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We read with great interest the recent article by Uzbeck et al1 demonstrating increased anxiety in patients following detailed risk disclosure prior to bronchoscopy. This timely well-conducted study engages with the challenging area of informed consent, and the authors eloquently outline the difficulties in balancing patient autonomy and physician desire to minimise patient anxiety but also to avoid litigation. We agree that the small increase in patient anxiety following explicit consent “seems a price worth paying for most patients”. We wish to comment, however, on a couple of methodological issues.
The study information sheets were provided on the day of bronchoscopy which allowed little time to rationalise the information and also discussed prominently the complications of transbronchial biopsy, although not all patients would have undergone this riskier procedure.
We have recently surveyed the consenting practices of 33 respiratory physicians in the north-east of England. Thirty-one respondents always provided procedural information prior to bronchoscopy and 2 often did so (verbal and written 26, verbal only 6, written only 1). Thirty respondents always, 2 often and 1 never explained the indication for performing bronchoscopy. There was a wide variation in individual consenting practices with regard to disclosure of serious or frequent risks which was tailored in the majority if the patient underwent transbronchial biopsy (figure 1). Particular risks were represented in terms of an exact percentage in 15 and in 6 by means of words (eg, occasional, common). Fifteen respondents tailored their consent in the presence of significant co-morbidity. Risk of death was communicated always by 3 respondents, often by 1, sometimes by 15 and never by 14.
The current British Thoracic Society guidance on consent for bronchoscopy from 20012 reflected the legal and ethical standard at that time where doctors were “entitled to withhold information” if it was thought to be detrimental to patient health and were under “no duty … to point out remote risks”. The ethicolegal landscape has been changed dramatically by rulings such as Chester v Afshar,3 and this is reflected in the recent General Medical Council publication on consent4 which states that a doctor “must tell patients if an investigation or treatment might result in a serious adverse outcome, even if the likelihood is very small”.
We feel that all patients with capacity undergoing bronchoscopy should be offered detailed risk disclosure with documentation of the decision in those patients wishing to “opt out”, and that this risk information should become standardised and individually tailored where possible.
The authors acknowledge the respiratory physicians who responded to the survey on consenting practice.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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