Advertisement

Beyond consent—improving understanding in surgical patients

      Abstract

      Background

      Little is known of the actual understanding that underlies patient choices with regard to their surgical treatment. This review explores current knowledge of patient understanding and techniques that may be used to improve this understanding.

      Methods

      MEDLINE and PubMed were searched using the terms “patient understanding,” “patient comprehension,” “consent,” “video,” “multimedia,” “patient information leaflet,” “internet,” “test-feedback,” “extended discussion,” “shared decision making,” and “decision aid.” All retrieved peer-reviewed studies were included in the review.

      Results

      Understanding in surgical patients is poor. There is little evidence to support the use of information leaflets, although multimedia appears to be effective in improving patient understanding. The internet is not used effectively as an aid to consent by health care providers. Patients with lower educational levels may gain most from additional interventions. Improving patient understanding does not impact on their satisfaction with the treatment they have received but may reduce periprocedural anxiety.

      Conclusions

      There is a need for greater awareness of patients' information needs, and novel approaches that may enhance decision making through improved understanding are required.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. Schloendorff v Society of New York Hospital 211 N.Y. 125,105 (N.E. 92 1914).

      2. Canterbury v. Spence 464 F.2d 772 (District of Columbia Court of Appeal 1972).

      3. Salgo v Leland Stanford Jr University Board of Trustees. 317 P2d 170. (California District Court of Appeal 1957).

      4. Smith v Tunbridge Wells Health Authority 5 Med LR 334.
        1994
      5. Chester v Afshar.
        2004 (UKHL;41)
      6. Geoghegan v Harris.
        2000 (3IR 536)
        • Benjamin D.M.
        Reducing medication errors and increasing patient safety: case studies in clinical pharmacology.
        J Clin Pharmacol. 2003; 43: 768-783
        • Akkad A.
        • Jackson C.
        • Kenyon S.
        • et al.
        Patients' perceptions of written consent: questionnaire study.
        BMJ. 2006; 333: 528
        • Akkad A.
        • Jackson C.
        • Kenyon S.
        • et al.
        Informed consent for elective and emergency surgery: questionnaire study.
        Br J Obstet Gynaecol. 2004; 111: 1133-1138
        • Habiba M.
        • Jackson C.
        • Akkad A.
        • et al.
        Women's accounts of consenting to surgery: is consent a quality problem?.
        Qual Saf Health Care. 2004; 13: 422-427
        • Whitney S.N.
        • McGuire A.L.
        • McCullough L.B.
        A typology of shared decision making, informed consent, and simple consent.
        Ann Intern Med. 2004; 140: 54-59
        • Larobina M.E.
        • Merry C.J.
        • Negri J.C.
        • et al.
        Is informed consent in cardiac surgery and percutaneous coronary intervention achievable?.
        Aust N Z J Surg. 2007; 77: 530-534
        • Lavelle-Jones C.
        • Byrne D.J.
        • Rice P.
        • et al.
        Factors affecting quality of informed consent.
        BMJ. 1993; 306: 885-890
        • McCormack D.
        • Evoy D.
        • Mulcahy D.
        • et al.
        An evaluation of patients comprehension of orthopaedic terminology: implications for informed consent.
        J R Coll Surg Edinb. 1997; 42: 33-35
        • Braddock 3rd, C.H.
        • Edwards K.A.
        • Hasenberg N.M.
        • et al.
        Informed decision making in outpatient practice: time to get back to basics.
        JAMA. 1999; 282: 2313-2320
        • Braddock 3rd, C.
        • Hudak P.L.
        • Feldman J.J.
        • et al.
        “Surgery is certainly one good option”: quality and time-efficiency of informed decision-making in surgery.
        J Bone Joint Surg Am. 2008; 90: 1830-1838
        • Kriwanek S.
        • Armbruster C.
        • Beckerhinn P.
        • et al.
