Presumed consent: licenses and limits inferred from the case of geriatric hip fractures

Abstract

BackgroundHip fractures are common and serious injuries in the geriatric population. Obtaining informed consent for surgery in geriatric patients can be difficult due to the high prevalence of comorbid cognitive impairment. Given that virtually all patients with hip fractures eventually undergo surgery, and given that delays in surgery are associated with increased mortality, we argue that there are select instances in which it may be ethically permissible, and indeed clinically preferable, to initiate surgical treatment in cognitively impaired patients under the doctrine of presumed consent. In this paper, we examine the boundaries of the license granted by presumed consent and use the example of geriatric hip fracture to build an ethical framework for understanding the doctrine of presumed consent.DiscussionThe license to act under presumed consent requires three factors: patient incapacity, clinical urgency and clarity on the correct course of action. All three can apply to geriatric hip fracture. The typical patient frequently lacks capacity. Delays in initiating surgical treatment are associated with markedly increased mortality rates. Last, there appears to be consensus that surgery is the preferred treatment. Nonetheless, because there is a window of safe delay during which treating physicians can stabilize the patient, address reversible causes of cognitive impairment and identify surrogate decision makers, presumed consent should be invoked only as a method of last resort.ConclusionsA medical situation need not be characterized by risk of imminent and certain death for presumed consent to be relevant. Rather, there are two distinct windows that must be considered: the time interval in which action may be delayed without danger, and the time interval needed to obtain a better form of consent. Presumed consent is appropriate only when the latter exceeds the former.

A Culture Change in Geriatric Traumatology: Holistic and Patient-Tailored Care for Frail Patients with Fractures

“…From a legal standpoint, patients have decisional capacity when they understand all of the relevant information, are able to appreciate the current situation and its consequences, and are able to manipulate this information in a rational manner 51 . While many patients may at first seem like they are able to consent, the use of probing questions often reveals substantial cognitive issues that may preclude the ability to provide informed consent 28,29,52 . When there is doubt regarding decisional capacity, a geriatrician can help with the assessment.…”

Impact of Age on Consent in a Geriatric Orthopaedic Trauma Patient Population

“…The pervasive nature of cognitive impairment among older patients with fragility fractures renders the assessment of decision making capacity a necessity. 3 Studies have reported prevalence of known dementia in adults over the age of 65 suffering from hip fractures at 28% with an additional 8% diagnosed upon presentation. 3 , 4 Prevalence of cognitive impairment in geriatric orthopaedic trauma patients has also been recorded at 35.1%.…”

“… 3 Studies have reported prevalence of known dementia in adults over the age of 65 suffering from hip fractures at 28% with an additional 8% diagnosed upon presentation. 3 , 4 Prevalence of cognitive impairment in geriatric orthopaedic trauma patients has also been recorded at 35.1%. 5 Obtaining a formal assessment in elderly orthopaedic trauma patients not only identifies patients with cognitive impairment but also provides physicians with data to support and uphold patient autonomy.…”

“…9 Considering the high rate of cognitive impairment in geriatric patients suffering orthopaedic trauma, we were interested in the surgical consenting process. 3,5 The Level 1 Trauma centers studied have a 2-step cognitive assessment protocol beginning with a Confusion Assessment Method to rule out delirium followed by a Mini-Cog evaluation. These 2 examinations are validated screening tools for delirium and dementia, respectively.…”

Not the Last Word: Informed Consent, Omakase Style

“…That restaurant visit made me wonder if there is a role for surgical informed consent, omakase style as well. In this model, patients can state some general preferences-a willingness to take some risk for a faster recovery, say, or a particular dislike of immobilization-but beyond that, the details of the care are left to the surgeon's experience, expertise, and best judgment, just as they'd be used in an emergency setting [4].…”