The informed consent process for emergency surgery at public and private hospital surgical emergency units in the urban Ugandan setting

Abstract

Introduction: Informed consent is a process that can have challenges when required for emergency surgery, because the patient might not have the capacity to consent, and consent may be obtained from the next of kin, or surrogate decision-makers. The key stakeholders in the informed consent process for patients undergoing emergency surgery are the patient, the next of kin or surrogate decision–makers, and the emergency staff. This study hoped to contribute to a better and more nuanced understanding of how patients and their next of kin engage with the informed consent process in cases where emergency surgery is required. The study was conducted in the emergency units of one urban public, and one urban private not-for-profit hospital, to assess the knowledge and perspectives of the patients, their next of kin, and the emergency staff, towards the informed consent process for emergency surgery. Methods: We used a descriptive cross-sectional study design, combining quantitative and qualitative methods. We conducted a quantitative survey of 380 patients and their next of kin (210 from the public hospital, and 170 from the private hospital). Qualitatively, we conducted 39 in-depth interviews of patients, and the next of kin of patients who had undergone emergency surgery, 17 key informant interviews of emergency staff involved in the informed consent process, and direct observation of emergency staff during the informed consent process at these 2 units. Results: From the survey, 79.7% of patients did not have the risks of the surgery communicated to them, 87.6% were not given alternative options, and 57.4% had no opportunity to ask questions. There were 7 themes from the in-depth interviews of the patients, and the next of kin. These were attitudes and experiences regarding the informed consent process, decision-making in the informed consent process, disclosure, knowledge, and communication of the informed consent process, emergency staff role in the informed consent process, resources affecting the consent process, challenges encountered during the consent process, and recommendations to improve the informed consent process. Six themes studied for the key informant interviews of emergency staff were; knowledge and perspectives on informed consent; processes, procedures, and practices regarding informed consent; communication strategies for informed consent; ethical considerations; benefits of informed consent; and challenges of emergency informed consent. Direct observation of emergency staff showed that consent was conducted in a noisy environment, greeting of patients, disclosure of risks, and assessment of understanding were poorly done at both institutions. Conclusions: Risks and benefits should be disclosed to the patient in simple language, and patients should be given an opportunity to ask questions, to improve understanding and decision-making during the consent process. A communitarian approach, combined with shared decision-making between the doctor and the patient and NOK, should be used during the consent process. Emergency staff at both institutions need procedure-specific consent documents, which capture the information that is given to the patient and institutional guidelines and policies on consent for incapacitated patients, who have no surrogates.