Date of Award

January 2018

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Vrunda B. Desai

Abstract

While there has been a shift in the view of informed consent over the past half century from a paternalistic legal protection to a shared decision that supports patient autonomy and the patient-doctor relationship, these theoretical changes have not been successfully operationalized. Repeat Cesarean Section (CS) is a scheduled procedure with a complex risk-benefit profile, and thus is an excellent lens through which to assess the quality and timing of informed consent documents. A chart review of informed consent documents for repeat Cesarean Section for six weeks from March 20th, 2017 to April 30th, 2017 was conducted (n=62). While all but one case in the sample had documented informed consent, there were significant differences with regards to documentation of risk and timing. Though bleeding (95%), infection (96%), and damage to adjacent structure (95%) were recorded in almost all cases, other risks such as need for hysterectomy (49%), abnormal placentation (49%), and need for cesarean section in subsequent pregnancy (40%) were documented less than half the time. Other maternal risks and fetal risks were rarely mentioned. Risks were more frequently documented by residents than attending physicians (5.6 v 3.2, p<0.00). Quantitative risk, benefits, and alternatives were never listed. Only 31% of consent forms were signed prior to the day of surgery with consents signed the day of signed, on average, one hour and a half prior to surgery. New shared decision making models and the use of multi-media technology in conjunction with new Center for Medicare and Medicaid guidelines for informed consent documentation may be a step forward towards improving medical decision making.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 06/25/2100

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