-18 19:39:58 |
Marty Polovich |
That should be documented somewhere in the record. |
| 2010-11-18 19:40:25 |
Marty Polovich |
Don’t' forget that research REQUIRES a signed consent form |
| 2010-11-18 19:40:50 |
Marty Polovich |
Nurses play a big role in consent |
| 2010-11-18 19:41:15 |
Marty Polovich |
Advocating for patients and their families |
| 2010-11-18 19:41:26 |
Marty Polovich |
Experienced oncology nurses know how to do that |
| 2010-11-18 19:41:42 |
Marty Polovich |
Nurses work with patients receiving cancer treatment daily |
| 2010-11-18 19:42:16 |
Marty Polovich |
Our experience is helpful in providing education and information that can help patients make decisions about their care |
| 2010-11-18 19:42:45 |
Marty Polovich |
Nurses can also recognize situations where patients have unrealistic expectations about care |
| 2010-11-18 19:42:57 |
dcafran@optonline.net |
Presently, our small hospital uses a pre-op check-list as a consent form and it needs to change...that's my goal here. |
| 2010-11-18 19:43:29 |
Marty Polovich |
A pre-op checklist is quite different from pre-chemo |
| 2010-11-18 19:44:17 |
dcafran@optonline.net |
Agreed...We do have a particular oncologist who would give a pt chemo in their casket if they consented to it. That's when we've advocated many times...there was no benefit for the pt. |
| 2010-11-18 19:44:47 |
Marty Polovich |
That's a difficult situation |
| 2010-11-18 19:45:13 |
Marty Polovich |
Only the patient can determine if a benefit is important enough to undergo treatment |
| 2010-11-18 19:45:13 |
dcafran@optonline.net |
He just has a difficult time giving up sometimes and has accused us of giving up too quickly. |
| 2010-11-18 19:45:30 |
Marty Polovich |
A lot of that has to do with how the treatment is explained to a patient |
| 2010-11-18 19:45:49 |
Marty Polovich |
"This will help" is not good enough |
| 2010-11-18 19:46:18 |
Marty Polovich |
How the nurse is involve In the informed consent process: |
| 2010-11-18 19:46:32 |
Marty Polovich |
Observe and document the informed consent process |
| 2010-11-18 19:46:43 |
Marty Polovich |
Provide informed consent document (if there is one) |
| 2010-11-18 19:46:53 |
Marty Polovich |
Provide time for the patient to read the form |
| 2010-11-18 19:47:05 |
Marty Polovich |
Assess the patient’s understanding of the consent document |
| 2010-11-18 19:47:12 |
dcafran@optonline.net |
Would you recommend that the MD has signed consent before starting chemo or it is OK for that to wait? |
| 2010-11-18 19:47:15 |
Marty Polovich |
Clarify information |
| 2010-11-18 19:47:33 |
Marty Polovich |
Notify the MD if a patient has questions about the treatment |
| 2010-11-18 19:47:46 |
Marty Polovich |
Explain procedures and provide education as needed |
| 2010-11-18 19:48:16 |
Marty Polovich |
Some nurses obtain verbal assent before each treatment |
| 2010-11-18 19:48:37 |
Marty Polovich |
Others figure if the patient "shows up" they consent |
| 2010-11-18 19:48:43 |
mosera |
I have the same question as dcafran. Is it okay to have the physician sign the consent after treatment has started, even on a different day than treatment started? |
| 2010-11-18 19:48:53 |
dcafran@optonline.net |
So a written consent is not even needed? Or is that by institution? |
| 2010-11-18 19:49:15 |
Marty Polovich |
States vary in the legal requirement for chemo consents. |
| 2010-11-18 19:49:30 |
Marty Polovich |
Some may use a "consent for treatment" |
| 2010-11-18 19:49:52 |
Marty Polovich |
Others may document consent in the record in progress notes |
| 2010-11-18 19:49:59 |
dcafran@optonline.net |
Where might we find legal requirements specific to our state? |
| 2010-11-18 19:50:16 |
Marty Polovich |
Ask your legal department or Risk Manager |
| 2010-11-18 19:50:36 |
Marty Polovich |
Chemo is usually seen differently from surgery |
| 2010-11-18 19:51:41 |
Marty Polovich |
We have an ethical responsibility to make sure patients consent to treatment |
| 2010-11-18 19:51:52 |
dcafran@optonline.net |
I'm sorry, I was called away before. Where did you say there was a consent template? |
| 2010-11-18 19:52:12 |
Marty Polovich |
ASCO website, ONS chemo virtual community |
| 2010-11-18 19:52:38 |
Marty Polovich |
I posted a dictation template on the Chemo discussion page, too |
| 2010-11-18 19:53:02 |
Stephanie@ons. |
What other questions might you have for Marty as our time is coming to a close? |
| 2010-11-18 19:54:09 |
Marty Polovich |
If you have a "good" consent, consider sharing on the Chemo discussion |
| 2010-11-18 19:54:32 |
dcafran@optonline.net |
Will do...thanks for the info! |
| 2010-11-18 19:55:02 |
madeliekilby |
thank you |
| 2010-11-18 19:55:14 |
Marty Polovich |
Your welcome, and good night! |
| 2010-11-18 19:55:18 |
mosera |
Thank you, Marty! |
| 2010-11-18 19:55:24 |
Stephanie@ons. |
The transcript for the chat will be posted on the ONS website within the next few days. |
| 2010-11-18 19:55:34 |
Stephanie@ons. |
Thank you all for joining us. |