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The Dilemma of Consent: To Tell or Not to Tell

Nov 16 | 2:30 PM

Health professionals are expected to always tell their patients the truth. Nonetheless, if they examined their work every day, there are demands in which the truth is not always a certain matter. This begs the question: Is it the obligation of health professionals to always tell their patients the truth, or are there situations where some dishonesty may be justifiable in order to avoid more serious harm to a patient? When and under what conditions could incomplete disclosure be justified? Informed consent is more than just protecting patients from unwanted bodily interference; it also allows them to make informed decisions about their care. Join us as Dr. Neeraj Nagpal discusses this practical dilemma of consent.

[Music] hello everyone good evening i am dr samadhnya and i welcome you all on behalf of team netflix uh today we have with us dr niraj nakpal convener and managing trustee medico's legal action group ex-president iama chandigarh sir also serves as the director of the gastrointestinal diagnostic clinic he is also an activist who has spoken out on numerous occasions in support of initiatives that benefit doctors sir has also written numerous books and chapters and books welcome sir over to you sir oh thank you so very much i i must thank raksha for giving me this platform uh the topic we discussed and we thought appropriate for discussion today was consent and what is to be told that what is not to be told to the patient and consent this is a dilemma which all of us face and if we scare the patient too much by telling them too many complications we fear that the patient will not get the procedure done and if we don't tell them enough then later we are hauled up in courts that we have not taken an appropriate informed consent so what is the legal status and how and what all is to be discussed in consent what all is to be shared in consent this is the topic for today the in law within indian law the only place where consent has been defined is in indian contract act of 1872. mind you the concept of consent did not come up till 1914 but in this indian contract act of 1872 uh the consent has been defined as per indian law and it says that two or more persons are said to consent when they agree upon the same thing in the same sense this in itself is there is a confusion between what is an agreement and what is a contract because consent has been defined as a contract so we also need to understand that what is a contract and what is an agreement you basically need to know that all contracts are agreements but all agreements are not contract a contract is something which is enforceable an agreement will become a contract or a consent if one it is done by free will there should be no force which has been used to get the other person to con to consent without undue influence without fraud without misrepresentation without mistake of fact or law the parties should be competent one they should be more than 18 years old and two they should be in the normal frame of mind a mentally challenged person cannot be concerned considered to be a competent viewer consent the term legal term uses is composed mentis so a minor cannot give consent and a mentally challenged person cannot give consent then you also need to realize that a contract or a consent can only be for the lawful consideration you cannot make an agreement with a patient or with anybody that we will go and rob state bank of india and this is an agreement between us but the fact remains this kind of agreement or this kind of contract is not enforceable because it is not for a lawful consideration and as i mentioned the principle of consent first came in 1914 where justice cardozo has stated that a surgeon who performs an operation without his patients consent commits an assault this was a in a u.s court and not only consent the person should give a consent to get the surgery done but he should be giving the consent after receiving adequate information this came in 1957 the concept of informed consent this is the crafts of the talk today what is an informed consent how much is too much and what can be told and what cannot be told what need not be told to the patients this concept of informed consent was added in 1957 again in u.s courts uh the problem and this was discussed threadbare as how much should be told so initially the benchmark was what do the other doctors nor so it was doctor centric versus patient center uk has always followed the doctor centric uh path and this was established from their supreme courts where if you have told let us say a procedure has 15 complications and you have told five if other doctors also tell the same five complications to their patients then what you have done is correct you do not need to tell all the 15 complications and this was in 1985 this judgment of sidway versus bethlehem royal hospital governors where this concept was established however an india follows the british law india does not follow the u.s law where the concept of informed consent is patient-centered so this montgomery's case recently in 2015 the uk supreme court has also moved on to say that rather than being a matter for clinical judgment to be assessed by professional medical opinion a patient should be told whatever they want to know not what the doctor thinks they should be told so basically with montgomery uk has also shifted towards what the u.s practice is and not only are you supposed to tell about procedures which are available within your establishment if there are procedures which are not available within your establishment even those have to be explained to the patient again this is a u.s supreme court which has given this law to date at least in india we are lucky that we do not have to follow the us law but the samira koli judgment which is the landmark judgment in case the landmark judgment where this was decided that right now we are going to follow the uk pattern which has kept the consent as a real consent meaning to say if a doctor tells all those complications which other doctors also tell then under those circumstances the doctor has taken an adequate consent the informed consent of u.s where everything had to be told this the samira kholi judgement has said we may be moving from real consent to informed consent if commercialization of medicine continues in india these are the words picked up from the judgement and now this was the recent case of dr karamjitse versus prempal javadharana high court 2019 where they have very clearly said be that as it may in view of the mandate of article 141 of the constitution this court is bound to follow the law laid down by the honorable supreme court in jacob matthew case instead of montgomery even though the latest judgment on point being a matter of judicial proprietary meaning to say the punjab high court accepted the position which was established by the montgomery case of 2015 in uk but because in india we are following what supreme court has decided so keeping within their powers they have not gone and accepted the montgomery but they have agreed with the principles of montgomery without penalizing the doctor in this case what you need to realize is the laws in india are very confusing one a boy can adopt a child at 18 years of age if a boy is 18 years of age he is competent to adopt the children he cannot get married till he is 21 and he cannot have an alcoholic drink till he is 25 this is the law in india and if you read the paragraph 24 of samira kohli judgment uh they say that in sidway versus bethlehem royal hospital governor's case this was clarified that remote risk of damage referred to as a risk of one to two percent need not be disclosed but if the risk of damage is substantial referred to as ten percent risk it may have to be disclosed now many medical legal experts i have heard them say if out of 100 patients who are operated 10 patients develop complication that complication only that has to be told if out of 100 one patient develops a complication that does not have to be told this is a wrong impression 10 complications 10 percent patients dying in a particular surgery that surgery will be banned what effectively was meant was let us say there are 100 complications of cholecystectomy 100 patients with complications of polycystic out of these 100 let us say 15 were a cbd injury then cbd injury has to be told but if there was one