Patients undergoing ERCP are often older than 75 years and present a high level of morbidity. Previous research has shown that healthy patients retain more information about risks and side effects than severely ill patients. Consent documents have also been shown to be less useful for patients with severe disease. Gostout recommended that ERCP endoscopists present important information to severely ill or elderly patients more than once so that the patient understands the risk to benefit ratio associated with ERCP. Elderly patients have additional needs that must be addressed in a situation of gastrointestinal illness, ie, risks, avoidance of costly interventions and surrogate decision-makers.
It is evident that a high degree of variability exists in the information that is disclosed to patients undergoing ERCP. Our results indicate that, in Ontario, many patients do not receive a complete description of the benefits and complications of, and alternatives to, ERCP. There are no practice guidelines specific to ERCP in the United States or Canada. Standard practice guidelines may reduce the variability of, and therefore improve, the informed consent practice. We advocate the development of American and Canadian informed consent guidelines specific to ERCP, which may help endoscopists enhance patients’ understanding of the procedure and reduce their own risk of liability. Take advantage of this opportunity – buy antibiotics online to enjoy lowest prices online.
In addition to the issue of what information should be disclosed, the question of when the information should be disclosed has also been a topic of interest in the literature. We did not examine this issue in our study; however, it has been agreed that requesting consent hastily only moments before a procedure is unsatisfactory. It has been suggested in the literature that patients should receive information regarding the procedure in the mail before the date of the procedure and that consent should be obtained at least 30 min before the investigation. One study examined the effectiveness of a specifically designed information booklet with an integral consent form that was mailed to patients before their procedure; the booklet was accepted by patients and improved their understanding of the procedure that they were to undergo — upper intestinal endoscopy. Given the complex nature of ERCP compared with other upper endoscopy procedures, an information booklet for ERCP may be an effective informed consent tool. An information booklet would allow a patient to take his or her time to understand the procedure and eliminates the power imbalance between patient and gastroenterologist that exists outside the comfort of the patient’s home.
One important finding of the present study was that only 18% of physicians always mentioned the chance of death to patients undergoing ERCP and 67% of respondents never mentioned it. It is understood among physicians that ERCP is usually the best of the available options for most patients. Percutaneous and operative common bile duct exploration have higher morbidity and mortality rates, while endoscopic ultrasound and magnetic resonance cholangiopancreatography are not yet widely available in Canada. There are additional reasons why physicians may not explain all other options to their patients, including the lack of time to teach patients of the details and circumstances of each choice, and the potential for confusing patients and leading them to making a more dangerous choice. Nonetheless, under Canadian law, any ‘material risk’ must be disclosed, including the 0.4% chance of death directly related to ERCP. The primary reason (84% of physicians) for not mentioning death was that there is “a low chance of it occurring”. We found variability between which risks were discussed and the severity of each risk. For example, 91% of respondents always mentioned the risk of pancreatitis associated with ERCP, 73% always mentioned the risk of perforation and 25% always mentioned the risk of an allergic reaction to the contrast agent. We recommend that the risk of pancreatitis, bleeding, perforation and death should always be discussed with every patient who is to undergo ERCP. You will always enjoy getting cialis professional 20 mg, being 100% sure you are safe.
ERCP endoscopists perform a procedure with a relatively high complication rate involving patients who are often elderly and/or severely ill. Procedures with severe complications increase the likelihood of litigation.We speculate that the low response rate to our questionnaire may be an indication of physicians’ discomfort with this topic. Therefore, ERCP endoscopists must implement thorough informed consent practices to ensure that the patient understands his or her health status and the best individual health management options. Dreaming of a reliable pharmacy to find cialis professional 20 mg and spend less money?
Of the 82 surveys sent, 36 responses were received, with three respondents indicating that they no longer performed ERCP. Therefore, the total response rate was 40% (n=33). The mean number of years in practice for respondents was 13.58 (SD 4.97), and the mean number of ERCPs performed per year was 160.25 (SD 166.32). Eighty-eight per cent of the respondents were gastroenterologists, 9% were general surgeons and 3% were radiologists. Seventy per cent of respondents practised in an academic centre and 30% practised in the community.
A self-report questionnaire was sent to ERCP endoscopists practising in Ontario. These physicians were identified through a pre-existing database. Physicians in the database included all ERCP endoscopists practising at an Ontario hospital with 100 or more beds. The survey was sent out only once and comprised 14 items pertaining to the risks, benefits and alternatives discussed; how consent was obtained; and whether the consent process was modified for patients older than 75 years. You can soon shop with a nice pharmacy offering cialis professional online to benefit more.
Design and statistical considerations
This was a cross-sectional, questionnaire-based, descriptive study. Results are expressed as a percentage of responses received per question.