— Cynthia B. Flynn, CNM, PhD
Associate Professor of Nursing, Seattle University

I'd like to add my thanks to Ms. Cohen for her efforts in creating this video, and for allowing to to be shared so openly! 

~Heather

The following is Wikipedia's entry on "informed consent":
"Informed consent is a legal condition whereby a person can be said to have given consent based upon an appreciation and understanding of the facts and implications of an action. The individual needs to be in possession of relevant facts and also of his or her reasoning faculties, such as not being mentally retarded or mentally ill and without an impairment of judgment at the time of consenting. Such impairments might include illness, intoxication, insufficient sleep, and other health problems."

I wonder how often, though, informed consent is actually and truly obtained for medical procedures and interventions during chidlbirth? I know for a fact, for example, that during my last birth, the admitting nurse CERTAINLY didn't obtain my informed consent before stripping my membranes. She actually explained to me WHILE she was examining me that she was was "loosening things up a bit", but never that stripping of my membranes could likely introduce infection that might be risky to my baby during a vaginal delivery before ASKING if I'd like to have it done. My attending doctor didn't obtain my INFORMED consent when proposing to break my bag of waters. He didn't tell me that one of the reasons that many women choose NOT to rupture their membranes is that it sometimes leads to fetal distress. Anyone want to venture a guess as to what happened as soon as my membranes were ruptured (aka: water broken)? My baby's heartrate began having decelerations during each contraction. He began exhibiting signs of fetal distress. Was the fact that that was a possible outcome included in the list of pros and cons discussed with me PRIOR to the procedure (i.e. informed consent)? In fact, were ANY cons disclosed? No. Not one. In fact, the only thing that was eluded to was that we "needed" to get things moving along. I don't remember being given any reason, just that we "needed" to. It wasn't until after the procedure that things went south. REAL QUICK. Less than 20 minutes later, my child was forceably ripped from my body through an incision in my abdomen and my doctor was the hero who had saved the day. Never mind that things were proceeding normally before the AROM (artificial rupture of membranes). Never mind that NO OTHER procedures were attempted, much less suggested, to remedy the situation. The FIRST course of action was c-section................or, as I was informed, we'd likely BOTH die horribly. Again, was true INFORMED consent given? Was I told of the risk of infection or the risk or hemmorage or the risk of any of the other PLENTY of things that can go wrong during a c-section? You guessed it. NEVER  ONCE.

My problem with procedures being performed without true informed consent is that the patient isn't armed with all the information they need to be able to effectively assess their risk during each procedure. My decisions weren't based on factual and proven risks and I know, after talking with lots of mothers lately, that it's pretty routinely done that way. I'm actually pregnant with another child and have, in fact, taken the intiative to inform myself. I've drawn up a birth plan and enlisted a support team who are totally on board with what it is that I want out of this birth and don't doubt that none of them will hesitate to obtain my informed consent for any proposed procedure. 

I encourage each of you to force your medical providers into a position of disclosure of ALL the possible risks and benefits of each procedure they propose. 

Here are some interesting tidbits concerning informed consent:

• Sometimes health care workers refer to the consent form itself as an informed consent. This is not quite accurate. Informed consent is the process or action that takes place as you learn about and consider a treatment before you agree to it. Your signature on the form is taken to be evidence that this took place. In other words, if you don't feel FULLY informed, DON'T SIGN THE CONSENT. Once you've signed it, you're as good as legally informed whether or not you're ACTUALLY informed.                                                                                                                                              

• Even when there are no other accepted medical treatment options, it is still your right as a competent adult to refuse to have a treatment that you do not want. But once you sign the consent form, it is considered to be your formal, legal agreement that you are okay with the plan or procedure that is listed on the form unless you revoke (take back) your consent before treatment is given. The doctor or facility will usually give you a copy of the consent form, but they keep the original as a legal record that you agreed to the treatment. In other words, once you DO sign the consent, you have no recourse unless you revoke it BEFORE a procedure is performed. You have, after all, signed that you understand and have been informed of ALL possible risks.

• For informed consent to take place, the information that is shared must be understood. This responsibility is shared by the patient, since the doctor won't know what you don't understand until you ask about it. The patient must have the chance to consider the information and ask questions. In other words, be certain that you understand exactly what is to be performed and what risks are involved before signing because after you sign, you can't say that you weren't informed that a negative outcome was possible. You've signed that you WERE informed.

• Informed consent requires disclosure of "material" (significant or important) information that will help the patient make an informed choice. The law defines material information in 2 ways; in terms of your health provider's responsibility and in terms of patient responsibility. Your health care provider's responsibility is limited to telling you those things that a health professional practicing in your community would tell you under the same or similar circumstances. Patient responsibility, however, and a patient-oriented standard of disclosure, is different. It means that the health provider is required to make known all the facts, risks, and alternatives that a reasonable person in the patient's situation would consider important in deciding whether to have a recommended treatment. In other words, you carry the majority of the burden of ensuring that you have given informed consent, not the doctor. His only burden of proof is obtaining your signature. He assumes that if you sign the consent, you're informed.

