Consent for septoplasty: Are we meeting patients’ expectations?

Abstract

The requirements for informed consent were modified in 2015 following the UK Supreme Court judgment of Montgomery v Lanarkshire Health Board. This marked a decisive shift from the traditional paternalistic ‘doctor knows best' model towards a more patient-centred approach. This study examines the current standard of consent for septoplasty and whether it complies with the law. We also report whether the ‘reasonable patient’ and surgeon agree about which risks should be discussed during the consent process. Ten complications were identified as common or serious via a literature search. Using questionnaires, 21 Ears, Nose and Throat surgeons were asked which of these they routinely discussed, and 103 patients were asked how seriously they regarded those complications. Results were compared using the Test of Proportions. Most surgeons routinely discuss all risks except negative change in sense of smell and numbness of upper incisors. The ‘reasonable patient’ regarded these two complications as serious or very serious. However, less than 70% of surgeons mentioned them. A significant proportion of Ears, Nose and Throat surgeons do not routinely mention all the risks that the ‘reasonable patient' would want to know about before undergoing a septoplasty. This may result in more clinical negligence claims, as managing a patient's reasonable expectations is an important factor.

Unmet challenges in septoplasty–nordic studies from a uniform healthcare and geographical area

“…How the surgical problem is communicated to the patient and how the patient perceives the message from the surgeon has not been well studied, but it could be a potentially important factor for success. In particular, the issue of possible complications of septoplasty appears to have been left out of the patient information ( 5 ). This discussion could also include objective and documented preoperative information such as rhinomanometry results.…”

“…It also gives the patient a negative impression of a surgical complication having occurred. In a study from England where both ENT surgeons and patients were asked if they addressed these complications prior to surgery it was shown that not all of the most common complications were discussed and furthermore, surgeons and patients do rate their severity differently ( 5 ). For example, pain was among the complications not discussed with the patients routinely, which could have a negative impact once it occurs .…”

“…In a comprehensive review of septoplasties from different parts of the world published in 2018, patient satisfaction after surgery (measured as patient-reported outcome measures, PROMS) was reported to be between 50% and 100% after a minimum of 12 months postoperatively, indicating scope for improvement ( 3 ). The correlation between patients' expectations, PROMS and objective measurements of nasal patency also demonstrates conflicting results ( 4 , 5 ). It is therefore crucial that the expected surgical outcome is considered carefully and discussed with the patient in the light of the known risk of complications, including an unsatisfactory surgical result ( 5 , 6 ).…”

“…The correlation between patients' expectations, PROMS and objective measurements of nasal patency also demonstrates conflicting results ( 4 , 5 ). It is therefore crucial that the expected surgical outcome is considered carefully and discussed with the patient in the light of the known risk of complications, including an unsatisfactory surgical result ( 5 , 6 ).…”

Consent for functional endoscopic sinus surgery: are we complying with the law?

“…A recent study exploring the consent process in septoplasty found that a significant proportion of ENT surgeons do not meet patients' expectations regarding risk disclosure for similar reasons. 15 In addition, a few ENT surgeons specifically did not consent for damage to the nasolacrimal duct because they felt it should never occur during routine FESS. These explanations, whilst possibly meeting the Bolam test, fail to adhere to the new legal standard defined by the 'Montgomery v Lanarkshire Health Board' case.…”