When informed consent backfires

Last month, there was a morning when many doctors, myself included, heaved a sigh of relief at a High Court judgment.

The case against an anaesthetist, who had been accused of causing neck injury while administering general anaesthesia to a patient, was dismissed.

The trial had taken 39 days.

When the incident happened, the patient was 35 years old and pregnant with her sixth child.

She was undergoing surgery to deliver her baby.

She claimed that the doctor caused her neck injuries when he inserted a breathing tube down her airway ahead of the caesarean section, which is delivery through an incision in the womb and abdomen.

After the delivery, she said, she continued to suffer pain in her neck and back, numbness in her hands and feet, and often lost her balance.

She sued the anaesthetist because she said he had failed to obtain her informed consent for the procedure to administer general anaesthesia.

In medicine, this issue of informed consent almost invariably comes up when things go wrong, or when the outcome is not what the patient had expected.

In every procedure and, indeed, in most types of treatment, there are risks.

But is it really possible, or desirable, for doctors to cover all the possible complications with each procedure and every drug administered?

Siok Hwee, a 50-year-old woman, has been under my care since 1995.

Her problem was that of stage 4 malignant lymphoma (also called non-Hodgkin's lymphoma), not unlike the type which the late President Ong Teng Cheong had.

There are many types of malignant lymphoma (primary cancer of the lymph nodes). These can be broadly classified as low grade (slow growing) or high grade (fast growing).

When Siok Hwee first saw me in July 1995, we confirmed that the lymphoma was low grade but at an advanced stage because her bone marrow had already been invaded by the cancer cells.

Although this type of cancer cannot be cured, it is a highly treatable disease with the majority of patients being able to lead a long life.

One of the problems with low-grade lymphoma is that it can transform into high-grade lymphoma.

This is believed to occur in up to 25 per cent of patients.

Indeed, in January 2002, Siok Hwee's lymphoma transformed into an aggressive form.

A new tumour was discovered in her liver and was confirmed by biopsy (testing of a sample of cells) to be lymphoma that had spread there.

We had to embark on an aggressive chemotherapy programme for four months and this successfully cured her of the high-grade lymphoma.

In 2007, a biopsy of a lymph node in her right armpit confirmed that the low-grade lymphoma was still lurking around.

Two months ago, we discovered another abnormal lymph node inside her abdomen.

In my explanation to her, I simply told her that we needed to stick a needle into the lymph node and extract some cells for examination by the pathologist.

I did not go into the details of the procedure. After all, she had the biopsy done several times before - when she first saw me in 1995 and also in 2002 and 2007.

The biopsy was to be done by the interventional radiologist under imaging guidance. In other words, the radiologist would be able to "see and localise" the lymph node using the computed tomography (CT) scan, before sticking the needle into it.

With so many recent medico-legal cases centring on informed consent, the interventional radiologist painstakingly described all the possible complications - puncturing the lung, spleen or intestines, bleeding, infection, need for emergency surgery and possible death.

He did the perfectly correct thing.

But after hearing the spiel of things that could go wrong, Siok Hwee had a fright and quickly called me on the phone.

"Dr Ang, what should I do?" she asked.

"Just do it!" I replied.

She happily hopped onto the procedure table and the biopsy was carried out uneventfully.

The result turned out to be low-grade lymphoma and she did not need to have any treatment.

We were most relieved - and that is when I remembered the court's judgment last month.

What if things had gone wrong?

I guess my head could possibly have been on the chopping board.

But I had been caring for Siok Hwee since 1995, and over the course of 17 years, I think she would trust me to make the right choice for her.

True, this trust has been earned, in her case, over many years, but I do not think I would do any differently for a new patient, and I hope the trust would be there too.

I truly believe that as doctors, we need to practise good clinical medicine - remembering always to comfort and heal - and not the defensive medicine that the times dictate.


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