patient or pulmonary embolism that one percent would not be considered appropriate to be told in a real and valid consent so this 10 figure is not 10 percent of the cases it is 10 percent of the complications which occur this has to be understood very well and this judgment very clearly said that a doctor has to seek and secure consent of the patient before commencing treatment the patient should be composed mentis his consent should be voluntary and on the basis of adequate information what do you need to tell them you need to tell them the nature of the procedure that of the treatment its purpose benefits and effects you have to tell what alternatives are available if any and you have to tell an outline of substantial risks involved in doing the same procedure also you need to tell adverse consequences of the alternative procedures or adverse consequences of refusing treatment the samira colleague judgment has clearly laid down the law for indian scenario where they have sided with the real and valid consent of uk where they have said and no need to explain remote or theoretical risks involved which may frighten or confuse a patient and result in refusal or consent for necessary treatment similarly there is no need to explain the remote or theoretical risks of refusal to take treatment which may persuade a patient to undergo a fanciful or unnecessary surgery the real concern it is for the doctor to decide with reference to the condition of the patient nature of illness and the prevailing established practices how much information regarding risks and consequences should be given to the patients most importantly if your patient is under anesthesia you have operated and you have taken consent for one particular surgery intraoperatively you find an additional pathology for which you feel it is in interest of the patient to get that operated as well it will avoid a second anesthesia it will avoid a second surgery it will avoid the unnecessary costs the code was very strict and very clear on this issue that you are not to bother that patient will have to undergo a second surgery it is not for you to concern that it will cost will go up for the patient if the patient has asked for one surgery you cannot extend it to do one and a half or two surgeries so you have to allow the patient to come out of anesthesia take a separate consent on a separate date and go ahead and do whatever the additional procedure you wanted to do and it was also told very clearly like in a case of hysterectomy you need to inform the patient regarding sterility premature menopause and you do not need to inform about urinary injury vesico vaginal fistula fatal hemorrhage anesthetic death this of course was established in samira poli and after that in national consumer disputed wrestle commission this issue came up where 14 weeks mdp along with laparoscopic tubal ligation was consented for perforation of uterus was noted following mtp repair was done intraoperatively decided to remove unhealthy appendix after all this rectal perforation and peptonitis occurred which required surgery in another hospital so even though the issue was why did you need to go ahead and remove the appendix when you you were doing an mtp there wasn't you're trying perforation you should have prepared that operation and go on there was no need to additionally do the appendix another recent case which had caused a lot of dispute dispute and confusion among doctors was this case of vinod khanna versus rg stone urology and laparoscopic center where the national consumer disputed wrestle commission in his wisdom stated that you cannot have uniform written consents typed pre-printed consent forms now this was something which was against what was the norm against what was being practiced all over the country in thousands and thousands of hospitals in all patients all hospitals have pre-printed consent forms and in these pre-printed consent forms there are spaces which are left to be filled by the doctor and regarding the name and the type of surgery and so on so forth so this case created a lot of confusion and despite in this judgment the code saying very clearly that we find the consent to be an informed consent now you have to realize samira kohli has asked us only to take a real and valid consent informed consent is one step above real and valid consent where you are telling everything to the patient that the patient wants to know and if this was an informed consent then and they did not find any deficiency in service or medical negligence or part of opposite party then how was this case penalized and it was said that this informed consent and undertaking was unfair trade practice the hospital was penalized this case was taken to supreme court by r.j stone and laparoscopic hospital and the supreme court heard the contentions of the petitioner and stayed the directions of ncdrc with regard to pre-printed forms so we do not need to worry about this as long as your consent forms are procedure specific they should be procedure specific please note this word you cannot have one uniform consent which is for cesarean hysterectomy cholecystectomy resection anastomosis there is no way you can have one bland consent which covers everything in this particular case uh from punjab state consumer disputed wrestle commission the court has specified three conditions where you are justified in withholding information from the patient number one a waiver situation is when a patient expressly states that he does not want to receive any further information this has to be documented well in writing number two in a medical emergency when life-saving treatment is required and patient temporarily lacks decision-making capacity number three therapeutic privileges when patients decision-making capabilities are impaired so much that the very act of giving the particular information would cause the patient serious physical or mental harm for example the patient with an anxiety disorder now when we read these judgments they seem so reasonable unfortunately this is not what happens in an emergency in a hospital a patient coming with gas and retrosternal discomfort when is told that he requires an angiography and he is anxious he is having an anxiety disorder at that time that may be temporary that may not be a permanent but in that time within that anxiety disorder he refuses to go undergo coronary angiography now without consent our doctors to go ahead and do that coronary angiography or not this is something which is the crux also when taking consent you need to be very clear who should sign the consent you cannot go ahead and do a procedure in a person whose adult who is conscious who is oriented who has the understanding to to grasp what you have told the patient under those circumstances there is no rule for husband signing the consent there is no role for wife signing the consent there is no role for sister brother father mother nobody it is the patient who has to give the consent whether a consultant or the nurse who has taken consent should also sign yes if the consultant does not sign the consent remember we already have established that consent was a contract and a contract is between two parties if only one party is signing it is not a valid contract what happens in a pediatric patient in a pediatric patient less than 12 years one parent can give consent it is not necessary that both parents should be there to give the consent between 12 and 18 years it is always better you take signatures of the child as well as of the parent in case a procedure could cause sterilization samira kohli judgment has already said yes we should have consent both of husband and wife uh but there is confusion regarding what should be done in situation of an mtp what should be done when duplication is being done because the government orders one thing where they have upheld the woman's right to undergo any of these procedures even without the husband's consent but on the other hand it has also been stated that a procedure which results in sterilization the consent should be both from the uh husband as well as wife next is the issue what should be the language of consent language of consent ideally should be a language which is understood by the patient now supposing you are doing medical tourism and you have a person come from iran he doesn't understand your language you don't understand his language you cannot have a pre-printed iranian consent form so their role of translators come in comes