        Patients' assessment and recall of surgical information after laparoscopic cholecystectomy.
        Dig Surg. 1998; 15: 669-673
        • Mishra P.K.
        • Ozalp F.
        • Gardner R.S.
        • et al.
        Informed consent in cardiac surgery: is it truly informed?.
        J Cardiovasc Med [Hagerstown]. 2006; 7: 675-681
        • Stanley B.M.
        • Walters D.J.
        • Maddern G.J.
        Informed consent: how much information is enough?.
        Aust N Z J Surg. 1998; 68: 788-791
        • Turner P.
        • Williams C.
        Informed consent: patients listen and read, but what information do they retain?.
        N Z Med J. 2002; 115: U218
        • Dillon M.F.
        • Carr C.J.
        • Feeley T.M.
        • et al.
        Impact of the informed consent process on patients' understanding of varicose veins and their treatment.
        Ir J Med Sci. 2005; 174: 23-27
        • Fagerlin A.
        • Lakhani I.
        • Lantz P.M.
        • et al.
        An informed decision?.
        Patient Educ Couns. 2006; 64: 303-312
        • Berman L.
        • Curry L.
        • Gusberg R.
        • et al.
        Informed consent for abdominal aortic aneurysm repair: the patient's perspective.
        J Vasc Surg. 2008; 48: 296-302
        • Williamson W.K.
        • Nicoloff A.D.
        • Taylor Jr, L.M.
        • et al.
        Functional outcome after open repair of abdominal aortic aneurysm.
        J Vasc Surg. 2001; 33: 913-920
        • Hutson M.M.
        • Blaha J.D.
        Patients' recall of preoperative instruction for informed consent for an operation.
        J Bone Joint Surg Am. 1991; 73: 160-162
        • Keulers B.J.
        • Scheltinga M.R.
        • Houterman S.
        • et al.
        Surgeons underestimate their patients' desire for preoperative information.
        World J Surg. 2008; 32: 964-970
        • Montgomery A.A.
        • Fahey T.
        How do patients' treatment preferences compare with those of clinicians?.
        Qual Health Care. 2001; 10: i39-i43
        • Elstein A.S.
        • Chapman G.B.
        • Knight S.J.
        Patients' values and clinical substituted judgments: the case of localized prostate cancer.
        Health Psychol. 2005; 24: S85-S92
        • Devereaux P.J.
        • Anderson D.R.
        • Gardner M.J.
        • et al.
        Differences between perspectives of physicians and patients on anticoagulation in patients with atrial fibrillation: observational study.
        BMJ. 2001; 323: 1218-1222
        • Degner L.F.
        • Kristjanson L.J.
        • Bowman D.
        • et al.
        Information needs and decisional preferences in women with breast cancer.
        JAMA. 1997; 277: 1485-1492
        • Davison B.J.
        • Degner L.F.
        • Morgan T.R.
        Information and decision-making preferences of men with prostate cancer.
        Oncol Nurs Forum. 1995; 22: 1401-1408
        • Masya L.M.
        • Young J.M.
        • Solomon M.J.
        • et al.
        Preferences for outcomes of treatment for rectal cancer: patient and clinician utilities and their application in an interactive computer-based decision aid.
        Dis Colon Rectum. 2009; 52: 1994-2002
        • Solomon M.J.
        • Pager C.K.
        • Keshava A.
        • et al.
        What do patients want? Patient preferences and surrogate decision making in the treatment of colorectal cancer.
        Dis Colon Rectum. 2003; 46: 1351-1357
        • Bossema E.R.
        • Marijnen C.A.
        • Baas-Thijssen M.C.
        • et al.
        Evaluation of the treatment tradeoff method in rectal cancer patients: is surgery preference related to outcome utilities?.
        Med Decis Making. 2008; 28: 888-898
        • Bossema E.
        • Stiggelbout A.
        • Baas-Thijssen M.
        • et al.
        Patients' preferences for low rectal cancer surgery.
        Eur J Surg Oncol. 2008; 34: 42-48
        • Harrison J.D.
        • Solomon M.J.
        • Young J.M.
        • et al.
        Patient and physician preferences for surgical and adjuvant treatment options for rectal cancer.
