Titled ‘Let’s talk about the “C” words’, Trevor John Cleveland’s (University Hospitals Plymouth, Plymouth, UK) Graham Plant lecture at this year’s British Society of Interventional Radiology (BSIR) annual congress (6–8 November, Brighton, UK) tackled nationwide inconsistencies across patient consent and the provision of interventional radiology (IR) clinics.
“Consent has evolved and changed significantly over the last few years,” Cleveland began, stating that, in the UK, the General Medical Council (GMC) sets out Good Medical Practice (GMP) guidelines which govern principals, values, standards and delivery of care. “They are very clear that, when we deliver care, this should be in the best interest of the patient. This may be stating the obvious for most of you, but I feel this can be lost in some of the discussions. We must keep this at the forefront.”
The GMC also outlines duties which must be carried out by interventional radiologists, which includes supporting patients to make informed decisions. Cleveland described the difficulties that can arise when explaining often complex procedures to patients, particularly in an ageing population with “increasing levels of dementia and confusion”.
The guidelines also state that clinicians should refer to another suitably qualified practitioner when necessary, “an important thing to bear in mind—it works both ways,” he said. “It’s reasonable to have support from our clinical colleagues, and when they need our help and refer to us, we’re on an equal footing.”
Placing his talk within its legal context, Cleveland detailed the Montgomery Ruling, which “changed the legal standards for consent which clinicians are expected to deliver”. The Montgomery Ruling, or Montgomery vs Lanarkshire Health Board, was a 2015 UK Supreme Court case which found the latter liable for negligence following patient harm as a result of undisclosed procedural risks.
“This ruling focuses on the patient’s right to decide, making sure that they’re not passive in that decision-making. This is not the decision we make in a multidisciplinary team—the board can make a recommendation, or have a view—but ultimately, it’s the patient who decides,” said Cleveland.
Referring again to the GMC guidelines, Cleveland stated that interventional radiologists must endeavour to “find out what matters to patients and give them time to understand what they need to know—it’s not a two-minute job”. He added that patients need to be made aware of the expected benefits, but as importantly risks, no matter how unlikely. When providing this care, the GMC states that clinicians should accommodate the patient’s wish to record the conversation. Cleveland remarked that the potential for this recording to be played back may appear “slightly threatening”.
The speaker made clear that to gain informed patient consent the provision of dedicated time during IR clinics is necessary. “This all comes down to time with the patient,” he stated. “It’s near impossible to make an assessment of a patient’s capacity in a day ward with two or three other patients listening, using curtains for privacy.”
Cleveland moved on to detail the importance of pre- and post-procedure clinics. Pre-procedure clinics work to reassure patients and guarantee they have adequately consented to treatment going forward. Provided this time, Cleveland underlined how the IR team is able to unify and align on pre-assessment plans and any necessary repeat procedures.
“As IR has become involved with more complex treatment pathways—an example would be diabetic foot care—these clinics give us the chance to actually get the patient the appropriate investigation and treatment fairly rapidly,” said Cleveland.
He continued that post-procedure clinics are equally as important as pre-procedure, to monitor any issues or complications that may have arisen. “[Post-procedure clinics] also allow patients to feedback to you on whether they thought [the treatment] was a great idea or not, and whether you offered them something they wanted. Sometimes it isn’t and you learn what not to do going forward,” Cleveland shared.
He summarised that consent is “a process, and a potentially complicated one”, but if carried out correctly, patient expectations and experiences are invariably improved. Clinics are of two-fold importance, Cleveland continued. He said that they not only facilitate the proper collection of patient consent but position interventional radiologists as the “clinical team leaders” who are afforded key responsibility over their patients’ care.