in between usually these people are students who are studying in indian universities they make money they earn their livelihood while staying in the country by acting as translators for these foreign patients who come into various corporate hospitals and this line will have to be added in a consent like this that the person who is the translator he has explained the contents of the consent form to the patient to the best of his knowledge and ability and the patient understands all these and exceeds or has given consent for the procedure to be done number two when should consent be taken consent should be taken ideally one we should give the information regarding the procedure we do in the opd and let the patient go home think it over before doing the procedure when the patient comes on the day of admission you should take a consent at that given time but the information should also already have been provided to the patient earlier what is the role of witnesses in consent there is a lot of confusion and dispute regarding this among medical legal consultants some people feel that witness should ideally be purely neither related to the patient nor related to the doctor yes this is ideal but why do we need witness from a doctor's angle if i have to argue i need a witness to prove my point in court and if an independent witness is not going to be approachable or not going to be able to come to court to support my version of the story then under those circumstances he is not a good witness for me a good witness for me is a person who will come into court and give a statement yes the what dr nagpal has said these this is the sequence of events and i have witnessed this so the issue arises should we choose a staff member versus should we choose an independent witness versus we we should choose a relative of the patient a relative of the patient may be the same person because the person who has brought the patient to hospital may be the same person who may be the complainant in your in the case against you and you cannot expect a complainant to give evidence in your favor so the role the witness should be chosen with the a lot of thought in mind i personally feel uh hospital staff other doctors not involved in treatment there is no point in taking witness signatures of people who are standing by who will never be able to be contacted later on in life then what about multi-stage treatment especially things like chemotherapy especially things like immunization do you need to take consent at every scheduled immunization or do you need to take consent at every time you give chemotherapy because it is already planned so you can take consent for multi-stage treatment giving all the details but again to my satisfaction because the views of the judiciary regarding doctors profession are such that we need to be overtly safe rather than sorry so i will strongly suggest that you should still take a separate consent on the day of the procedure which may be part of a multi-stage procedure so you take a consent which is a multi-stage consent but problem arises like places like in chemotherapy recently there was a case where six cycles of adreamycin were supposed to be given now after five cycles the patient had dropped the weight so much that when the sixth cycle was given it was grossly the dose was grossly more than what was needed by the patient of that weight and this resulted in congestive cardiac failure so my point is if every time you are taking consent you are bound to look at the patient in that angle and the dose is and number two can patient refuse to get procedure after consent this is very interesting because we had discussed in this lecture that consent is a contract and contract is something which is unforeseeable so now once a patient has given consent that i am willing to donate my kidney to and tomorrow he says he may i am not willing to donate so is this contract enforceable no a patient can refuse to get the procedure even before he is given anesthesia on the table and if he refuses we cannot proceed to give to do the procedure unless and until it is a life-saving procedure for which no consent is needed consent in emergency situation i have already mentioned if it is life saving you can go ahead without consent and this life-saving procedure can be done without consent consent for special requests doctor please don't write in the history my history of alcohol intake doctor please do cesarean on 11th november between 12 a.m and 2 p.m because this time is what is the best time as per astrological so these are special requests for whatever reason if a patient is asking you to do something you need to tell them clearly we are going to go by the book we will take your signatures on the discharge summary which will say clearly yes this patient is a known alcoholic for the past 30 years and there is a whatever history he is trying to hide on with the discharge summary will contain that history will contain the signatures of the patient and after that only with a written request will a separate discharge summary be provided to him if at all which uh would mention yes without mentioning the history of alcohol intake so that will be only on a special written request from the patient regarding insurance company will not pay my bill or my employers will come to know whatever reasons he may have given but unless and until you have a request in writing please do not concede two special requests which can get you into trouble tomorrow because tomorrow you will say i did the cholecystectomy all right when i put the laparoscope in the liver was found to be ceratic they were not used and the court will say why if you had already written that the history of alcoholism was there then there was no issue but now you have not written and you are the one who will be held responsible and remember consent is not only a simple stamp or a simple thumb impression consent is a dialogue you need to talk to your patients also remember regarding consent in ipc there are number of sections where if you are doing something which is in interest of the patient it is not an offense whether you are doing something with consent without consent it doesn't matter but if you are doing something in which is something which is lawful and you feel it is to help the person then it is not a consent it is not a offense there is section 80 87 88 92 92 clearly says if you have done an action in good faith for the benefit of the person without consent it is not an offence so criminal charges should ideally not be applied even though the first definition was if a surgeon operates on a patient without his consent he will be prosecuted for assault which is a criminal offence even in india i have not found many criminal cases in fact any criminal case being filed against a doctor for assault purely on for the reason that he has not taken consent i have already covered this that consent of one parent is more than enough you do not require consent this also we have covered that the consent form has to be signed by the consultant or by the person who is taking the consent the most important uh issue regarding consent arises where you need to withdraw the ventilator from a patient where you need to stop providing supportive treatment to a comatose patient or a patient a vegetative state because these number of cases like this are there all over the country in various hospitals where for two years five years 11 years patients have been admitted they had come basically for a surgery during surgery they was a cardiac arrest after the cardiac arrest they were revived but unfortunately brain damage was there and the patient is in a vegetative state or the patient has been shifted to icu in on ventilator now after some time the finances of the patient party obviously are going to be affected and nobody can continue to afford the kind of treatment with the kind of technology we have today indefinitely so this is a frequent request from relatives to remove the patient from ventilator to stop supportive treatment to a patient with vegetative state and these issues were first taken up in a case of gyan carver's state of punjab in 1996 where the court had held that right to life under article 21 of the constitution does not include right to die so they had clearly said no arunachamba case versus union of india was a landmark case this was a nurse in km hospital and she was taken care of by her colleagues for 16 17 years finally one friend of hers had put