Giving patients the information they need - Medical imaging consent

[caption id="attachment_6185" align="alignright" width="200"] ‘Information about the risks of medical imaging services can and should be provided at appropriate times from the beginning to the end of this journey.’[/caption]
Consent is a hot topic in medical imaging – and it’s something everyone in the sector needs to consider. Together we need to develop practice guidelines and consumer resources which are as helpful as possible for radiologists and their patients, writes Dr Chris Wriedt.
At the moment, the Consumer Health Forum is working on a project about ‘Diagnostic Imaging and Informed Consent’, and the Royal Australian and New Zealand College of Radiologists is reviewing its guidelines for radiologists.
These projects provide the opportunity for deep thinking about the place of consent in medical imaging, and how professional expectations and standards can be calibrated to give patients the most appropriate care.
Consent in the context of medical procedures has both ethical and legal dimensions. As part of their entitlement to autonomy, patients expect to participate in the decision about the medical imaging services they undertake. In turn, this means that medical practitioners are expected to discuss with patients the purpose and risks associated with a proposed imaging service prior to it taking place. This is essential for patients to be able to make an informed decision about whether to undertake an imaging service.
While obtaining patient consent for radiology services is important, by focussing on it we can be distracted from the central issue, which is providing patients with the information they need – what information is provided, when it is provided and who provides it. We need to move beyond the rigid thinking of focussing on the point at which a patient consents to a medical imaging service, when this is only the end point of the patient journey. Information about the risks of medical imaging services can and should be provided at appropriate times from the beginning to the end of this journey.
By setting the right expectations around the provision of information to patients, we can help ensure patients have access to sufficient information before they undertake medical imaging services.
An example of rigid thinking is using legal cases that have set out the law for surgeons to indicate obligations for radiologists, without considering the joint role of the referrer and provider in providing information to patients.
The common law currently imposes an obligation on medical practitioners to warn a patient of a material risk inherent in a proposed treatment (Rogers v Whitaker). In Rogers, an ophthalmic surgeon failed to warn the patient of the risk that following surgery on her right eye, she might develop sympathetic ophthalmia in her left eye. The High Court found that:
“A medical practitioner has a duty to warn a patient of a material risk inherent in the proposed treatment; a risk is material if, in the circumstances of the particular case, a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it.”
Other leading cases on the disclosure of medical risks have also involved surgeons.
This means that the precise nature of the legal obligation of radiologists to disclose medical risk to their patients is not clear, because radiology is inherently different to surgery and other medical specialties.
The referring doctor or allied health professional usually discusses the radiology service they recommend with the patient in the course of providing them with a referral or request. They have a key role in providing relevant information to the patient regarding the service requested. In many cases the radiologist is provided with very little information about the patient’s condition.
The respective roles of the referrer and the radiologist in providing information to the patient is yet to be tested in court. This is an issue which should be the subject of broader discussion within the radiology profession, other specialty groups, and the medical community generally.
Radiology is also unique because it is mostly non-invasive or minimally invasive, as compared to other medical specialties such as surgery.
If a case involving a radiologist’s obligation to warn a patient about the risks of a proposed service went to court, it is possible that the court would consider the unique and special characteristics of radiology when determining the extent of that obligation. It might find that what is considered a reasonable obligation for radiologists differs to that which applies to other medical practitioners such as surgeons.
Accordingly, in the production of guidelines for consent in medical imaging, considerable care needs to be taken to ensure that the guidelines reflect the unique role of the radiologist in the care of the patients, in the context of the range of services they provide. Guidelines should also reflect the principal role of the referrer in managing the patient’s care. This will ensure that an appropriate minimum standard for radiologists is established.
With the referrer having a unique role in the radiology patient journey, there is also a significant opportunity to use consumer resources to empower patients. Referrers usually know the most about the patient and their condition, putting them in the ideal position to provide general information and give specific advice about the risks associated with the radiology service or services they recommend.
Consumer resources could be used to educate patients about the different roles of healthcare providers in providing them with information about radiology services, as well as encourage them to seek information at the earliest available opportunity from their referrer (often during the consultation). This would give patients more time to digest information about the risks of particular radiology services, in contrast to receiving this information on the day of the service from a radiologist.
In instances where radiologists are still best placed to provide information to patients, it is unlikely to be appropriate for them to provide the same scope of information for all examinations or procedures. For example, intravenous contrast administration, cervical nerve root injection (also called a transforaminal epidural), and complex elective interventional procedures such as intracranial embolisation, involve very different levels of complexity and risk to patients. Accordingly, the obligation to provide information should also be different – the scope of information and the time that information is provided needs to be appropriate to the level of risk.
A ‘one size fits all’ approach in guidelines would not reflect this complexity, and might artificially increase what is expected of radiologists to an aspirational level which cannot be realistically achieved.
The approach is unlikely to improve patient outcomes as the practical impact of increasing obligations needs to be considered. If radiologists are required to give patients extensive information and receive written consent for most or all services, patients might be less likely to take notice when this information is provided for more risky services. In addition, today’s patients do not necessarily read all the information they are given, particularly patients with cultural and language barriers.
If the medical imaging community is serious about fulfilling our obligations to our patients, then we need to ensure that the approach to providing information is appropriate – both the scope of information and when this information is provided in the patient journey. This will allow us to focus on patient care rather than managing legal risk.
ADIA welcomes further consideration by the healthcare community on the scope of consent in medical imaging, with the overarching goal to make guidelines and consumer resources as helpful as possible for all concerned.
‘Consumer resources could be used to educate patients about the different roles of healthcare providers in providing them with information about radiology services, as well as encourage them to seek information at the earliest available opportunity from their referrer.’
Dr Chris Wriedt
Dr Chris Wriedt
President of the Australian Diagnostic Imaging Association
ADIA represents medical imaging practices throughout Australia, both in the community and in hospitals, and promotes ongoing development of quality practice standards so doctors and their patients can have certainty of quality, access and delivery of medical imaging services.
Visit our website www.adia.asn.au