Informed Consent and Shared Decision Making

Yesterday we began the morning by watching a film about Michael Skolnik, a young man who died from the aftermath of an unnecessarily aggressive brain surgery for what was ultimately an incidental imaging finding. This case highlighted several errors in the delivery of his care, but the most obvious was the absence of shared decision making. The Skolnik family was not given a complete picture of the risks of their son’s surgery as well as the alternatives available to them. Following the film we discussed several problems with the existing informed consent process. Many people noted that the current function of informed consent documents is to provide legal protection to the hospital and providers rather than truly inform the patient or obtain their consent in any meaningful sense of the word. Others noted the inherent conflict of interests that underlie the process: when hospitals and proceduralists rely on volume to stay profitable, can they really give an unbiased picture of the risks and benefits to their patients?

One additional consideration I’ve been thinking about are the limits of shared decision making. Even in a perfect world where all conflicts of interest are stripped away and the doctor does everything possible to fully inform and counsel the patient, there are still serious barriers to real understanding and comprehension that form the basis for informed consent. Take the concept of risk, for example. Risk is inherently probabilistic, which is a type of thinking that humans are notoriously bad at. There are all sorts of biases inherent to thinking about bad outcomes, particularly when they are rare or the patient has no point of reference for them. Even taking into account a patient’s preferences and values, how can we help them weigh the easy-to-explain benefits of a procedure against the nebulous list of rare but catastrophic outcomes? As payers shift from volume- to value-based models, unnecessary procedures will hopefully decline in response to economic incentives. I am hopeful that this shift will encourage the field to revisit shared decision making and provide better ways for our patients to fully consider the risks they are facing when they consent to any procedure or treatment.