in an appeal in the supreme court to end her agony by withdrawing the supportive support that was being given to her including the nasoja nasogastric feeds including the nursing care and the supreme court in its wisdom had made certain observations some of them were if an adult person of sound mind refuses however unreasonably to consent to treatment or care by which his life would or might be prolonged the doctors responsible for his care must give effect to his wishes even though they do not consider it to be in the best interest they also said that this kind of withdrawal of life support from an incompetent patient can only be done by high court order under article 226 and only the high court can grant such a permission they laid down the procedure on how high court was to be approached for this then came the case of living will where common cause versus union of india this was a march 2018 judgment where again this issue was re-wasted and they said the law of the land as existing today is that no one is permitted to cause death active euthanasia was declared unlawful they also recognize that an adult human being of conscious mind is fully entitled to refuse medical treatment and may decide to embrace the death in natural way but passive euthanasia they said is legally acceptable they also laid down the procedure though arnold schambach case it was a high court only which could take the decision in the common cause versus union of india the best interest principle was said to be applied and such decisions to be taken by specific competent medical experts not by high court advanced medical directive is something which was defined in this case of common cause versus union of india number of times we also get requests of do not resuscitate so this is at least one judgment which has upheld the issue that if you patient party or if the guardian of the patient has one signed uh do not have sustained he cannot later take the hospital to court on this ground the problem is the people who are taking care of the actual patient are usually different from the people who suddenly appear after the death of the patient claiming to be the legal hairs mostly you will find there will be one daughter who has been accompanying the old gentleman throughout the three months the person has been under treatment after the death of the person you will suddenly find an nri walking and barging and asking you bombarding you with questions and cases have been filed against doctors that you in collusion with my sister this is not something which happens only in india this case which i am showing here the same thing happened in uk also so while taking consent you need to tell the patient diagnosis of the disease nature of the proposed treatment potential risks of the treatment consequences of patient refusing the suggested line of treatment what degree of disclosure of risk is best left to clinical judgment of the doctor the real and valid consent in order to recover damages for failure the complainant must show that he had been born he would not have he would not have considered the treatment now this consent for non-availability of equipment apollo hospitals chennai was prosecuted that they did not declare that they do not have a machine to check the methotrexate level in blood now if all hospitals especially the small and medium healthcare establishments i had run a hospital in general for 25 years if i had to write down in the constraint form all the equipment i did not have it would take 45 pages just to completely write down what all technology i do not have how is it possible but here this hospital was penalized for this reason number two a written consent has been taken and after written consent hysterectomy has been done initially the issue in this case was suspicion was of carcinoma ovary and a hysterectomy and bilateral loophole to me was done and now the gentleman says he we were under duress and under duress we signed the consent forms and now that because after the histopathology was done and there was no malignancy found in the dissected specimen so he disclaimed that the written consent was the informed consent or real consent in this case he said we were so scared that we were not in a frame of mind where we could understand the consequences and hence this was not a valid consent consent not taken for a common complication this is something when you do lasik laser stride are very common complications which occur we have already discussed regarding the 10 uh rule this in this particular case the idea is after lasik if you have let us say 100 patients who have had complications of lasix lassi complication which occur more than 10 percent out of these 100 will need to be told to the patients and that is something which is uh to be understood very clearly consent taken for a very minor procedure when actually the patient lost his eyesight this was the first procedure functional endoscopic sinus surgery was being done and it wasn't the local anesthesia but the patient lost the eye so the case was you also need to take appropriate consent for oral pills and non-surgical mtp you need to take consent this case i had already discussed regarding the facing criminal charges in this particular case the case was that the patient was started on hormone replacement therapy after she went into menopause she had developed menopause due to cyclophosphamide which was being given to her for sp so after she developed menopause the gynecologist they did her hormone screening and after that decided to give her hormone replacement therapy two years down the line she developed infiltrating carcinoma breast and now she claimed that you did not tell me that hormone replacement therapy could uh cause infiltrating carcinoma breast and if you had told me i would not have taken it so this case was very aggressively fought in a high court and finally high court dismissed the criminal part but the civil prosecution was on after that you do not need to take consent for postmodern if you have had a death a young person coming for a cesarean dies in your operation theater please ask for a postmortem and all you need to do is inform the police and ask them to come and take charge of the body and get the postmortem conducted because this is a sudden death the relatives consent for the postmodern is not important you do not need to take their consent if there is anything in your mind this could be suspicious this could be the reason you do not know the cause of death please do not issue a death certificate and inform the police and ask them to get a postmodern conducted it is between the police and the relatives if they decide still and the police decides to let them go without the postmortem that is between the police and then you have done your duty you also need to take consent if other doctors are going to be involved in the treatment supposing you are going for a conference you are going abroad you are going for a marriage please take consent beforehand if you are doing a major procedure that other doctors will be looking after the patient you need a separate consent for blood transfusion you need a separate consent for anesthesia from over and above the consent for the procedure you are going to do this was a very strange judgment came from national consequent distributed wrestle commission where they said you are to take consent and in consent you are to declare the complications but you are to declare complications related to you if you have done 100 cases how many cases had the complication this they said you are not to tell what is the complication rate of as published in indian society or gastroenterology journal or as published in any other international figures what is your complication rate is what has to be mentioned in the constraint this was a very dangerous judgment unfortunately no organization appealed against it because this will have lot of impact on how surgeons and those who do therapeutic procedures trained supposing you are doing an ercp and you are going to take consent and you are in the learning phase and you have done one ercp in the past and that patient died what are you going to write in the constraint form i have my my complication rate is 100 percent of mortality by that argument no patient will get any procedure done from you number two if you are going to do a procedure in a different way from what you have consented please take separate consent from that for that the high court this was you need