        Arch Surg. 2008; 143: 389-394
        • Ashraff S.
        • Malawa G.
        • Dolan T.
        • et al.
        Prospective randomised controlled trial on the role of patient information leaflets in obtaining informed consent.
        Aust N Z J Surg. 2006; 76: 139-141
        • Langdon I.J.
        • Hardin R.
        • Learmonth I.D.
        Informed consent for total hip arthroplasty: does a written information sheet improve recall by patients?.
        Ann R Coll Surg Engl. 2002; 84: 404-408
        • Brown T.F.
        • Massoud E.
        • Bance M.
        Informed consent in otologic surgery: prospective study of risk recall by patients and impact of written summaries of risk.
        J Otolaryngol. 2003; 32: 368-372
        • Mauffrey C.
        • Prempeh E.M.
        • John J.
        • et al.
        The influence of written information during the consenting process on patients' recall of operative risks.
        Int Orthop. 2008; 32: 425-429
        • Winterton R.I.
        • Alaani A.
        • Loke D.
        • et al.
        Role of information leaflets in improving the practice of informed consent for patients undergoing septoplasty.
        J Laryngol Otol. 2007; 121: 134-137
        • Layton S.
        • Korsen J.
        Informed consent in oral and maxillofacial surgery: a study of the value of written warnings.
        Br J Oral Maxillofac Surg. 1994; 32: 34-36
        • Henry E.
        • Brown T.
        • Bartlett C.
        • et al.
        Informed consent in otologic surgery: prospective randomized study comparing risk recall with an illustrated handout and a nonillustrated handout.
        Otolaryngol Head Neck Surg. 2008; 37: 273-278
        • Felley C.
        • Perneger T.V.
        • Goulet I.
        • et al.
        Combined written and oral information prior to gastrointestinal endoscopy compared with oral information alone: a randomized trial.
        BMC Gastroenterol. 2008; 8: 22
        • Brown H.
        • Ramchandani M.
        • Gillow J.T.
        • et al.
        Are patient information leaflets contributing to informed consent for cataract surgery?.
        J Med Ethics. 2004; 30: 218-220
        • Harwood A.
        • Harrison J.E.
        How readable are orthodontic patient information leaflets?.
        J Orthod. 2004; 31 (discussion, 201): 210-219
        • Beaver K.
        • Luker K.
        Readability of patient information booklets for women with breast cancer.
        Patient Educ Couns. 1997; 31: 95-102
        • Sarma M.
        • Alpers J.H.
        • Prideaux D.J.
        • et al.
        The comprehensibility of Australian educational literature for patients with asthma.
        Med J Aust. 1995; 162: 360-363
        • Zion A.B.
        • Aiman J.
        Level of reading difficulty in the American College of Obstetricians and Gynecologists patient education pamphlets.
        Obstet Gynecol. 1989; 74: 955-960
        • Fox R.
        Informed choice in screening programmes: do leaflets help?.
        J Public Health (Oxf). 2006; 28: 309-317
        • Mayer R.E.
        Cognitive theory and the design of multimedia instruction: an example of the two-way street between cognition and instruction.
        in: Halpern D.F. Hakel M.D. Applying the Science of Learning to University Teaching and Beyond: New Directions for Teaching and Learning. 1st ed. Jossey-Bass, San Francisco, CA2002
        • Bollschweiler E.
        • Apitzsch J.
        • Obliers R.
        • et al.
        Improving informed consent of surgical patients using a multimedia-based program?.
        Ann Surg. 2008; 248: 205-211
        • Stergiopoulou A.
        • Birbas K.
        • Katostaras T.
        • et al.
        The effect of interactive multimedia on preoperative knowledge and postoperative recovery of patients undergoing laparoscopic cholecystectomy.
        Methods Inf Med. 2007; 46: 406-409
        • Wilhelm D.
        • Gillen S.
        • Wirnhier H.
        • et al.
        Extended preoperative patient education using a multimedia DVD—impact on patients receiving a laparoscopic cholecystectomy: a randomised controlled trial.
