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We happened upon the idea of using checklists for consent when researching legal cases of family-provider conflict. From our work, we identified that a number of procedural errors were made by some clinicians who were losing their legal cases despite strong arguments. When we considered that consent is a process, and that procedural (often simple) errors in medical practice were the impetus for surgical safety checklists, we realized that a similar approach could improve the quality of care via appropriate consent.
A consent-focused checklist would only be useful however, if the kinds of errors we identified in a small sample of legal cases were in fact made on a regular basis. Initially, we might assume that if a new kind of ‘error’ were occurring all the time, it would be hard not to be aware of it. But, as it turns out, the nature of consent-related errors (ethical errors) is such that it is very easy for them to go unnoticed. For example, when an incapable patient comes to hospital, and they are accompanied by a family member who provides consent for initial treatments – it is very easy for providers to never question whether the family member is actually the legal substitute decision-maker. Those of us who act as clinical ethicists were able to validate our hypothesis in that many of our clinical consults arise as a result of consent-related confusion. Unfortunately, chart audits are unable to capture these kinds of errors because they may go unrecognized after a patient is discharged or dies in hospital. However, through clinician perspective surveys (see here), we have been able to locally identify that in fact such errors are not only common, but may be the norm.
The value in a checklist is to ensure that individuals and teams consistently perform several discrete, yet simple, tasks involved in a more complex process. Consent fits this mold perfectly and we believe (and are busy researching) the application of a consent-focused checklist across the entire trajectory of a patients acute care stay (ie. admission, treatment, and discharge/disposition)