Optimism and consent to treatmentBMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6118 (Published 09 October 2014) Cite this as: BMJ 2014;349:g6118
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When I wrote that I believed a recent editorial was our first co-authored by patients, I thought I was probably wrong. And so it turns out. We have published lots of editorials by patients, both alone and as co-authors. Here are some:
BMJ 2014; 349 – Editorial: Jeff Whittle: Patients are overoptimistic about PCI (Published 18 September 2014)
BMJ 2014; 349 – Editorial: Tom Fahey, Bebhinn NicLiam: Assembling the evidence for patient centred care (Published 29 July 2014)
BMJ 2014; 348 – Editorial: Alf Collins, Anya de longh: Independent Commission on Whole Person Care for the UK Labour Party
(Published 20 March 2014)
BMJ 2013; 346 : - Editorial: Tessa Richards et al: Let the patient revolution begin (Published 14 May 2013)
BMJ 2008;336:903 – Editorial: Hazel Thornton: Patient and public involvement in clinical trials (Published 24 Apr 2008)
Joanne Shaw, Mary Baker
BMJ 2004;328:723 Editorial: “Expert patient”—dream or nightmare?
BMJ 2003;327:693 Editorial: Hazel Thornton: Patients' understanding of risk (Published 25 September 2003)
BMJ 2002; 325:725-6 - Editorial: Hazel Thornton, Mary Dixon-Woods: Prostate specific antigen testing for prostate cancer: new approaches to risk management (Published 5 October 2002)
Competing interests: I am editor in chief of The BMJ and responsible for all it contains.
It is not surprising that patients do not understand the issues. Goff et al.(1) found that cardiologists tend to overstate the benefits and understate the risks of angiography. They “found evidence that cardiologists may contribute to patients’ misperceptions of benefit through explicit or implicit overstatement of benefits, understatement of risks, and communication styles that may hinder patient understanding and/or participation in decision making.”
While attending the annual Veith Symposium in New York, a conference for vascular surgeons and interventional cardiologists and radiologists, I have often heard the term “ticking time bomb” used in reference to asymptomatic carotid stenosis, a condition that in 90% of cases is better treated with medical therapy than with endarterectomy or stenting (2). That phrase turned up in research by Helen Reifler and Pamela Wescott of the Foundation for Informed Medical Decision among patients considering intervention for asymptomatic carotid stenosis, during focus groups they conducted in San Diego (3).
A blog post by Dr. Bernard Lown at http://bernardlown.wordpress.com/2012/03/10/mavericks-lonely-path-in-car... includes the following:
“Cardiologists and cardiac surgeons frequently resort to frightening verbiage in summarizing angiographic findings. This no doubt compels unquestioning acceptance of the recommended procedure. Over the years I have heard several hundred expressions, such as: “You have a time bomb in your chest” and its variant “You are a walking time bomb.” Or, “This narrowed coronary is a widow maker.” And if patients wish to delay an intervention, a series of fear-mongering expressions hasten their resolve to proceed: “We must not lose any time by playing Hamlet.” Or, “You are living on borrowed time.” Or, “You are in luck — a slot is available on the operating schedule.” Maiming words can infantilize patients so they regard doctors as parental figures to guide them to some safe harbor.”
This pattern of communication is all too common, and probably not only perpetrated by cardiologists. Patients deserve better.
(1) Goff SL, Mazor KM, Ting HH, Kleppel R, Rothberg MB. How Cardiologists Present the Benefits of Percutaneous Coronary Interventions to Patients With Stable Angina: A Qualitative Analysis. JAMA Intern Med 2014;174:1614-21.
(2) Spence JD, Pelz D, Veith FJ. Asymptomatic Carotid Stenosis: Identifying Patients at High Enough Risk to Warrant Endarterectomy or Stenting. Stroke 2014;45:655-7.
(3) Reifler EJ, Wescott P. Carotid Endarterectomy A Shared Decision Making Lost Opportunity. 16-6-2009. http://www.powershow.com/view/122b6b-MzBkY/Carotid_Endarterectomy_A_Shar... Presented at the International Shared Decision Making Conference, Boston, MA, Foundation for informed medical decision making. Accessed October 7, 2014.
Competing interests: No competing interests
Informed consent is a redundancy, because being properly informed is a precondition of consent. Without being properly informed, a patient or client cannot give any legitimate, binding consent. Therefore, it is imperative that all professionals withhold any request for agreement or signatures, until after all information and questions have been fully addressed.
Competing interests: No competing interests