Olena Yakobchuk
When used effectively, involving family members in the consent process can help avoid challenges in treating patients with chronic ailments or multiple health issues, as Fay A. Rozovsky, president of The Rozovsky Group, explains.
Dan Tosh, a 59-year-old retail store manager, went to see his primary care provider, Dr. Keckler. Dan had hypertension and his blood sugar levels were of concern. Dr. Keckler admonished Dan that he had to lose about 20 pounds, stop smoking and start exercising. He warned him that unless he modified his lifestyle, he would be well down the road towards developing Type 2 diabetes.
Dr. Keckler prescribed medication to help control his patient’s high blood pressure. He had treated both of the patient’s parents in their later years. He knew that there was a strong family history of coronary artery disease and stroke. Indeed, Dr. Keckler knew that Dan’s father had developed serious health problems associated with hypertension. “I hope that when I see you in about one month that all the numbers are moving in the right direction, Dan,” said Dr. Keckler.
Four weeks later, Dan returned for a follow-up visit with Dr. Keckler, accompanied by his wife. The couple were greeted by the doctor’s medical assistant who took Dan’s blood pressure and measured his weight. The young medical assistant said, “So have you been following your diet? Have you been taking your high blood pressure medication?”
Dan nodded his head up and down to signify “yes.”
When Dr. Keckler entered the examination room, Dan introduced him to his wife. As she started to leave Dr. Keckler said, “Unless Dan has any objection, you are welcome to stay. I really encourage my patients to have their ‘significant others’ with them. Dan, I see from the record you gave your wife authorization to receive your healthcare information, so is it okay if your wife is with us today?”
Dan said, “Sure.”
Dr. Keckler took a moment to review Dan’s blood pressure and weight. He looked over at Dan and said, “Have you been taking the medication that I prescribed for you?”
Dan: “Yes, I take it.”
Dr. Keckler: “All the time? Are you following the instructions on the bottle?”
Dan: “Uh huh.”
Dr. Keckler: “Have you stopped smoking?”
Dan: “Well, not completely.”
Dr. Keckler: “And what about the diet? Are you following the diet that I gave you to help you lose weight?”
Dan: “It is kind of a pain, you know. At work I mean.”
Dr. Keckler: “Well this is very interesting, Dan. In the four weeks since I saw you, your have gained more than 8 pounds and your blood pressure has gone up quite a bit. Can you help me understand what is happening here?
“Is there something that you do not understand about the treatment plan? Is the medication bothering you? I thought we both understood that you are very close to Type 2 diabetes and that your blood pressure is of particular concern.”
"The family-focused consent process creates the context for a caregiving ‘team’ to help the patient stay on course with lifestyle changes, medications, and other treatment."
Dan did not respond. However, his wife spoke up and said, “I had no idea that Dan’s situation was that serious. He came home and told me that you had recommended he exercise, try to lose a couple of pounds and quit smoking. He never mentioned all the rest of this information.
“I did not know that he could be close to becoming a diabetic. And, I did not know that the medication he stopped taking last week was to control his blood pressure.”
Dan looked uncomfortable and said, “Okay. I guess I have to admit that I really did not follow the diet. It does not contain any of the foods I like to eat. I got a lot of ribbing at work from some of my buddies about it. And those pills, honestly, I felt funny after taking the medication. When I stopped taking the medication, I felt better.”
“Thank you for leveling with me, Dan. I want to suggest something. Let’s start from the beginning and with your permission, this time I want to involve your wife in the discussion. She is just the right person to help you follow the care plan.
“Let me begin by explaining the reasons for the recommended treatment plan, the benefit, the risks, and alternatives. And, then I will discuss the consequences of not following either the recommended plan or an alternative,” said Dr. Keckler.
The way forward
After the couple had agreed to the recommended treatment plan, Dr. Keckler said, “Going forward, I want you to promise me that if you are having problems with the medication that you will call me. I selected one type of high blood pressure medication that I thought would be good for you. But I will have no idea if it does not agree with you unless you let me know.
“I have other medications that can be prescribed and different dosing options, but I cannot help you unless you speak up. As to the diet, I am going to suggest a formal consultation for both of you with Stan Westley, our nutritionist, Stan will give you strategies for preparing your favorite foods in a way that fits your diet and he will give you suggestions for what to select when you are dining out or at work. Is that acceptable?”
Dan and his wife agreed.
“There are three other items we need to discuss: exercise, smoking cessation, and adhering to the care plan. Dan, your health insurance plan includes a free gym membership. Take advantage of it, please. As to smoking cessation, we have a person in the practice who works with patients on the best strategies to stop smoking. While you are here today I will introduce both of you to her. She can get you started right away,” said Dr. Keckler.
