Reply: Consent for cataract surgery: A patient perspective

Abstract

The audit performed by Kotagiri et al. brings up several points for discussion. Perhaps the reason for their results was a relative contrast in information given to patients who had provided consent at the pre-assessment, caused by an increased level of “cognitive dissonance”1 experienced by patients immediately before surgery. Reducing the stressfulness of the surgical environment for patients, as well as for health professionals, may therefore be a key factor in improving the overall efficacy of the consent process. In our original paper, we looked at the correlation between current practice and policy produced by the Department of Health (DoH) and a National Health Service (NHS) trust.2 Having critically appraised the implementation and practice of guidelines at a local level, we recognize our narrow focus by excluding details concerning knowledge management solutions to improve the guidelines themselves.2 The high-volume model of cataract surgery within the NHS fits with a mechanistic model of an ideal bureaucracy.3 However, this approach may have led to the demoralization of staff4 and lack of patient focus, with numerous paper documents, including consent forms, having to be routinely completed by health professionals. The dilemma for the DoH and NHS trusts at policy level, with particular regard to consent, relates to the progression towards electronic paperless records. The standard generic national “consent form 1”5,6 is currently used for cataract surgery and although we feel it is wholly unsuitable as a good source for conveying risks and benefits, we recognize and endorse the growing trend toward the use of preprinted forms, which Kotagiri et al. may have used in their audit. Kotagiri et al. also mention the action of patients being “consented,” conveying the widely bureaucratic approach to consent described in our paper as “a process lasting 30 to 45 minutes” rather than a continuous policy of interactive engagement. The problem with obtaining written consent at surgery also applies to pre-assessment at some “one-stop” cataract centers, where the handwritten form must be signed by a dilated patient with cataract, who would not have had more than a few hours to consider their decision. Once the patient has been consented, the process can be regarded as complete. Although we agree that accurate documentation is crucial, the change from a form-filling activity to a mechanistic digital culture may undermine the process in similar terms of dehumanization. As we enter further into a digital world, the changing conditions of communication mean that we need to recognize language and paper-based texts as not the sole, the main, let alone the major means for representation and communication. Other modes are there, and in many environments in which writing occurs, these other modes may be more prominent and more significant.7 Decisions about whether to use a particular mode for maximum effect are related to purpose and audience.8 In rethinking paths into writing, multimodal digital texts have been shown to support pedagogies in underachieving groups (Bhojwani, unpublished PhD thesis submitted to the School of Education, University of Nottingham, Nottingham, UK). Therefore, in choosing the best form of communication for our patients, messages must now be more multimodally constituted.