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NewBBSup

Informed consent. Who explains risks/benefits?

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My hospital's transfusion committee is re-evaluating who's responsibility it is to provide informed consent.  Currently our procedure states it's the physician's responsibility to explain the risks, benefits and alternative treatments of transfusion.  After discussion with several physicians it was discovered that this hardly ever happens.  We are considering shifting this responsibility to the nurses as they are getting the signature from the patient.  Is there any specific rule/regulatory mandate that the physician has to be the one to provide this explanation?

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1 hour ago, NewBBSup said:

Is there any specific rule/regulatory mandate that the physician has to be the one to provide this explanation?

If there isn't, there should be.  As I have said many times on this site, I have a huge respect for nurses, but they cannot be expected to keep up to date with all of the latest reasons why a transfusion is, or is not the best or safest treatment for a particular patient, with a particular condition.  It is equally difficult for a doctor to keep up-to-date, but it is easier to keep the Consultant Physician/Surgeon abreast of such things, via the Haematologist, and for him/her to cascade this "news" to their staff, and these more junior doctors would also have the knowledge (or should have the knowledge) to answer any of the patient's questions on the subject honestly.

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I know that it is the law in Washington and Oregon to have the physician obtain informed consent.  I don't know about other states.  I also know that it is rarely done here by physicians, even though all other treatments or procedures are explained by the physician.  I don't know why transfusion is being treated differently, but we have a new QI person and TJC will be inspecting soon, so hopefully they will decide to follow the law!  Plus, it is very rarely fully completed here and I have beaten my head against the wall many times trying to get compliance.  I just might make a comment when TJC comes in to talk to blood bank, even though the lab is inspected by CAP.

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In Massachusetts, it's the physicians.

We audit a small percentage of transfusions every month, and consent in one of the things we look for.  We've stopped "letters from the committee" as they are ignored.  We report No Consent directly to Patient Safety/Risk Management.  The hospital lawyers then contact individual MD and their chiefs.  This is also reviewed at Medical Executive meetings.  Very rarely now do we miss a consent. ;)

The higher up the food chain you report, the better the results.

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Informed consent should be done by the physician, as it is for other treatments/procedures. Risk/benefit explanations should be done by the individual ordering the transfusion as he/she is the person who is 'supposed' to be most familiar with the patient's condition. For some reason, consent for transfusions isn't taken as seriously as it should be. Shoving the responsibility onto nursing staff isn't fixing the problem. That's a tough one but it's something that I think is going to be a TJC issue - once a problem fits in that category, you have more teeth to address it.

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Yes, informed consent is part of physician credentialing.  It cannot be done by the nurse.  You could have your nurses offer an info sheet to patients, but the conversation about risks, benefits, alternatives, and consequences of refusal MUST be a conversation between patient and physician/provider (can be PA or NP but not an RN).

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I thought this role was being shifted specifically to TSOs (transfusion safety officers), who acted as a sort of clinical pt care/laboratory liaison? Unless this is still a relatively new position...

I know they were attempting to popularize it in an article within one of the immunohematology journals of this year.

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Not sure how I missed this discussion when it first came out but here's my 2 cents worth.  It is the physicians responsibility to inform the patients of ALL risk / benefits of every aspect of their treatment to include transfusions of any and all blood products!  Granted, this is not always possible due to the situation but that does not absolve the physician of the responsibility!  In no way should this responsibility ever be dumped on anyone else.  :coffeecup:

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In Australia it is the doctor's responsibility to have the informed consent/shared-decision making discussions, and to document this in the patient's medical record.

There are a number of resources available to assist and to educate doctors on how to do do it. I've listed some below that maybe of interest.

BloodSafe eLearning Australia provides online education and resources on clinical transfusion practice and patient blood management, and have exemplar videos on informed consent:

  • Shared decision making and consent for adult patients
  • Transfusion consent for neonates: A shared decision
  • Transfusion consent for paediatrics (currently being developed)

These are available at no cost.

The Australian Red Cross Blood Service also has a range of resources that can assist doctors with informed consent.

Disclosure of Interest: I am a transfusion medicine scientist and  previously laboratory manager, and am currently the manager of BloodSafe eLearning Australia, an Australian government-funded program that develops clinical transfusion education. 

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On 7/15/2019 at 8:18 PM, Ward_X said:

I thought this role was being shifted specifically to TSOs (transfusion safety officers), who acted as a sort of clinical pt care/laboratory liaison? Unless this is still a relatively new position...