        Langenbecks Arch Surg. 2009; 394: 227-233
        • Eggers C.
        • Obliers R.
        • Koerfer A.
        • et al.
        A multimedia tool for the informed consent of patients prior to gastric banding.
        Obesity (Silver Spring). 2007; 15: 2866-2873
        • Luck A.
        • Pearson S.
        • Maddern G.
        • et al.
        Effects of video information on precolonoscopy anxiety and knowledge: a randomised trial.
        Lancet. 1999; 354: 2032-2035
        • Danino A.M.
        • Chahraoui K.
        • Frachebois L.
        • et al.
        Effects of an informational CD-ROM on anxiety and knowledge before aesthetic surgery: a randomised trial.
        Br J Plast Surg. 2005; 58: 379-383
        • Keulers B.J.
        • Welters C.F.
        • Spauwen P.H.
        • et al.
        Can face-to-face patient education be replaced by computer-based patient education?.
        Patient Educ Couns. 2007; 67: 176-182
        • Rossi M.
        • McClellan R.
        • Chou L.
        • et al.
        Informed consent for ankle fracture surgery: patient comprehension of verbal and videotaped information.
        Foot Ankle Int. 2004; 25: 756-762
        • Rossi M.J.
        • Guttmann D.
        • MacLennan M.J.
        • et al.
        Video informed consent improves knee arthroscopy patient comprehension.
        Arthroscopy. 2005; 21: 739-743
        • Evrard S.
        • Mathoulin-Pelissier S.
        • Larrue C.
        • et al.
        Evaluation of a preoperative multimedia information program in surgical oncology.
        Eur J Surg Oncol. 2005; 31: 106-110
        • Jeste D.V.
        • Dunn L.B.
        • Folsom D.P.
        • et al.
        Multimedia educational aids for improving consumer knowledge about illness management and treatment decisions: a review of randomized controlled trials.
        J Psychiatr Res. 2008; 42: 1-21
        • Flory J.
        • Emanuel E.
        Interventions to improve research participants' understanding in informed consent for research: a systematic review.
        JAMA. 2004; 292: 1593-1601
        • Ryan R.E.
        • Prictor M.J.
        • McLaughlin K.J.
        • et al.
        Audio-visual presentation of information for informed consent for participation in clinical trials.
        Cochrane Database Syst Rev. 2008; 1 (CD003717)
        • O'Connor A.M.
        • Bennett C.L.
        • Stacey D.
        • et al.
        Decision aids for people facing health treatment or screening decisions.
        Cochrane Database Syst Rev. 2009; 3 (CD001431)
        • Whelan T.
        • Levine M.
        • Willan A.
        • et al.
        Effect of a decision aid on knowledge and treatment decision making for breast cancer surgery: a randomized trial.
        JAMA. 2004; 292: 435-441
        • Tamhankar A.
        • Mazari F.
        • Everitt N.
        • et al.
        Use of the internet by patients undergoing elective hernia repair or cholecystectomy.
        Ann R Coll Surg Engl. 2009; 91: 460
        • Murphy J.O.
        • Sweeney K.J.
        • O'Mahony J.C.
        • et al.
        Surgical informatics on the internet: any improvement?.
        Surgeon. 2003; 1: 177-179
        • Scurr J.R.
        • Hufton A.
        • Jeffrey V.
        • et al.
        Ann R Coll Surg Engl. 2008; 90: 554-556
        • Evans R.
        • Elwyn G.
        • Edwards A.
        Making interactive decision support for patients a reality.
        Inform Prim Care. 2004; 12: 109-113
        • Atrey A.
        • Leslie I.
        • Carvell J.
        • et al.
        Standardised consent forms on the website of the British Orthopaedic Association.
        J Bone Joint Surg Br. 2008; 90: 422-423
        • Dawes P.J.
        • O'Keefe L.
        • Adcock S.
        Informed consent: the assessment of two structured interview approaches compared to the current approach.
        J Laryngol Otol. 1992; 106: 420-424
        • Dawes P.J.
        • O'Keefe L.
        • Adcock S.
        Informed consent: using a structured interview changes patients' attitudes towards informed consent.
