A survey on current practice of informed consent process in surgical specialties of a Portuguese tertiary teaching hospital center: What is the state of play?

Abstract

Informed consent is essential in current medical practice and should be a gold standard to be sought in all instances when doctors interact with patients. The aim of this study was to evaluate compliance to the guidelines of the Portuguese health entity regarding the correct filling process of informed consent. An audit was conducted at the operating rooms of a tertiary teaching hospital center in Portugal, in March 2021, in order to verify the presence of informed consent in the clinical file of surgical patients. A representative cohort of 202 clinical files was collected. An informed consent document was found in only 47% of the clinical files. Merely 21.8% of the informed consent documents included all the items recommended by the guidelines of the Portuguese health entity. Most of these informed consent documents (SIC) included only basic information, with only a small minority including reports about the surgical procedure, information regarding treatment, possible consequences of a missed treatment or complications and possible treatment alternatives. These results do not conform to the standard regulations of the Portuguese health guidelines regarding SIC. Even though improvements in SIC were attained in recent years, our study suggests that the implementation of SIC is still suboptimal in surgical practice. It is important to raise awareness for the obtention of SIC by the healthcare team, given the ethical importance of such a document in the context of any invasive procedure.