I know they were attempting to popularize it in an article within one of the immunohematology journals of this year.

I wonder how many facilities have a TSO. Mine doesn't. I suspect many smaller, maybe even medium size facilities don't have them.

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1 hour ago, jnadeau said:

I came up with the attached and had them laminated and distributed to every unit - can't confirm that the info is always presented in full but...all we can do is try to help.informed consent2.docinformed consent2.docinformed consent2.doc

Thanks for this.  I love the marriage quote.  Any idea who it should attributed to?  You?

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Sorry no,  I'm not that clever Mable.  Came across it a while ago (2009) researching best practices on consents to update our P&Ps.  Obviously it's much older with that language (wantonly!).   Maybe some youngster can find out.   My search engine is tired.

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12 hours ago, David Peterson said:

In Australia it is the doctor's responsibility to have the informed consent/shared-decision making discussions, and to document this in the patient's medical record.

There are a number of resources available to assist and to educate doctors on how to do do it. I've listed some below that maybe of interest.

BloodSafe eLearning Australia provides online education and resources on clinical transfusion practice and patient blood management, and have exemplar videos on informed consent:

  • Shared decision making and consent for adult patients
  • Transfusion consent for neonates: A shared decision
  • Transfusion consent for paediatrics (currently being developed)

These are available at no cost.

The Australian Red Cross Blood Service also has a range of resources that can assist doctors with informed consent.

Disclosure of Interest: I am a transfusion medicine scientist and  previously laboratory manager, and am currently the manager of BloodSafe eLearning Australia, an Australian government-funded program that develops clinical transfusion education. 

Some great resources here.  Thanks.  Can anyone register for the eLearnings and is there a fee?

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19 minutes ago, jnadeau said:

Sorry no,  I'm not that clever Mable.  Came across it a while ago (2009) researching best practices on consents to update our P&Ps.  Obviously it's much older with that language (wantonly!).   Maybe some youngster can find out.   My search engine is tired.

Looks like it can be credited to Dr. Robert Beal per Google and a 2008 article in Blood.

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On ‎7‎/‎15‎/‎2019 at 9:18 PM, Ward_X said:

I thought this role was being shifted specifically to TSOs (transfusion safety officers), who acted as a sort of clinical pt care/laboratory liaison? Unless this is still a relatively new position...

I know they were attempting to popularize it in an article within one of the immunohematology journals of this year.

Its written in AABB News, April 2019, Vol. 21 Vol. 4

 

On ‎7‎/‎30‎/‎2019 at 8:25 AM, AMcCord said:

I wonder how many facilities have a TSO. Mine doesn't. I suspect many smaller, maybe even medium size facilities don't have them.

They definitely are trying to highlight it as an option; not many people are aware it's a thing.

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On 8/2/2019 at 8:42 AM, Ward_X said:

Its written in AABB News, April 2019, Vol. 21 Vol. 4

 

They definitely are trying to highlight it as an option; not many people are aware it's a thing.

I suspect that nursing management or quality is aware of it in many places, but in smaller to mid-size facilities they are going to be looking hard at the cost to benefit ratio. At what point are there enough units transfused so that the institution feels that it can 'justify' the expense of full- or part- time employees to supervise transfusions. Transfusions happen 24/7, so it wouldn't be just one person. Until it becomes a recommendation or requirement from somebody like TJC or an excellent case can be made for cost savings, it's probably not going to happen. I think my facility would benefit from a specialized 'transfusion team' who could take on some aspects of the TSO.

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On ‎8‎/‎7‎/‎2019 at 9:05 AM, AMcCord said:

I suspect that nursing management or quality is aware of it in many places, but in smaller to mid-size facilities they are going to be looking hard at the cost to benefit ratio. At what point are there enough units transfused so that the institution feels that it can 'justify' the expense of full- or part- time employees to supervise transfusions. Transfusions happen 24/7, so it wouldn't be just one person. Until it becomes a recommendation or requirement from somebody like TJC or an excellent case can be made for cost savings, it's probably not going to happen. I think my facility would benefit from a specialized 'transfusion team' who could take on some aspects of the TSO.

I agree, and at this point, as long as it isn't being reduced to the nurses it should be okay to absorb onto other existing positions

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On 7/31/2019 at 4:04 AM, Mabel Adams said:

Some great resources here.  Thanks.  Can anyone register for the eLearnings and is there a fee?

Yes Mabel, all free and accessible to anyone. just be aware that all courses are based on Australian guidelines

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