Obtaining More Than a Signature: Ethical Challenges of Reconsidered Informed Consent in Trauma Patients

​When a trauma patient in a non-life-threatening situation reconsiders informed consent that he or she has previously given, the goal should be to achieve a "mutual buy-in" with the patient and not to "simply obtain a signature," said a study in the June 2016 issue of Surgery. The authors presented the case of a 27-year-old man with partial amputation of his dominant hand from a machinery accident, who had given informed consent for replantation of his severed fingers. In the period between consent and transfer to the operating room, the patient began to express concerns about postoperative treatment (for instance, that he would not be able to smoke during this period). He subsequently requested that his fingers be completely amputated instead of reimplanted. In this case, the authors said, the injury was considered favorable for replantation since it was not life-threatening and use of the hand could be salvaged, but the patient was not favorable toward replantation, since he was a smoker with misgivings about staying in the hospital and participating in postoperative therapy. The patient exhibited acute stress and anxiety over the operation, and had been given a narcotic pain medicine. The authors said it is usually impossible to wait until the effects of pain medication wear off to obtain informed consent. The authors outlined four clinical options for the operative team: proceed with the operation based on the patient's original consent; cancel the procedure and proceed with a revised amputation; repeat the risks and benefits of both to the patient and give him the option to consult with family or other decision makers before proceeding; or conclude that the patient does not have decisional capacity and designate a surrogate.