whether you need to take consent to put a patient on ventilator now this this case was from state consumer distributed wrestle commission delhi the judgment said that in absence of any consent in writing and of the considered opinion that ops were deficient in services and they have been keeping a brain dead patient on ventilator and this is negligence now the question is when do we put a patient on ventilator when his life is at risk i have been told to understand that if a person's life is at risk and you are going to do a procedure which will save a person's life you do not require consent but then such is the law of our land that doctors will be prosecuted one way or the other consent for surgery is also consent for consequences this was a thankful judgment from alhabad high court and how beneficial it will be for us because this was also only in the discussion part of the judgment the statement was made it is not part of the final conclusion refusal of consent if somebody you have advised somebody to get caesarean and the person does not get the cesarean done it is your duty to get a refusal of consent signed if the patient does not sign the refusal of consent put down in your medical records patient has been told that he requires cesarean the patient's relative and the patient are refusing to get the cesarean and they're refusing to sign the refusal of consent and put down your signature ask one nurse and one other doctor from the hospital to sign it can consent to be taken by a qualified staff member under supervision so far in india yes samira kohli judgment a junior doctor could be taking consent as long as they understand the procedure and they understand the consequences was the issue is consent of a husband necessary to conduct mtp this case of ajay kumar malhotra versus ajay pasricha after the mtp was done there was a dispute between husband and wife and the husband had dragged the doctors also to court so the court thankfully supreme court in this case dismissed the appeal filed by the husband against punjab and had a high court decision and the supreme court upheld that the woman has the right to decide about abortion and the consent of husband is not required under the act indian medical council regulations 2002 demand consent of both husband as well as wife for procedures which could result in sterility whereas mtp act and bghs guidelines for tribalization demand only revives consent what is the situation as rewards video consent it is mandatory under transplantation of human organs act may be preferable for very high risk patients especially if you are going to be operating on advocates and judiciary i think there this kind of video consent may be needed now the father is signing in marathi but the consent is in english this is obviously negligence 21 lakhs was awarded in this case against a government hospital where treatment have been done free of cost proxy consent for minor incompetent emergency patients can be taken but there is a specific procedure for that thank you so very much i hope i have not exceeded my time limit and welcome any questions in case there are some oh yes sir thank you so i'll just read out the questions for you so there's a question uh from dr kitty she's asking what cases can be a suspicious death suspicious death is anything which you cannot certify because when you are issuing a death certificate you have to mention what is the cause of death underlying disease is something different and cardiac arrest cardio respiratory arrest is not a cause of death cause of death you have to specify so if you are conducting a delivery and you have pulmonary embolism or any articular fluid embolism and the person dies and you suspect amniotic fluid embolism and you have no way of confirming it no this is a suspicious step without knowing because we had a case from karnataka high court where a young patient for cesarean was taken up in the operation theater without surgery the doctor came out after some time and explained that due to anesthesia the patient had a reaction and died now the relatives they filed the police complaint the police came to the body did postmodern and they found there was a huge fracture pelvis with such massive extra peritoneal bleed that it resulted in patients death what had happened was probably in shifting the patient from trolley to the operation theater to the operation table the patient fell down injured the pelvis and probably under anesthesia this was there or what the thing was we don't know but the death was due to bleeding and the doctors had mentioned in that case that this was due to anesthesia so somebody was hiding something maybe the doctors knew maybe the doctors did not know but the fact remains he this was a suspicious death young female coming for caesarean you are saying there is sudden death you should have informed the police yourself rather than covering up so many of times this situation arises that similarly poisoning cases when they come to you those are outright medical legal cases but not all poisoning cases tell you beforehand when they come that that this is a case of poisoning they will say if they had something to eat outside or whatever history some fever they never give you the proper history at that time so if you are suspicious under those circumstances always better to inform the police similarly uh people who will take oral details from the chemist and come to a doctor with excessive bleeding suddenly at night without giving history so if this person expires it is a suspicious death and you don't know the cause of death and you have to inform the police this is what i suspect this is what has happened yes sir sir we have one more question from dr akilah she's asking wouldn't invoking therapeutic privilege go against patient autonomy the patient autonomy is something very good it sounds very rational it sounds very progressive but i for one would like this patient autonomy to be restricted to patients who are capable of autonomy now in india you have india and you have bharat and bharat is 90 india is that 10 so for that 10 and maybe 10 percent of that 10 are the ones who are creating this problem of medical negligence or litigation against doctors for the sake of that one percent we are penalizing the rest of the population who have no concept they still want you to [Music] that trust is still there and they do not have the health literacy we are not here i am not talking of uh um no no no education i am talking of health literacy now because in india one we have five six different systems of pathys then we have many babas and many people who claim to treat everything so there is a lot of confusion in the minds of general public health literacy is very very poor and when you are trying to explain to a patient here this is not gas which you are having this is a cardiac event which you are having and you need an angiography or you need an angioplasty we are unable to get through to him in the golden hour this is what is the problem so we this autonomy is something which should be restricted to people who deserve this autonomy because the population we are dealing is so diverse that we cannot extrapolate what happens in u.s on to what we are practicing in india in this regard yes sir so we have a question from dr aranya she's asking if there is a patient with psychological problems and does not have any family member then in that case who will get the consent psychological problems do not automatically mean the patient is incompetent it depends on what psychological because psychiatric problem i can understand psychological problems there would be very few in which i would consider the patient to be incompetent to give a consent in case whether the person is for psychological reason psychiatric reason age reason for whatever reason if the person cannot give consent and there is nobody with him to give the consent as a guardian then under those circumstances two doctors or three doctors of the hospital not including the one who is going to be treating can sign the medical superintendent can sign as a as a temporary guardian and go ahead and do the procedure which is needed so dr karthik is asking uh people and attenders threatened doctors not to inform the police so how does one handle this situation and do we inform the police without counseling the attenders listen the person who's threatening you today with one thing is more than 100 likely to threaten you again tomorrow because once you have