Chronic Refractory Angina

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Patient centred consent

Modern consent requires that patients should be fully involved in the decision making process. In most instances this means that patients need to be informed about all the available treatment options before making a decision about the best treatment for themselves and their carers. This is simple when there are only 2 alternatives, such as treatment A or no treatment. It is also simple when one therapy has a significantly better chance of improving life expectancy than another.

For chronic stable conditions with many possible treatments the situation is much more complex. Unless a patient elects to empower her doctor to decide what is best then it is necessary for the doctor to explain in understandable terms what each treatment involves, its risks and potential benefits. Failure to do so might invalidate the consent process. A patient could claim that they consented to treatment B because they thought they had no alternative and did not know that treatments C, D and E were available.

At the National Refractory Angina Centre we follow the NHS DoH and BMA best practice guidelines. However we have developed an innovative imporvement (see BMJ 2003 Nov 15;327: 1159-61 Making consent patient centred). In our model patients define their objectives at the outset. This enables us to focus on the therapies that can realistically achieve their objectives. In our experience patients are often willing to compromise. They will often settle for mild angina at negligible risk rather than no angina at high risk of death or deterioration. Unless they are aware of the low risk alternatives such compromises are impossible and the patient may consent to the high risk strategy in the mistaken believe that it is that or nothing.

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