The consent form for operation is different from the medical record. Is the doctor responsible?

Recently, there was a question in the Zhihu, "What's the difference between internal medicine and surgery?" The answer was particularly interesting and made me very happy. The main meaning of most answers is that doctors make careful rounds, have detailed medical records and act cautiously; Surgeons are always in a hurry, making rounds very quickly, and the cases are simple, because most of the time is spent on surgery.

In fact, besides surgery, young doctors like me also need to do a job that physicians rarely do, that is, preoperative conversation. (Of course, the regulations are more detailed now. Puncture biopsy and gastrointestinal endoscopy also need to be signed, and doctors may have similar conversations. ) I don't know how many people who read this article have experienced preoperative conversations and how they feel. According to my experience in preoperative conversations over the years, this process is really uncomfortable for patients' families, especially at the last moment of writing and signing. Most of them will take a deep breath and bite their lips after hesitating for a few seconds.

We don't want everyone to experience such suffering, but to be honest, with the growth of age, similar experiences are hard to avoid. So here, I want to talk about the nature and general process of preoperative conversation, and make a psychological preparation for everyone. In case I really face preoperative conversation one day, I won't be completely at a loss.

Preoperative conversation is not a hospital disclaimer.

I often meet such family members and ask me when signing: "Is this the kind of life and death?" After signing, there is life and death, and the doctor is completely irresponsible? Every time I say, "This is a hospital, not a competition". "

The document that needs to be signed by family members after preoperative conversation is called informed consent form of operation. This name is completely from the patient's point of view and contains two meanings:

Inform: After the doctor's explanation, I fully understand the scheme and possible risks of this operation;

Consent: I consent to the doctor's operation on my family on the premise of knowing.

Signing, on behalf of the family, recognizes that he has obtained the right to know and autonomy in this operation, and has not received the operation under the deception and coercion of hospitals and doctors.

But this does not mean that the doctor is not responsible after signing. Patients and their families who have objections to the operation after operation may apply for medical appraisal. If the doctor is really at fault, the medical institution must bear the corresponding responsibility.

In fact, it is an obligation for doctors to talk with their families before surgery and get them to sign, just like operating on patients. If the doctor performed the operation, but did not talk before the operation, and the family members did not sign the informed consent of the operation, then even if the operation is successful, the doctor still has medical negligence, and the patient can still sue the hospital for "infringement of the right to know".

Preoperative conversation consists of three parts.

The content of preoperative conversation is different for different operations. But it is roughly divided into three parts in form. Take pancreaticoduodenectomy, which is often done in hepatobiliary department, as an example to talk about it in detail.

Premise: The patient was diagnosed as pancreatic head cancer by preoperative imaging and decided to undergo radical resection-pancreaticoduodenectomy.

The first piece

Introduce the surgical plan, that is, how the doctor will cut it.

In addition, if distant metastasis of tumor or other conditions that can't be cured are found during operation, what alternatives are there?

The second largest chunk

Inform of operational risks. This is the most important part, and it is also the part that family members have been complaining about being scared to death by you. There are various surgical risks, some of which may be encountered in all general anesthesia operations, and some of which are specific risks faced by specific operations.

Let me introduce the risks of * * *.

Risk 1: infection.

This is the same risk as all surgical operations. Usually, a broken skin may be infected, let alone major surgery.

Moreover, pancreaticoduodenectomy needs to move the intestine, and there are various microorganisms in the intestine. It is a class II operation that may be contaminated, not only the abdominal cavity, but also the incision, which is not as clean as the head and heart.

Risk 2: anesthesia.

Before this breakup, the anesthesiologist will talk alone and sign the informed consent form of anesthesia. Surgeons don't know much about it, so I won't go into details. General risks include: vomiting, inhalation asphyxia, respiratory depression, drug allergy, myocardial infarction, etc. Every situation can be fatal when it is serious.

The basic situation of each patient is different, and the probability of anesthesia risk is also different. Before the operation, the anesthesiologist will make a comprehensive evaluation of the patient, and if the risk is too great, he will not recommend the operation. But even so, the risk of anesthesia cannot be completely avoided.

Risk 3: bleeding.

