Informed Consent

HAHD_Informed_ConsentInformed consent is a legal requirement with a foundation based in healthcare. It enables the patient, parent, guardian, blood relative or court appointed entity to participate in the making of collaborative decisions, along with the responsible healthcare provider, regarding the medical treatment of the patient. Case law clearly defines exceptions to this rule, e.g., emergencies. Additionally, informed consent also applies to research and clinical trials.

Informed consent becomes a most powerful tool to ensure that the best interests of the patient are paramount and given utmost consideration by the responsible healthcare provider.  By law, if the patient/guardian is not provided full disclosure of the information surrounding a test or procedure, they cannot legally consent to it. Full disclosure refers to the veterinarian’s requirement to provide information regarding risks, benefits and alternatives/options when a test or procedure is prescribed.

Legal experts describe the requirements and guidelines (with case sources for these citations) for informed consent as follows:

  • “‘A physician has a duty to inform a patient in lay terms of the dangers inherently and potentially involved in a proposed treatment.” (Cobbs v. Grant (1972) 8 Cal.3d 229, 243; McKinney v. Nash (1981) 120 Cal.App.3d 428, 440.)
  • “The scope of a physician’s duty to disclose is measured by the amount of knowledge a patient needs in order to make an informed choice. All information material to the patient’s decision should be given.” (Cobbs, supra, at 245.)
  • “Material information is that which the physician knows or should know would be regarded as significant by a reasonable person in the patient’s position when deciding to accept or reject the recommended medical procedure.” (McKinney, supra. at 440.)

It should be pointed out that the American Veterinary Medical Association has moved away from the term “informed consent” and has chosen to substitute the term  “owner consent“. The AVMA claims this does not change the requirement for notification; they just don’t want to acknowledge the term guardian. They prefer the designation of our pets as property in large part because, as a practical matter, it makes vets unaccountable for malpractice. (See our Corporate Influence page for a more complete explanation). Regardless of terminology, simply put: Pet guardians/owners have an inherent right to make an informed decision about what diagnostic tests and subsequent treatments, if any, will be performed upon their pet. Period.

When the veterinary procedures being authorized are diagnostic tests, the issue of informed consent is somewhat simplified; the doctor is merely explaining to you what tests he/she believes will allow them to determine what exactly is wrong with your pet. The important issues at this stage are:

  • providing you with information regarding the risks of performing these tests
  • the intended use or benefit of the results
  • alternative tests that might provide the same or better information
  • the impact (if any) should you choose to reject a test
  • the cost (since the fees for diagnostic tests are generally derived from a fee schedule, there should not be a significant margin of error in this cost estimate)

One of the reasons we discuss testing separately is because there is a feeling among pet guardians that testing is often excessive and costly. The best way to protect yourself and your dog from unnecessary testing is to ask very specific questions of the veterinarian  recommending these tests. Every test run should have a tangible benefit to the patient, i.e., your dog. An example of an abuse of this concept occurred in our history with our female dog named Sally who preceded Billy in our lives. Sally was at UC Davis for care after a prolonged seizure. She had an MRI and it was determined she had a brain tumor. The next step proposed by the resident vet was to perform a brain biopsy. This would entail opening up her skull and removing some tumor, testing the extracted tissue and then closing her back up. It is very common to biopsy tumors, however, it is not always “standard operating procedure”. Our questions to the resident vet were:

  1. What are the risks of performing this test? To us, the opening of her skull to get a sample of tissue qualifies as a complex surgery with substantial risks. Upon questioning, the vet acknowledged we were correct.
  2. If after this procedure you are able to determine the type of tumor she has, will that in any way influence your treatment plan?

Her answer was, “No, we will just know what kind of tumor she has.” In actuality, it was unlawful for the resident vet to even propose a brain biopsy, because the information gathered and the procedure itself would in no way benefit the patient. This is a classic example of a vet recommending a procedure that may seem reasonable on its face, but is actually just intended to give a resident a little more surgical experience and run up the billable charges. The take home message: Ask about risks, benefits and options, because you cannot assume the vet is recommending a test for the right reasons.

Once a diagnosis is reached, pet guardians also have a right to make an informed decision about their pet’s treatment. Informed consent is the process of giving guardians the information they need to make decisions, including the full spectrum of choices as to what the guardian can do. Too often veterinarians only discuss the treatment they think would be best from their perspective.

For each possible treatment procedure (or no treatment) the guardian should be provided the specific risks of the procedure, intended medical benefit, likelihood of success/probable outcome, and estimated cost of the proposed procedure. If you don’t get the specifics for each potential treatment, ask for what was not disclosed. In our experience, omissions can be huge. For example, Billy had an inner ear tumor which was only partially removed by surgery. We were referred by the surgeon to a veterinary oncology clinic which provided head and neck radiation. There was no discussion by the oncologist that the biopsy results were not definitive (always ask for copies of these reports so you can review and ask questions). The oncologist recommended 19 sessions of head/neck radiation, without ever mentioning the inescapable side effect of mouth sores, which are painful, and often debilitating. Further, with Billy being an uncontrolled diabetic, these sores would predictably become infected, perhaps necrotic. I could imagine Billy would have to be euthanized as a humane intervention before he ever completed treatment.  It was only my training as a dentist that allowed me the confidence to reject radiation treatment as a dangerous choice when the tumor may or may not have even been malignant.

This discussion highlights the need to disclose the consequences of not providing the recommended treatment. The guardian must be made aware if a failure to treat would likely cause the pet undue suffering, in which case immediate euthanasia might be suggested. It follows that informed consent is more than a signed form in the pet’s file. It is a detailed discussion between veterinarians and guardians, and all informed consent discussions should be documented in the pet’s medical record. Notes should be made about the guardian’s decision and any questions that were asked and the answers given.

Often, veterinarians have written consent forms which a guardian is asked to sign before treatment can begin. However, these forms are ALWAYS incomplete with respect to establishing whether informed consent was really provided. This is because the form you sign provides the risks, costs and required details for only the treatment you decide upon. It does not establish that the veterinarian provided you with all your options, as informed consent requires. This signed document (consent to treat) is considered a contract for services between you and the veterinarian, and it is important that you treat it as such.

And finally, it is critical for the guardian to understand that the veterinarian, as the more knowledgeable party to the contract, is solely responsible for ensuring that the guardian has been provided all the information needed to make an informed decision. It is the doctor’s responsibility to be sure that the guardian fully understands the information given to them as well as the decision they have made, including all of its ramifications.

It seems reasonable here to provide the reader with the text of the “Veterinarian’s Oath”:

“Being admitted to the profession of veterinary medicine, I solemnly swear to use my scientific knowledge and skills for the benefit of society through the protection of animal health and welfare, the prevention and relief of animal suffering, the conservation of animal resources, the promotion of public health, and the advancement of medical knowledge.

“I will practice my profession conscientiously, with dignity, and in keeping with the principles of veterinary medical ethics.

“I accept as a lifelong obligation the continual improvement of my professional knowledge and competence.”

Informed consent exists for the protection of both the guardian and the treated pet, and the veterinary practitioner must always be held to it.