Abstract:
Informed consent is
routinely obtained before any surgical procedure and after
careful planning, includes any possible scenario occurring
during the surgical treatment. Every so often during emergent
surgery, not all scenarios are considered and the surgeon is
faced with difficult decisions. We are presenting a case report
on internal fixation of the acetabulum in a trauma patient using
the ilioinguinal approach. The ilioinguinal approachto the
acetabulum has been utilized for internal fixation of complex
anterior column fractures, anterior wall fractures, and certain
both column and transverse fractures of theacetabulum. To our
knowledge, there have been no reports of unanticipated encounter
of a preexisting asymptomatic inguinal hernia during the
ilioinguinal surgical approach. This is a case report of such a
case, and the resultant informed consent dilemma.
J.Orthopaedics 2009;6(2)e8
Keywords:
informed
consent; unplanned surgery; emergent surgery;acetabular fracture
Introduction:
The ilioinguinal approach to the acetabulum was
first described in 1965, and has been utilized for internal
fixation of complex anterior column fractures, anterior wall
fractures, and certain both column and transverse fractures of
the acetabulum. (1) The ilioinguinal approach has
been associated with few complications, including minimal muscle
dysfunction and a low incidence of peri-articular heterotopic
ossification. (2) One complication much discussed
but rarely encountered is laceration of the corona mortis, an
anastomosis between the obturator artery and either the external
iliac or inferior epigastric artery, during the surgical
approach with resultant significant hemorrhage. (3) To our
knowledge, there have been no reports of unanticipated encounter
of a preexisting asymptomatic inguinal hernia during the
ilioinguinal surgical approach. This is a case report of
such a case, and the resultant informed consent dilemma.
Case
Report:
A
33 year old obese Hispanic male presented to the Emergency
Department of Grady Memorial Hospital following a high energy
motor vehicle accident. His initial survey revealed a
pulmonary contusion, a left Gustilo-Anderson Type II open
diaphyseal femur fracture, and a displaced right transverse
acetabular fracture. He appeared intoxicated, and a
subsequent blood alcohol level was elevated. An attempt
was made to obtain informed consent for emergent surgery with a
Spanish interpreter, but because of his impaired cognition from
alcohol, was unsuccessful. There were no family members
with him, and an attempt to contact family members was
unsuccessful. On the night of admission, he
underwent emergent irrigation and debridement and antegrade
intramedullary rodding of the left diaphyseal femur fracture.
He was placed in 20 pound axial traction through a tibial pin
for the right acetabular fracture. Postoperatively, a CT
scan was obtained of the pelvis which demonstrated a displaced
transverse fracture of the acetabulum. On the fourth post
admission day, the patient’s cognitive status was normal, and
informed consent for operative fixation of the acetabular
fracture was obtained by the 2nd year orthopaedic resident. The
resident is fluent in Spanish, and she subsequently was not
involved in the surgical management of the patient.
Per prevailing custom, the operating surgeon on the preprinted
consent form was listed as “Emory Orthopaedic Service”. The
attending surgeon on rounds, who was the planned surgeon for the
acetabular surgery, explained the procedure through an
interpreter and wrote on the chart that “it has been discussed
with the patient alternative treatment and the possible
complications of excessive blood loss, nerve injury, infection
and post traumatic arthrosis.” On the 6th day following
injury, the patient underwent operative stabilization of the
acetabular fracture through an ilioinguinal approach. Upon
dividing the inguinal ligament, there was clear protrusion of
preperitoneal contents. At the time of the patient’s
history and physical, the patient did not complain of any groin
discomfort prior to the accident, and his obesity precluded
physical detection of the hernia prior to surgery.
Upon completion of the internal fixation of the acetabular
fracture, the orthopaedic service did not feel comfortable
closing the wound as the major concern was of potential
incarceration of the hernia by the closure. Intraoperative
consultation was obtained from the Emory general surgery
service. After further dissection, a large direct hernia
was identified, with fat and bladder contents. An unsuccessful
attempt was made to contact family members to discuss the
operative findings. A decision was made to proceed with a
standard tension-free Lichtenstein mesh closure (Figure 3).
Postoperatively, the hernia repair was discussed with the
patient by both the orthopaedic service as well as the general
surgery service. The patient appeared grateful, and
recovery was uneventful.
Discussion :
This case report
illustrates some of the issues involved in obtaining informed
consent in the surgical patient. The case was reviewed by
the Clinical Ethicist (who is also a lawyer) of the Ethics
Committee of Grady Hospital. The initial emergent surgery
was performed without informed consent due to the patient’s
obtunded condition. No family members were available in person
or by phone. The Official Code of Georgia Annotated (O.C.G.A.)§
31-9-3defines an emergency procedure as “a situation wherein
(1) according to competent medical judgment, the proposed
surgical or medical treatment or procedures are reasonably
necessary and (2) a person authorized to consent under Code
section 31-9-2 is not readily available, and any delay in
treatment could reasonably be expected to jeopardize the
life or health of the person affected, or could reasonably
result in disfigurement or impaired faculties.” (4) The
Georgia Medical Consent Law (O.C.G.A § 31-9-2) defines who can
give consent for emergent surgery for obtunded patients: 1) any
person authorized by the “ Durable Power of Attorney Act for
Healthcare”, 2) any parent for adult or minor child, 3) any
adult child for parent, 4) any adult for sibling, 5) any
grandparent for grandchild, and 6) married adult for spouse”.