This is an eternal challenge for surgery, especially pancreaticoduodenectomy. There are various blood vessels around the head of the pancreas, so blood preparation is more than general surgery. At this point, we usually take out the anatomical map and say it while gesturing.

Risk 4: diagnosis.

Simply put, it is found that the condition after laparotomy is different from the preoperative diagnosis. The preoperative imaging diagnosis was pancreatic head cancer, but the postoperative pathological diagnosis was benign. No way, pathology is the gold standard, which is limited by the current examination methods.

Risk 5: Recurrence.

All cancer operations are at risk of postoperative recurrence. This is especially true for pancreatic cancer, which is characterized by a high recurrence rate, and many people relapse one year after surgery.

At this point, there are usually several famous examples, such as Pavarotti and so on.

Risk 6: Other organ problems.

Such as lung infection and pulmonary embolism.

The above six points are the same risk of surgery for all tumor patients, followed by the unique risk of pancreatoduodenectomy.

Risk 7: all kinds of leaks.

There are still many anastomoses that need to be reconstructed after this operation, such as pancreaticojejunostomy+cholangiojejunostomy+gastrointestinal anastomosis. As long as there is anastomosis, there is a risk of anastomotic leakage, which is partly caused by surgery, but it is more common in patients with poor self-healing.

The strangest one is pancreatic leakage, which is a worldwide problem no matter how high the technology is. Doctors who have done this kind of operation have encountered extreme cases of pancreatic leakage after operation, as well as bleeding and abdominal infection caused by pancreatic leakage, and died. So far, no doctor dares to clap his chest and say that he has made a guarantee that pancreatic leakage will not occur.

Risk 8: postoperative gastrointestinal dysfunction.

Generally speaking, it is gastroparesis. If the stomach doesn't wriggle, you can't eat anything, from a week to months. This is another world problem that has not been completely solved.

Risk 9: The quality of life is worse than before operation.

Such as diabetes caused by insufficient insulin secretion of residual pancreas and cholangitis caused by stricture of biliary-intestinal anastomosis.

Risk 10: Other.

Due to individual differences, some rare other complications may occur, and the time relationship cannot be discussed one by one.

The third big piece

Answer the questions and show your attitude. This is the best time to communicate with doctors. If you have any questions, just ask. But there are some questions that doctors really can't answer, such as "what is the success rate of this operation" and "what is the probability of risk".

You can't just sign it.

The conversation is over. It's time to sign. Under normal circumstances, family members will sign it. After all, the operation was decided after careful consideration.

However, the attitude of signing the contract is different, mainly divided into three types:

Number one: I understand all the risks. In order to cure the disease, I have to face these risks with the doctor. I believe the doctor will try his best to finish the operation. This is the most common and best attitude.

Second: Doctor, are you scaring me? It's not that serious, is it In this way, we must tell him seriously: "I have experienced the above risks personally, not bluffing." Although the probability of occurrence is low, I do meet them. "

Third: I can't understand what you said. I just know that I can only do surgery if I sign it. I have no choice but to sign. In this case, you can't get him to sign. Tell him what you don't understand, just ask and we'll explain it to you. When do you understand and when do you sign the operation?

What doctors fear most is the third attitude. First of all, from the point of view of doctors performing their duties, this attitude shows that the preoperative conversation is invalid, and the right to know of patients and their families has not been met and cannot be perfunctory. On the other hand, from the point of view of the patient's family, the relatives do not care about the possible risks if they want to have such a big operation. They just want to sign the operation quickly, and there is a great possibility of disputes in the future.

It's not that doctors don't trust patients. I heard of a real case that happened in another hospital. The patient developed postoperative complications and his family went to court. The court ruled that there was no medical fault. However, the family members said that they did not understand the preoperative conversation and did not understand the risks. If they had fully understood the risks, they wouldn't have signed the operation at all.

Finally, out of sympathy for the weak, the hospital awarded some "humanitarian compensation". Since then, the hospital has set up a video camera to record all the conversations before the operation.

To tell the truth, having been a doctor for several years, it is difficult for me to sympathize with those "weak people" who can be seen at a glance. They are actually crying children with milk to eat, and often occupy more medical resources than others. What I appreciate more are those patients and their families who are low-key and introverted and easy to communicate. But then again, what's the use of my appreciation?