released the body they will go and do the cremation and they will come back with 50 people after week or 10 days and at that time you will not have the body to be said to send for postmortem to confirm your version of what the events were so if you are being threatened it is violence against doctors 19 states already have a act for prevention of violence against doctors it is your duty to inform the police i am being threatened by these people and they are creating a nuisance in my hospital and this is what has happened and this is for this i need to inform you and they are refusing because even if you get it in writing from them this is a criminal matter so so their consent is of no consequence i know it is easy for me to say when i am sitting in a city in small villages in small towns where the doctor is isolated these issues can become very very tricky and they can create a massive problem but my suggestion still is in let the person take the body away if they are physically strong and if they are if you feel you cannot stop them physically but immediately after they have gone and from the police if this is what has happened this is what the situation is and note down the diary number note down the name of the person whom you've given the information to that's the end of your responsibility then it is up to the police to go to the house of the patient party and they take charge of the body or not uh so dr prana dr kavi are saying very informative session so thank you so much sir so uh dr aathi is uh asking uh hysterectomy and bilateral of opherectomy also leads to sterility uh so is husband's constant mandatory in this situation well hysterectomy and oophorectomy no obviously because i've already told you that consent is needed only from the patient the confusion is because at different places different laws are given the indian medical council regulations had said that if something is going to result in sterility it is better to take consent of husband and wife now whether it is tubal ligation whether it is hysterectomy and oophorectomy whatever which is likely to cause according to indian medical council regulations 2002 yes husband pipes wants to be taken but what is the normal concept of consent it is the patient the patient is the one whose consent is mandatory whether you take of the husband or not i will be able to defend but it is the patient's consent which is most important um so we have a question from dr savita so in current pandemic relatives may not be available to give consent especially if patient is on ventilator so who can then give the concept she's asking patient is on ventilator what do you need a consent for cvp line if the patient is already on ventilator what are you needing the consent for probably just to insert a cbp line or some such procedure all that as long if there is nobody available then some senior doctor from the hospital acts as a guardian and with their signatures you can go ahead you can document there is no relative available and this is the reason the important thing is when the patient first came what was the situation was the patient conscious was the patient competent could he have given consent then because when we say like we have cases i haven't shown them over here uh where a person comes he leaves his wife with the nursing home he goes to another city to call the mother of the wife to stay with her in those four or five hours the patient's condition deteriorates and the doctor decides to go ahead with surgery and now there is no husband and the wife's condition was serious so no consent was taken so the court said if the wife was all right at four hours ago obviously you have done the surgery after five hours of admission right so if the wife was so critical at the time of admission why did you not do the surgery immediately or if the wife was okay then why did you not take the consent beforehand because if there was a sudden deterioration and let us say four and a half hours later so then you had these four and a half hours to take the consent you understand so the point is consent is from the patient and you cannot say because after all the patient does not come on a ventilator from home you have placed the patient or ventilator when the patient came he has given you history there is v where there is breathlessness whatever and you have found it maybe the spo2 is following during this time the consent can easily be taken so we have a question from dr arvin in case of rta if both party are ready not to inform the police so can we treat the patient and then release after the treatment this is very very tricky because uh there is one party which is obviously making the payments to the hospital and the other party is the one which is injured so the first thing priority is to get the injury treated and they don't want any medical legal issues it is in your interest to take details of both the parties including proof of uh identity from both the parties if you are not informing the police both parties agree they don't want to inform the police fine take it in writing from them whatever else you may do but the problem arises tomorrow after the roadside accident there was a laceration on the leg you have sutured the laceration and you have missed a blunt trauma to the head and you have sent the patient home and after the patient goes home he is carrying your prescription and three hours later the patient has been found to be dead or he develops a seizure and dies after that this has happened in already institute of medical sciences i am not generalizing or now the aims people after roadside accident they treated the mother uh for for neurosurgery they sent the daughter home and the daughter expired at home you get a point so once this kind of thing occurs the concept of both the people signing not to inform the medical legal uh the to the police carries no relevance you are going to be dragged in that litigation which will occur and somebody or the other will make a complaint because that person has died because of head injury so this is a very tricky situation and only and only if you are 100 sure the person does not have anything which will even if the person remains always some lawyer somebody will come some friend of his will then the person realizes he has made a mistake by signing and then he comes and blames the doctor as well as the other party so this is a tricky situation where the best is if you come across a roadside road traffic accident which is brought to you at least in general what i was doing but then i could do it because i i was more a gastroenterologist than a surgeon or an orthopedician so i could simply do first aid and say you take the patient to a pga or use a general hospital or wherever but this opportunity is not available to 70 80 90 percent of the doctors who are working in isolated areas so they will have to give some kind of treatment and it is a dicey situation it is not there is no easy answer here so we have a question from uh dr prabhakaran uh is vibes consent necessary if husband undergoes vasectomy no again the only place which is special which is specifying is indian medical council regulations rest otherwise a person is competent to because now after this judgment from supreme court the the need for the spouse's consent is taken away so even though so far the situation is that can a wife give consent only without the husband but now what you are saying is this is the reverse but if it is true for the wife why not for the husband so the same arguments will hold true there also though we don't have a case law per se regarding this but i'm sure the same arguments will hold true here so we have a question from dr sanjay uh if a person alone under the influence of alcohol and has trauma needs suturing what should be done in such cases you cannot not treat the person the person is in alcoholic intoxication so he is incompetent he is not composed mentis this fact needs to be documented very very clearly in the medical records after that taking consent of the medical superintendent or in case of small hospitals there will be people who will have brought him you can take consent from them you can take consent from a senior staff nurse or somebody so anybody who can give witness yes i was asked this was the condition the patient was in this state and he could not give consent on his own and this treatment was needed that is why with my consent the treatment was proceeded with also we have one reason request