CLINICAL RISK REDUCTION
One key passage in GMC guidance regarding informed patient consent states: “You must tell patients if an investigation or treatment might result in a serious adverse outcome, even if the likelihood is very small. You should also tell patients about less serious side-effects or complications if they occur frequently, and explain what the patient should do if they experience any of them.”
Stick men and smiley faces Communicating risk to patients can be problematic at the best of times. Just as the MMR vaccine example above demonstrates, decision-making among patients is not always “rational”. Research has shown that people oſten use shortcuts to simplify decision-making and risk, such as categorising something as either “dangerous” or “safe.” One commonly cited example comes from the mid-1990s when the press publicised results of a study reporting a 100 per cent increase in the risk of thromboembolism in women using a particular contraceptive. Te actual risk was still slight but thousands of British women panicked and stopped taking the pill leading to an increase in unwanted pregnancies.
Most doctors and dentists understand risk according to basic concepts such as relative risk (RR) or absolute risk reduction (ARR) or number needed to treat or harm (NNT or NNH). But many patients will grow frustrated or simply ‘turn off’ if a discussion aimed at joint decision-making becomes a lecture in statistics. Nor can risk be treated in too simplistic a fashion. Descriptive terms such as ‘common’ or ‘rare’ assume a shared perspective when in fact patients may judge risk by a different order of magnitude. One study looking at the probabilities of harm and benefit from treatments found that the term “frequent” was interpreted on average as equivalent to around 70 per cent but with a wide range
SUMMER 2011
from 30 to 90 per cent.
Common wisdom is that people will usually best understand absolute risk expressed in percentages or natural frequencies, such as one in 200 patients suffer a particular post-operative complication. Such figures can be presented in comparison with everyday risks such as the chance of having a car crash while driving over a certain distance. Presenting absolute risk figures alone has been shown to lead to either an overweighting of low probabilities or an underweighting of high probabilities.
Some centres have found most success by communicating risk using visual representations, such as diagrams displaying 100 stick figures or other graphic elements designed to represent patients and possible outcomes. Such devices offer a handy short-hand of risk and can be utilised as part of a range or “shopping basket” of
lawyers and regulators happy but it also serves to highlight another dilemma facing healthcare professionals seeking informed consent. No medical procedure is completely risk free so when is a particular risk likely or severe enough to merit being divulged to patients?
“Terms such as ‘common’ and ‘rare’ assume a shared perspective when in fact patients may judge risk by a different order of magnitude”
complementary data formats with enough flexibility to address the needs of a variety of patients. Tese might include other “decision aids” such as leaflets and booklets, websites, CDs and interactive computer programmes.
Life is a risky business A common feature of USA magazine advertisements for proprietary drugs is screeds of additional text listing in minute detail every possible contra-indication and attendant clinical risk. No doubt this keeps
Law courts tend to support a ‘test’ based on what a “reasonable doctor” would divulge in similar circumstances but this still leaves a grey area when it comes to low risks with severe consequences as in the spinal surgery case example above. Robert Heywood, a lecturer in law at Sheffield Hallam University, commented in an article on risk disclosure: “It now seems the profession have ‘got together’ and taken it upon themselves to set professional standards of disclosure at around all risks within the 1-2 per cent region and above.” Tis was the specific risk factor cited in the landmark medico-legal case of Chester v Afshar, which established that a doctor is liable if he fails to warn of a known risk of harm which then occurs. But the figure has never been formally suggested as benchmark for risk disclosure. Clearly what the GMC considers a “serious adverse outcome, even if the likelihood is very small” or “less serious side effects or complications if they occur frequently” is subject to interpretation. It is probably best to air on the side of disclosure if in doubt and be willing to back-up any decisions made with comprehensive notes recorded in the consent process.
Ask colleagues if in doubt or seek advice from MDDUS – the decision to disclose a risk may be yours but there is no need to make it alone.
n Article by Dr Gail Gilmartin, MDDUS medical adviser, and Jim Killgore, editor of Summons
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