Skip to main content

Can a Doctor Do a Medical Procedure Without Consent?

Image
By

Some time ago, I performed a colonoscopy on a patient who was having serious internal bleeding.  He had already received multiple transfusions since he was admitted to the hospital.  After obtaining informed consent for the procedure, I performed the colon exam.   I encountered blood throughout the entire colon, but saw no definite bleeding site, raising the possibility that the source of blood might be higher up than the colon, such as from the stomach.  I had not considered this possibility when I met the patient, but this was now plausible.  Can I proceed with the upper scope test, which the patient did not consent to, while the patient is still sedated from the colon exam?


Could the Stomach be the Culprit?


Seasoned gastroenterologists can usually predict the site of internal bleeding based on numerous medical facts, but there are times that we are surprised or misled.  Patients don’t always behave according to the textbook presentations we learned. 

At this point, which of the following options are most reasonable?
  • Do not scope the stomach now as the patient is still sedated from the colonoscopy and cannot give consent.  Once the patient has awakened and recovered, discuss the new diagnostic hypothesis and obtain informed consent to examine the stomach to look for a bleeding site.
  • Forge ahead with the stomach scope exam while the patient is still sedated.  Assume informed consent and proceed.
I opted for the latter option.  Ethically, I felt that I was on terra firma as the patient had already consented to a colon exam to evaluate the bleeding.  It seemed absurd that he would have consented for a colonoscopy but withhold consent for a stomach exam that was now deemed essential to pursue the same diagnostic mission.   Moreover, the patient had received multiple transfusions so there was clearly a medical urgency to identify the bleeding site.

Assuming consent for a subsequent procedure that was not initially anticipated is rational and defensible if the test is clearly in parallel with the medical evaluation and there is a medical exigency present.  Presuming informed consent, however, is an exceptional event.  Physicians are not permitted to go rogue. 

The blood in the colon didn’t come from the colon, as I had wrongly suspected.  It came from a duodenal ulcer just beyond the stomach, which I easily spotted with the stomach scope exam. 

This patient didn’t go by the book.  Sometimes, we physicians need to deviate from established policies also. 





Labels:

Comments

  1. TarigalJanuary 2, 2020 at 5:30 PM

    As a layman, I do not see any issue with what you did, as stomach scope is non invasive...now if you found something in the stomach scope, and proceeded to remove part of the pancreas, stomach, gall bladder, or removed some lower intestine...well then I would see a problem. No one likes waking up with less organs then when they went to sleep.

    Impact, although not well defined, would dictate your decision.

    ReplyDelete
  2. Michael Kirsch, M.D.January 4, 2020 at 3:06 PM

    @Tarigal, thanks for the comment. Your comment regarding ...waking up with less organs... is quotable! MK

    ReplyDelete

Post a Comment

Popular posts from this blog

Becoming a Part-Time Physician

By
Next month my schedule will change.  I will henceforth be off on Fridays with my work week truncated to Monday through Thursday.   I am excited to be enjoying a long weekend every weekend.  And while the schedule change is relatively minor, this event does feel like an important career moment for me.  It is the first step on a journey that will ultimately lead beyond my professional career.  It is this recognition that makes this modest schedule modification more significant than one would think it deserves.  As some readers know,   my current employed position has been a dream job for me.   Prior to this, I was in a small private practice, which I loved, but was much more challenging professionally and personally.   My partner and I ran the business.   Working nights, weekends and holidays were routine for decades.   On an on-call night, if I slept  through until morning, I felt as if I had won the lottery.   And w...
15 comments
Read more

When Should Doctors Retire?

By
I am asked with some regularity whether I am aiming to retire in the near term.  Years ago, I never received such inquiries.  Why now?   Might it be because my coiffure and goatee – although finely-manicured – has long entered the gray area?  Could it be because many other even younger physicians have given up their stethoscopes for lives of leisure? (Hopefully, my inquiring patients are not suspecting me of professional performance lapses!) Interestingly, a nurse in my office recently approached me and asked me sotto voce that she heard I was retiring.    “Interesting,” I remarked.   Since I was unaware of this retirement news, I asked her when would be my last day at work.   I have no idea where this erroneous rumor originated from.   I requested that my nurse-friend contact her flawed intel source and set him or her straight.   Retirement might seem tempting to me as I have so many other interests.   Indeed, reading and ...
69 comments
Read more

Personal Responsibility for Health

By
One of the advantages of the computer era is that patients and physicians can communicate via a portal system.  A patient can submit an inquiry which I typically respond to promptly.  It also offers me the opportunity to provide advice or test results to patients.  Moreover, the system documents that the patient has in fact read my message.  Beyond the medical value, it also provides some legal protection if it is later alleged that ‘my doctor never sent me my results’.  I have always endorsed the concept that patients must accept personal responsibility.   Consider this hypothetical example. A patient undergoes a screening colonoscopy and a polyp is removed.   The patient is told to expect a portal message detailing the results in the coming days.   Once the analysis of the polyp has been completed, the doctor sends a message via the portal communicating that the polyp is benign, but is regarded as ‘precancerous'.   The patient is advise...
3 comments
Read more