i'll just accept it thank you madam um my question is sir to what extent should we explain the facilities available in our hospital for example neonatal echo is not available it's a very rare thing so should we tell the patient that um neonatal echo i mean ecmo or inhale nitric oxide is not available in most of the centers so should we tell the patient that this treatment might be required and it's not available in our hospital listen the thing is will not have all the equipment required to treat all the patients in the world so ultimately you are to focus on the important issues if you are taking a delivery do you have incubator facility do you have phototherapy do you have new needle icu can you manage ventilation up to a certain level you are expected to have till that time you should be there it should be there but if you say neonatal ecmo now ecmo is something which is not available in many major hospitals also it is something like saying do you have facilities to check methotrexate levels i mean this is what has been there is a case law deciding on this issue so you need to explain yes under certain circumstances additional treatments may be needed for which we may need to refer a patient to a higher center that line has to come into your consent and then that does not mean only for ecmo it can mean for so many other things can't hear you thank you so much can we go for gender reassignment surgery with patient alone consent and legal workup if the patient is an adult if he is competent if he does not have a psychiatric disorder i don't see any reason why anybody else's consent is needed for a gender reassignment or for any other surgery there is no specific additional requirements for gender surgery there is additional requirement is only for transplantation of human organs act where it says video consent is mandatory but for this gender reassignment surgery there are no specific guidelines which are available and if the person is conscious yes you should document your counseling very well because obviously the person has a poor image of himself and that kind of frame of mind after the gender reassignment surgery if the person does not like that and he comes back uh it could create problems but that problem is there even for plastic surgeons even for cosmetic surgeons somebody wants a breast implant but then does not like the breast implant after the breasts have been implanted so these kind of situations they need to be documented the consent needs to be documented clearly some kind of counseling with a psychotherapy is with a psychologist again documented well before the procedure may be helpful but for consent the content is of the person and unless the and obviously the person is incompetent you will not do any surgery on of this kind of oh so we have a race request a few years back we had a train accident and some time back we had a bus accident and a patient was brought who was put on the table in the casualty and his name was no name was there so we wrote unknown okay can you hear me so we wrote unknown we treated and there was there was a problem we had to send one patient for vascular surgery at hyderabad which is the nearest 200 kilometers from here and next day some attenders came from bombay and they told he is my he is my relative how could you send it to hyderabad i would have taken him to bombay or some delhi so he created a lot of problems so in such in such situations what should we do sir so listen any person can make any kind of allegations that is the beauty of law in india and it is up to you to defend yourself the point remains the patient's relative has been sent to hyderabad and the patient is coming the person is coming and fighting with you you simply need your documents to be in order this person was not there you have not sent to hyderabad against his express wish so what you have done is correct what you have done is not wrong in any way hello yes sir the the problem is he was fighting with us why did you send it to send him to hyderabad till i came i told we told them that it was in the real emergency we had to send him somewhere the nearest super speciality services available that was the reason sir so you have done nothing wrong you have done nothing wrong if the person wants to make a police complaint he can go ahead and make a police complaint you can be defended if the person wants to provide a consumer case against you on this grounds it will be dismissed 99 there is no reason the point is they come and create a hassle and we are a community which is a community of cowards the moment somebody comes into our opinion and starts shouting we we cover we we do not somehow we are not built in that mode like advocates or other professionals who will retaliate immediately so the point remains if somebody is come coming and threatening you or if coming and creating a new sense or threatening violence you have 19 states prevention of violence act you are within your rights to inform the police he said this is what is happening in my establishment this person has come and this is what he is creating a new sense document the things properly sent to the police station and let the police deal with it yes sir agreed because another question i want to ask you is in lifeline express in the 80s and 90s there was a lifeline experience with government of india for treatment of polio cerebral palsy and other conditions so we used to operate there many of the cases hundreds of cases were operated one of them they one of them he developed a complication not because of uh our polio treatment he developed because of some other problem he came and fought with us when we are doing the type of work we do we are definitely going to face these kind of problems and we simply need to keep this very clear this is my threshold i will listen to this much beyond this if the situation transgresses i will take these these steps that is why i always say doctors who spend diwali gifts or who send various gifts on various festivals to people who refer them cases it is much better to send that gift to the nearest police station on the because that police person that show is more important to you than any referral doctor so have good relations with your local police station that is very very important because these kind of incidents if you are running an establishment of your own are bound to occur one way or the other in this case sir we have been on a government service prior medical college but we have been posted to work in a lifeline express and later on that patient came to us and created created problem saying that this is not right this is not right the calipers which you are given is not right and all that so that was the problem at that time sir nothing government hospital or private hospital there is no difference criminal cases can be filed against government hospital doctors consumer cases can be filed against government doctor hospitals so it does not matter whether you are a government doctor or a private doctor even though government doctors tend to think that these problems do not concern them they are mistaken they are very much within their within the purview i have doctors from bgi i have doctors from general hospitals i have doctors from civil hospitals who have faced cases and allegations and when an allegation is made you have to defend yourself the last question is for example most of the serious cardiac and cardiac conditions and cervical cerebrovascular accidents and some serious head injuries we refer to hyderabad on the way in between it is 200 kilometers they die sir in the ambulance itself and they say because of our negligence uh it has happened what should be a house how should we defend sir there is an article i have written though it has still not been published this is on legal and ethical issues of referral in medical practice this is a very very important matter and the judiciary expects that when you refer a patient in an emergency to a higher center a doctor or you yourself should be accompanying the patient we have multiple judgments on this issue and even though what this is the whole point which i am raising in that article that a small and medium health care establishment may be run by a single doctor or a doctor couple yes and if they are having 20 beds or 25 beds and other beds are full if that doctor lead abandons those patients just to accompany this one patient to a higher center one of the other 20 patients who are admitted in the hospital