Doctors Say COVID-19 Risk Should Be Part of Surgical Informed Consent

By Will Boggs MD

May 19, 2020

NEW YORK (Reuters Health) - The risk of infection with SARS-CoV-2, the virus that causes COVID-19, should be part of informed consent for surgery, according to a new paper.

"Surgical consent has traditionally focused on the specific risks and anticipated benefits and likely outcomes of the proposed procedure and the option for alternative therapies," said Dr. Jeffrey B. Matthews of The University of Chicago Medicine and Biological Sciences.

"The current pandemic has introduced unprecedented uncertainties into the informed consent discussion regarding the timing of operation (related to state-mandated postponement of non-essential surgery and subsequent relaxation of those policies), resource availability (PPE, ventilators, ICU beds depending upon stage of the pandemic), the risk of either acquiring COVID19 during the hospital stay or transmitting it to health care workers, and the potential for increased risk of serious postoperative complications if surgery is performed on asymptomatic or pre-symptomatic patients," he told Reuters Health by email.

Dr. Matthews and colleagues discuss their approach to these uncertainties in an essay in the Annals of Surgery.

The authors, with the approval of their academic medical center, instituted several policy changes regarding surgical informed consent during the COVID-19 pandemic. They implemented a policy that an appropriately "enhanced" informed consent discussion regarding the risks of surgery during the pandemic must occur prior to patient arrival at the hospital on the day of surgery, and that this discussion must be conducted by the responsible surgeon, not a designee.

To aid in this process, they developed a script to outline some of the unique considerations that might be included in these conversations. The script covered five topics. First, the enhanced informed consent addressed the lack of information on the true risks of otherwise routine procedures during the pandemic.

Second, the discussion should include the uncertain (but likely increased) risk of nosocomial infection with SARS-CoV-2.

Third, patients should be informed that the pandemic has changed day-to-day hospital operations in ways that have the potential to significantly alter their perioperative care and experience.

Fourth, surgeons should discuss the possible impact of pandemic-associated healthcare-resource shortages on the care of the postoperative patient.

Finally, surgeons need to emphasize the particular importance of advance directives and living wills for patients considering operative procedures during the pandemic. This allows care teams to make critical, time-sensitive medical decisions that respect the wishes and dignity of the patient.

"The introduction of a COVID-19 informed-consent process required internal medicolegal review but was enthusiastically supported at all levels of leadership," Dr. Matthews said.

He encourages all physicians "to consider the considerable uncertainties that the pandemic has introduced into clinical decision-making and the ethical implications of informed consent during a rapidly evolving public-health crisis."

SOURCE: Annals of Surgery, online April 29, 2020.