Altering notes

Question 1

You are the IMT1 working on the gastroenterology ward.

One of your registrars has asked you to amend an entry in the notes from yesterday in which you documented the patient’s consent for a ward-based procedure.

You have been asked to add in writing that “the risks of bleeding, infection and damage to local structures were explained to the patient who fully understands this”. At the time, you did not think these risks were fully discussed with the patient.

How would you approach this scenario?

Answer 1

Issues raised - patient’s consent, autonomy, professionalism

Seek information- Clarify exactly what has been said and why your colelague is wanting me to do this (could be that they are anxious about forgoting to document a discussion they genuinely with the pt). It is also possible that the pt came to harm or raised a complaint.

Patient safety
My first concern would be patient safety. In an extreme case, the reg could be performing procedures on capacitous patient without informed consent, which could constitute abuse. They may also generally be unsafe to practice and be trying to cover their tracks after performing an unsafe procedure (major concern for this patient and any others in their care)

Initial measures
Next, I would refuse to alter the notes on behalf of the registrar since this would not constitute good medical practice and could be misleading. I would instead suggest that they write a new entry in the notes stating exactly what was discussed at the time. If they insisted, I would explain why this is not a good medical practice and inform them that I would need to escalate this.

Escalate
Escalating to the consultant responsible for the patient or my clinical supervisor would most likely be necessary in this case regardless of the initial response of the registrar. This would be particularly important if the patient came to harm.

If escalation to their direct supervisor would not be appropriate, I would seek to escalate to the head of the department or clinical director.

Document & Reflect
Finally, I would reflect on this very challenging situation personally. This could be a written reflection or meeting with a senior.

Question 2

How would you escalate or report this situation?

Answer 2

This scenario requires escalation regardless of the initial response of my registrar.

1. Consultant responsible for the patient care or my clinical supervisor
2. If not appropriate, external teams (e.g. educational supervisor or clinical director).
3. Finally, if all fails&raquo_space; GMC

Question 3

How would you define informed consent?

Answer 3

Informed consent is the process where a patient is provided with clear, comprehensive information about the risks, benefits, alternatives, and rationale for a medical procedure or treatment. This enables them to make an informed, voluntary decision to agree or decline the proposed course of action.

Question 4

In what scenarios is written consent usually requierd in hospital medicine?

Answer 4

Written consent is essential for certain procedures (e.g. elective surgery) but may not be for others. Usually we don’t seek written consent for simple procedures like venepuncture or cannulation, but written consent would be necessary for procedures like lumbar puncture, ascitic drain, or chest drains, despite them being bedside tests that happen on a normal medical ward.

It is also not appropriate for junior doctors to take consent for procedures that they are not qualified to carry out make this clear to the interviewers

Question 5

What would you do about written consent if a patient is deemed not to have capacity and a procedure is needed in their best interests?

Answer 5

1. Assess Capacity:
* Can they: Understand, Retain, Weigh up, Communicate?
* Use aids (hearing aids, translators) to support assessment.

2. Consider Regaining Capacity:
* Is regaining capacity possible? Can the procedure wait?

3. Involve Communication Specialists:
* E.g., Speech & Language Therapist if barriers exist.

4. Check Advance Directives:
* Look for documents like RESPECT form, DNAR, or other ceiling of care decisions.

5. If No Capacity & No Advance Directives:
* Act in patient’s best interests.
* Follow hospital-specific consent policies (e.g., Consent Form 4).
* Consult LPA (Lasting Power of Attorney) or next of kin if no LPA exists.

If an LPA for health and welfare exists and is registered, the LPA (e.g., your wife) has legal authority to make treatment decisions, including refusal, if in the patient’s best interests. If no LPA exists, the next of kin can provide input on the patient’s preferences, but the healthcare team has the final responsibility to act in the patient’s best interests.

Question 6

Can you outline how you would communicate the risks and benefits of a diagnostic procedure (such as an ascitic tap) to a patient?

Answer 6

1. Explain the purpose of the procedure
   * Using clear and simple language to explain why the procedure is needed
2. Outline the benefits
   * Describe the potential benefits, focusing on how it could improve clarify their diagnosis and help their care
3. Describe the risks
   * Give a balanced overview of common and serious risks without causing unnecessary alarm
4. Address pain and discomfort
   * Reassure the pt about pain management
5. Use visual aids if helpful
   * E.g. diagrams to help understanding
   6.** Check understanding and address concerns**
   * Encourage the pt to ask questions and clarify any doubts
6. Confirm Consent
   * Ensure the pt understands the information and consents to proceed