may tomorrow file a case of abandonment because if that patient has a problem it will be on this doctor's head but so far the judiciary has been consistent in expecting a doctor to accompany a patient who is being referred to a higher center and not in an accompanying car the doctor should be in the ambulance this is this is the expectation of the judiciary sir as far as i know in the west they have got helicopter ambulance they have got a car ambulance and all vehicles ambulance and all that available every 50 kilometers on the highways but when you cannot provide when the government or the services cannot provide this facility asking only doctors and only the criminalizing doctors only putting blame on the doctors in suspicion you cannot extrapolate what happens in u.s to what is the ground situation in india this issue i hope will be published soon because i have been trying to get it published in one of the indexed journals you are absolutely right the government in india does not invest on healthcare and wants to find scapegoats to blame when the public demands what have you done regarding health care and this is what is happening across the board whether it is involving government doctors or it is involving private doctors even when i ask the government how many posts do you have vacant for mbbs doctors to work in villages the answer under rti is 1726 you are producing 85 000 mbbs doctors every year you do not have we can see for 1756. what are the rest of the doctors doing you are expecting them to start their practices you do not wish to give them employment so the whole thing is the medical community has to realize you are being targeted as the skateboards there used to be something called you know when when the king's son used to go and study in school the teacher could not beat the prince because he was a king sir so there used to be another boy who used to accompany the prince who would be beaten if the prince did something wrong now this is the kind of situation in india unfortunately we do not get together we do not fight unifiedly and these kind of issues will remain till the time we don't realize what is happening sir one more thing the judges the liars the ordinary public and those intellectuals are medically have no knowledge and they don't know what are the problems in the medical profession and they are the judges and i on our head sitting on our head that is creating a big problem since past 10 to 15 years yes but this issue was already recited in vp and others versus indian medical association yeah dr sanjeev we requested you to step down there are many questions we need to take we're already running over time yeah sorry dr nagpal it was uh amazing to hear you it was a fantastic session very very engaging and i just had one question which i wanted to ask so uh everything that you explain to the patient about the chances of complications or the lack of facilities do you also need a record of that i mean a lot of it would be verbal so how will because you there is one thing called implied consent there is another thing which is you have written consent so whatever you are explaining has to already be in the written form maybe you are not explaining everything which is written but there should be nothing which you have told which is not written understand the difference so in the written consent there will be 50 complications you have written maybe you have discussed five but it should not happen that you have discussed 50 and you have written 5 in your written consent sir how will we have data for the percentage of those 50 complications for the operating team like you said that for a junior resident it's obviously difficult but even for a senior doctor it is difficult because we won't have that kind of whatever are the common complications you should know and document basically you don't need to document rare complications as of now so the the common complications the way mbbs exam is headed what are the five common complications of polycystic meaning what are the five complex common complications of appendectomy what are the five complications of hysterectomy you are supposed to know those five you may not know the rest of the 45 that is all right but the common complications should have been mentioned and discussed when we are preparing a consent like there is a website consent for doctors instead of form in for it is consent for doctors you can go into that you can download procedure specific consents from there everything which needs to be told is there similarly institute of medicine and law is there in mumbai they also i am also an advisor to them so we prepare we update the standard operating procedure of writing consent on that and it is available free of cost on their website so basically when you are designing these consents because every doctor in india does not do every procedure one doctor may be doing 10 15 20 procedures and you can definitely have 10 20 15 procedure specific consents prepared correct yeah so in that the commoner ones you should definitely mention and so nowadays many corporate hospitals have video consent especially for procedures so there's a separate room where the video consent is taken uh so if the video consent is being taken uh the recording of the patient is done that i give my consent uh but at that time the counselor or the doctor of team member should read out what is written on that consent form the complications i never advise corporate hospitals to take video concerns i will tell you the reason also why in india out of any con any city our electricity will go on an average for let's say 30 minutes to one hour every day you are taking a video consent there is a glitch in the electrical supply when your consent video is being made there is going to be a disruption in between tomorrow if i am arguing from on side of the patient i will say this evidence is tampered you are not only going to be prosecuted for medical negligence you will also be prosecuted for tampering of evidence you understand my point unnecessarily why do we create a problem number two if you are making a video consent please remember the patient party when they ask for medical records are fully entitled to that record also which is in video nature because that is also part of the medical records and courts have very clearly said that you are to provide all the medical records which have been asked for within 72 hours so this is a gray area video consent for transplantation yes video consent if you already know the person is an advocate who has already created a request already there is a problem yes but be very careful not to make it a generalized thing because sometimes somewhere there will be a problem with the computer there will be a problem with the hard drive there will be a problem and you will get caught into a situation which you did not need to get caught in you understand my point yeah because ultimately where you store the the video consent where will you store on your computers someday some computer will crash and now tomorrow you are exposing yourself this hospital is not giving me the video consent because they are hiding something which will not actually be your fault thank you sir so uh no this was on consent and i think 90 of discussion was on consent we had some non-consent conversations but uh we'd love to have you more frequently clearly uh medical legal areas are areas where a lot more awareness discussion is required especially if there's somebody who can come on stage and concretely tell us that this is right and this is wrong because a lot of times the answer we get generally is it depends and it's very refreshing to have very clear concrete guidelines uh we had a wonderful evening sir thank you so much uh for for making time and really over extending the time thank you good night viewers uh please send us topic suggestions and we'll power them to dr nagpal if he is available uh he'll touch upon topics in the time to come thank you thanks a lot you

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dr. Neeraj Nagpal

Dr. Neeraj Nagpal

Dr. Neeraj Nagpal is a Gastroenterologist and presently the Director and Chief Endoscopist at Hope Gastrointestinal Diagnostic Clinic, Chandigarh and Convenor of Medicolegal Action Group. He was also ...

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dr. Neeraj Nagpal

Dr. Neeraj Nagpal

Dr. Neeraj Nagpal is a Gastroenterologist and...

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