• Part of the informed consent process includes allowing you to ask questions about other treatments that may help you or other options that may offer you something that you prefer. You may choose other options, even if they are not as well proven as the one your doctor recommends or prefers. This is the part where you bring to the table all the research you've done BEFORE the proposed procedure and suggest alternatives that you'd like to try first. Examples might include changing laboring positions to encourage quicker labor progression as opposed to using medicinal augmentation, having a hep lock placed as opposed to a continuous IV line or intermittent fetal monitoring as opposed to continuous so long as everybody's doing well.

• If you are competent to make your own medical decisions, you have the right to refuse any and all medical treatment and diagnostic procedures. Even if not treating the disease or condition means that a patient will die, US courts have affirmed the right of patients to reject treatment. If you have decided to refuse treatment or diagnostic tests, the health provider may inform you of the risks or likely outcomes of this choice. This is called informed refusal. The doctor or facility may ask you to sign a form that states you received this information, and that you still choose not to be treated. If you do not wish to sign, the doctor may ask witnesses to sign that you were so informed in order to protect himself.

As much as informed consent is talked about in medical circles, it's sometimes unclear how to go about making sure you are being given the whole laundry list of pros and cons when actually having "the" conversation with your doctor. Here is a list of of some good talking points to consider when discussing procedures and interventions:

• What is my diagnosis (the medical name for the illness I have) and what does that mean for my pregnancy and/or labor?
• How serious is my diagnosis? (There should be a diagnosis for any recommended course of action.) 
• What methods of treatment/procedures are recommended?
• Are there other treatment options/procedures we should consider? If so, what are they?
• What benefits for myself and my child would you expect from the recommended treatments/procedures and other options?
• What are the risks to myself and my child or complications of the recommended treatment/procedure and the other treatment/procedure options?
• Are there discomforts for myself and my child that may be caused by the treatment/procedure?
• What are all the possible side effects of the treatment/procedure to myself and my child -- immediate, short-term, and long-term?
• How will having the treatment/procedure affect my normal process of labor?
• How would having not having treatment/procedure affect my normal process of labor?
• Is there a time frame that you are willing to delay the treatment/procedure in an effort for the condition to normalize on its own?
• Can you suggest any natural alternatives to the treatment/procedure that might be as effective?

Once you have gone through the process of becoming informed, the decision must be made as to whether you will follow your doctor's recommendation and proceed with his suggested treatment. Your doctor should give you ample time and not resort to bullying and unethical treatment to sway your decision. Assuming that you've been informed of the risks of denying treatment, the risks shouldn't have to be repeated to you unless you specifically ask for them to be. Generally, there is time for a private discussion between yourself and your spouse of other support person even in an emergency situation. Ask for 5 minutes alone to regroup and assess what risk is acceptable to you and what risk you aren't willing to consider. 

One important point to remember is that your doctor is obligated to continue his care of you regardless of your decision. According to ICAN (ican-online.org), professional ethical guidelines state that a physician may only drop you from his care after giving you 30 days notice. This means that if you are within 30 days of your likely delivery date, your care provider cannot terminate your care. In addition, if you are pregnant and are outside of that 30 day time frame, your provider must give you a referral and ensure you are transferred to a specific provider. Physicians who fail to meet these guidelines may be charged with patient abandonment, which is grounds for malpractice and constitutes a violation of ethical conduct that could result in loss of licensure.

In addition, a hospital may not refuse to admit you or treat you even if you refuse a procedure that is deemed necessary by them or their doctors. This includes hospitals who have "banned" VBAC (vaginal birth after cesarean) even if you refuse a cesarean section. The federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to admit women in active labor and to abide by their treatment decisions until after the baby and placenta are delivered. The act was originally designed to prevent hospitals from "dumping" patients who couldn’t pay but has since been widely used to hold hospitals accountable for violating other patient rights, including the right to refuse treatment. If your hospital threatens to perform a cesarean despite your refusal, notify them that they are in violation of your rights under EMTALA and that you plan to file a complaint. To find out where to report an EMTALA violation, go to MedLaw.

Understanding informed consent is a huge first step in ensuring that you get the birth experience you want especially in a birth culture like our local one. When you realize that YOU are the person who calls the shots in your medical treatment (or lack thereof), you become empowered in a way that you never realized before that you could be. In that scenario, doctors, nurses and hospitals become exactly what they were always intended to be - consultants who are being paid for their professional medical opinions. They have no more power over what happens to you than you give them. The "god" complex that has grown to become associated with doctors is one WE have handed to them through our own lack of education and blind trust that they always have our best interests at heart. As much as I truly believe that there aren't very many doctors who would cause intentional harm to their patients, I also know that sometimes their primary motivation is to avoid litigation even if it means suggesting a course of action that might not be at all what their patient would have chosen given access to all the information.

~ Amy

**Portions of this blog were directly quoted from ICAN (ican-online.org) and the American Cancer Society website (cancer.org).

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