        J Laryngol Otol. 1993; 107: 775-779
        • Fink A.S.
        • Prochazka A.V.
        • Henderson W.G.
        • et al.
        Enhancement of surgical informed consent by addition of repeat back: a multicenter, randomized controlled clinical trial.
        Ann Surg. 2010; 252: 27-36
        • Medical Council of Ireland
        Guide to Professional Conduct and Ethics for Registered Medical Practitioners. 7th ed. Medical Council of Ireland, Dublin 22009
        • Lee C.N.
        • Ko C.Y.
        Beyond outcomes—the appropriateness of surgical care.
        JAMA. 2009; 302: 1580-1581
        • Elwyn G.
        • O'Connor A.
        • Stacey D.
        • et al.
        Developing a quality criteria framework for patient decision aids: online international Delphi consensus process.
        BMJ. 2006; 333: 417
        • Berman L.
        • Dardik A.
        • Bradley E.H.
        • et al.
        Informed consent for abdominal aortic aneurysm repair: assessing variations in surgeon opinion through a national survey.
        J Vasc Surg. 2008; 47: 287-295
        • Feldman-Stewart D.
        • Brundage M.D.
        • Hayter C.
        • et al.
        What the prostate cancer patient should know: variations in urologists' opinions.
        Can J Urol. 1997; 4: 438-444
        • Childers R.
        • Lipsett P.A.
        • Pawlik T.M.
        Informed consent and the surgeon.
        J Am Coll Surg. 2009; 208: 627-634
        • Janz N.K.
        • Mujahid M.S.
        • Hawley S.T.
        • et al.
        Racial/ethnic differences in adequacy of information and support for women with breast cancer.
        Cancer. 2008; 113: 1058-1067
        • Bleicher R.J.
        • Abrahamse P.
        • Hawley S.T.
        • et al.
        The influence of age on the breast surgery decision-making process.
        Ann Surg Oncol. 2008; 15: 854-862
        • Fink A.S.
        • Prochazka A.V.
        • Henderson W.G.
        • et al.
        Predictors of comprehension during surgical informed consent.
        J Am Coll Surg. 2010; 210: 919-926
        • Hawley S.T.
        • Griggs J.J.
        • Hamilton A.S.
        • et al.
        Decision involvement and receipt of mastectomy among racially and ethnically diverse breast cancer patients.
        J Natl Cancer Inst. 2009; 101: 1337-1347
        • Keating N.L.
        • Guadagnoli E.
        • Landrum M.B.
        • et al.
        Treatment decision making in early-stage breast cancer: should surgeons match patients' desired level of involvement?.
        J Clin Oncol. 2002; 20: 1473-1479
        • Hack T.F.
        • Degner L.F.
        • Watson P.
        • et al.
        Do patients benefit from participating in medical decision making?.
        Psychooncology. 2006; 15: 9-19
        • Hudak P.L.
        • Armstrong K.
        • Braddock 3rd, C.
        • et al.
        Older patients' unexpressed concerns about orthopaedic surgery.
        J Bone Joint Surg Am. 2008; 90: 1427-1435
        • Dartey W.
        • Borase H.
        • Organ A.
        • et al.
        Preoperative assessment and consent for surgery: a role for the gynaecology nurse-practitioner.
        J Obstet Gynaecol. 2010; 30: 166-170
        • Vohra H.A.
        • Ledsham J.
        • Vohra H.
        • et al.
        Issues concerning consent in patients undergoing cardiac surgery—the need for patient-directed improvements: a UK perspective.
        Cardiovasc Surg. 2003; 11: 64-69
        • Ivarsson B.
        • Larsson S.
        • Luhrs C.
        • et al.
        Extended written pre-operative information about possible complications at cardiac surgery—do the patients want to know?.
        Eur J Cardiothorac Surg. 2005; 28: 407-414
        • Garrud P.
        • Wood M.
        • Stainsby L.
        Impact of risk information in a patient education leaflet.
        Patient Educ Couns. 2001; 43: 301-304
        • Bytzer P.
        • Lindeberg B.
        Impact of an information video before colonoscopy on patient satisfaction and anxiety—a randomized trial.
        Endoscopy. 2007; 39: 710-714