“I am not trying to frighten you. I am not trying to bully you into doing what I think is best for you. Rather, I am looking at the realities of the situation. You have to take control of your health. You have your life partner right here with you. Make this a team effort. The alternative is ugly: heart disease, stroke, diabetes and all the complications that go with it. So please, take charge of your health.”
As the couple got up to leave Dr. Keckler said, “Mrs. Tosh, thank you for being here. I feel confident that you are going to be a terrific source of support for Dan. It is not easy to make all these changes, but with your help, he can do it. Remember, both of you, if you have any questions or concerns, just call me.”
Ask the family
The ‘family’ component of such a consent communication does not have to involve a spouse or an adult child. It may be a patient’s partner, significant other, or trusted, support person who constitutes the ‘family’ member. In fact, in some instances the term ‘family’ may refer to more than one individual accompanying the patient.
Dan’s example illustrates an important facet of consent communication: the family-focused approach to caring for patients with chronic ailments or multiple health issues. In such circumstances there is considerable benefit to involving caring spouses or partners in the consent communication. Once ‘on board’ with the care plan, it is often the family caregiver who helps manage the patient’s treatment. It is the family caregiver who may detect subtle changes, adverse reactions, or a worsening condition that the patient does not either see or acknowledge.
In essence, the family-focused consent process creates the context for a caregiving ‘team’ to help the patient stay on course with lifestyle changes, medications, and other treatment. The results can be quite beneficial in terms of avoiding the consequences of treatment non-adherence and early detection of the need for adjustments to the care plan.
The family-focused consent process may not achieve the same results in all situations. Indeed, it is possible that the discussion may unearth issues of blame, shame, and deep-seated tension in the family dynamic. To the extent that other issues emerge from the discussion, the care provider can use this information to fine-tune the proposed care plan and make important referrals that benefit the patient and family.
The bottom line is that when used effectively, the family-focused consent process can help avoid challenges in treating patients with chronic ailments or multiple health issues.
The family-focused consent process is not for every patient. Some individuals may be reluctant to involve a family member or even a trusted, support person in the discussion. Sometimes the patient may dismiss the use of the family-focused approach and at other times, it will be the patient who encourages such a process.
Care providers should be poised to manage challenges that occur during a family-focused consent process. Disputes and arguments might erupt, replete with a ‘it is your fault’ or ‘blame’ mentality. Using appropriate communication skills, the care provider can put ‘other issues’ in a discussion parking lot, channeling the discussion back to a family-focused consent communication process for the patient’s benefit.
Fay A. Rozovsky, JD, MPH, is president of The Rozovsky Group, a firm specializing in healthcare enterprise risk management and patient safety. She is the author of Consent to Treatment: A Practical Guide, 5th Edition (2015) published by Wolters Kluwer Law and Business. She can be contacted at: fay@therozovskygroup.com
Risk management approaches
There are several considerations to contemplate when using a family-focused consent process. These include the following items:
- Obtain patient permission for the family-focused consent process. Exclude any family member that the patient does not want involved. Recognize, however, that if the patient is under a guardianship of the person and the family member is the duly authorized guardian, that the discussion will be with the guardian. Patient input may still prove very useful to the extent that the individual can participate on such issues as the effects of medication, diet, and ability to follow the treatment plan.
- Reserve the right to excuse the family member at certain points in the process. Recognize that excusing the family member may be done at the request of the patient, the family member or the care provider.
- Complete a family-focused consent time out. Use this approach to identify communication challenges or needs that should be addressed prior to having the discussion. Consider, for example, the need for language interpretive services, or the issues associated with health literacy, health numeracy, and cultural sensibilities. Use the consent-time out to determine the best approach for communication, whether it involves using educational tools, instructional websites, or written documentation.
- Use a family-focused teach-back process. Confirm that the patient and the family member both understand the agreed-upon care plan by using a set of teach-back questions pertinent to the patient and to the family member.
- Document the family-focused consent process. Follow applicable policy and procedure set forth for a family-focused consent process. Include in the documentation the name(s) and relationship(s) of family member(s) who participate in the consent process. Note if specific accommodations were made to facilitate the consent process, including the use of language interpretation, and the name of the interpreter and language used in the discussion. Document too, the titles of any written information provided to the patient and relative, including different language versions for the patient and family member. Summarize the information provided, questions asked and answers provided, as well as the agreed-upon care plan with the role of the family member included in the documentation.
Risk management, Family-focused consent, Healthcare, Fay A Rozovsky, The Rozovsky Group, US