If none of the above are available to give consent, emergent
surgery can proceed, provided the proposed procedure or
intervention meets the requirements of defined emergent surgery
as listed above. It is desirable to have a physician with
similar expertise and knowledge as the planned surgeon, and who
is not specifically involved in the case, to concur with the
planned surgery. (5) The initial surgery, irrigation and
debridement of the open fracture and intramedullary rodding of
the femur fracture, was an appropriate emergent surgery, where
significant delay could result in impaired function or loss of
limb. Furthermore, the attending surgeon wrote a detailed
note documenting the necessity of the procedure, the lack of
someone to consent, and the emergent condition of the patient at
the time of the emergent surgery. However, a second
surgeon with similar credentials as the operating surgeon, not
involved in the surgery, was not available to write a note
agreeing with the procedure; this is often the situation in
emergent surgery during night time hours.
The second
surgery, the stabilization of the acetabular fracture, presented
more difficult informed consent questions. It has been
demonstrated that obtaining informed consent in several groups,
including patients who do not have English as their primary
language and geriatric patients, is particularly difficult. (6)
In addition, it has been estimated that 60% of
the American public is medically illiterate to understand
informed consent completely(7).
The surgical
consent for the elective surgery was obtained by a 2nd year
resident fluent in Spanish. The patient signed the
standard Grady preprinted consent form, which is written in
English, with the operating surgeon listed as “the Emory
orthopaedic service.” The attending surgeon discussed
the surgical procedure, including potential complications, with
the patient through a Spanish interpreter, and documented the
discussion with a note on the chart.
It has been
demonstrated that informed consent obtained in the clinic or
office, with family members present, and with either a dictated
or written note documenting potential complications is more
desirable than a preprinted consent form obtained in the
preoperative area.(8) Although not optimal, the presence of
preoperative medications, including analgesics, does not
preclude satisfactory informed consent.(9) The Emory-Grady
Ethics Committee felt that the consent form should list the
individual surgeon rather a surgical service. Ideally, a
hospital-provided interpreter is preferable to a resident in
providing translation for informed consent.
The decision to
proceed with the repair of the inguinal hernia was decided
intraoperatively. From a surgical standpoint, the exposure
to repair the hernia was excellent, and elective repair of the
hernia at a later date would be more difficult because of
postoperative scarring. In addition, an inappropriate closure
could result in incarceration of the hernia. A statement
in the preprinted Grady consent form states: “I understand
that unforeseen complications or conditions may arise during
this procedure, and I consent to any additional procedures that
the physician(s) may deem advisable in their professional
judgment.” The general surgical team proceeded
with the surgical repair of the hernia, including the use of
mesh, on this basis. The clinical ethicist from the Ethics
Committee raised several concerns: 1) she suggested that any
surgical consent should name the specific surgeon scheduled to
perform the procedure. The repair of the hernia, usually an
elective procedure, was done without informed consent by a
surgical team not mentioned in the initial consent.
Arguably, the hernia repair was not emergent nor a known or
anticipated complication. 2) The patient has the right to decide
if he wants to undergo additional surgery and potential
complications and this requires that he-or his surrogate
decision maker-have the opportunity to receive the information
required to make an informed decision.
In biomedical
ethics, there are four major principles that are considered in
determining the ethics of a given situation. (13) Autonomy
is the obligation to respect the decision making capacities of
autonomous persons. This right of self-determination is
strongly supported in the fields of law and ethics.
Adherence to the principle of autonomy would suggest that the
surgical team defer the hernia repair to a later date when
consent could be obtained. Non-maleficence is the
obligation to avoid causing harm. Beneficence is the
obligation to provide benefits and to balance benefits against
risks. Justice is the obligation to determine fairness in
the distribution of benefits. 3) The ethical principle of
beneficence, doing good for the patient, could support the
intraoperative repair if the evidence shows that deferring the
surgery could cause greater harm to the patient. Balancing
the benefit of the surgery against the intrusion on the
patient’s autonomy was required to determine whether the
surgeons behaved in an ethical manner. Both the
orthopaedic and general surgical team decided that the principle
of beneficence outweighed the principle of automony.
It has been
suggested that the majority of orthopaedic surgeons, both
residents and attendings, are not knowledgeable about issues of
informed consent. (10) Much has been written concerning
informed consent for research, but much less has been written
about informed consent for emergent situations or unanticipated
findings in surgery. (11) The issue of listed surgeons on
consent forms, especially residents in teaching programs, has
also been a topic of recent interest.(11,12) It is
necessary to be knowledgeable about informed consent in treating
patients in a trauma situation to avoid potential litigation for
violating the patient’s right to decide what happens to his
own body and to avoid violating the ethical principle of
autonomy.
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