2nd February 2018, Volume 131 Number 1469

Rachel McKenzie, Jasper Diong, Jeanne Snelling, Lynley Anderson, André M van Rij

Occasionally during surgery, an additional abnormality is found which is unrelated to the condition for which the procedure is being undertaken. While uncommon, such findings highlight the limitations of pre-operative…

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Summary

When surgeons carrying out an operation incidentally find an unrelated problem, should they go ahead and treat this too during the same surgery or wait for another time until having discussed it with the patient, and obtaining consent for further surgery if still required? This question was asked of New Zealand surgeons and those in training to see what they thought were the important things to consider and what they would do in different circumstances such as whether it was an emergency, whether the extra surgery could lead to serious complications or if it avoided another operation. The results showed that surgeons vary in what they emphasised but made decisions that reflected a sensible approach. It would be easier to make these decisions if there was a discussion between patient and surgeon beforehand prompted in the surgical consent process.

Abstract

Aim

Sometimes during an elective surgical procedure, an abnormality is found which is unrelated to the scheduled procedure. In many instances, immediate treatment of this unexpected pathology is in the patient’s medical interests, however, specific patient consent has not been obtained. This study investigates current surgical practice when confronted by an incidental finding (IF), as well as surgeons’ views on informed consent in this context.

Method

An online survey was sent to all practicing surgeons and surgical trainees within New Zealand. Respondents were presented with hypothetical scenarios involving IFs and asked to decide whether or not they would proceed with treatment. Opinion was sought on the factors influencing such decisions and the need for a clause within surgical consent documents to prompt discussion about IFs.

Results

151/450 (33.6%) surgeons and trainees responded. Immediate treatment was more likely with IFs of greater clinical significance, lower-risk procedures and where there was prior consent for IF treatment. A proportion of surgeons did not follow these trends. Although a great deal of variation exists in the way that IFs are dealt with in the consent process, the majority of respondents (111/129, 86%) favoured a clause within a consent form that prompts discussion and seeks consent for the treatment of IFs.

Conclusion

Responses to the IF scenarios were generally consistent with good practice. While variation in decision-making is to be expected, some decisions were concerning. Most surgeons agree that a clause within the consent form should trigger a discussion of IFs during the consent process.

Author Information

Rachel McKenzie, Medical Student, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin; Jasper Diong, Assistant Research Fellow, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin;
Jeanne Snelling, Research Fellow, Bioethics Centre, University of Otago, Dunedin;
Lynley Anderson, Associate Professor, Bioethics Centre, University of Otago, Dunedin;
André M van Rij, Professor, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin.

Correspondence

André M van Rij, Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin 9054.

Correspondence Email

andre.vanrij@otago.ac.nz

Competing Interests

Nil.

References

  1. Davis SS Jr1, Goldblatt MI, Hazey JW, Melvin WS. Unexpected gastrointestinal tract conditions. Curr Probl Surg. 2006 Feb; 43(2):74–118.
  2. Katz J. Informed consent--a fairy tale? Law’s vision. Univ Pittsbg Law Rev. 1977 Winter; 39(2):137–74.
  3. Snelling J, Anderson L, van Rij A. Incidental findings during surgery: a surgical dilemma or the price paid for autonomy? Otago Law Rev. 2013; 13(1):81–106.
  4. Medical Council of New Zealand. 2015; Wellington: New Zealand. Information, choice of treatment and informed consent. Available from: http://www.mcnz.org.nz/assets/News-and-Publications/Statements/Information-choice-of-treatment-and-informed-consent.pdf
  5. Hall JF1, Stein SL. Unexpected intra-operative findings. Surg Clin North Am. 2013 Feb;93(1):45-59. doi: 10.1016/j.suc.2012.09.008. Epub 2012 Oct 22.
  6. Hayes-Jordan A1. Surgical management of the incidentally identified ovarian mass. Semin Pediatr Surg. 2005 May; 14(2):106–10.
  7. Hopper KD1, TenHave TR, Tully DA, Hall TE. The readability of currently used surgical/procedure consent forms in the United States. Surgery. 1998 May; 123(5):496–503.
  8. Royal Australasian College of Surgeons: RACS. 2013; 2(9). New Zealand Surgical Workforce Projections to 2025. Available from: http://www.surgeons.org/media/20470543/2013-06-13_rpt_nz_2025_projections_final.pdf
  9. New Zealand Medical Association. 2015; Wellington: New Zealand.NZMA Code of Ethics. Available from: http://www.nzma.org.nz/__data/assets/pdf_file/0016/31435/NZMA-Code-of-Ethics-2014-A4.pdf
  10. Nadey H, Papalois V, Epstein M. Consent for Clinical Interventions and Medical Research. Ethical and Legal Issues in Modern Surgery (Chapter 2). London: Imperial College Press, 2015; Ch 2. 
  11. Croskerry P1. The theory and practice of clinical decision-making. Can J Anaesth. 2005; 52(Suppl 1):R1–R8.
  12. Anderson L1, Snelling J, van Rij A. Incidental findings in surgery. Br J Surg. 2015 Apr; 102(5):433–5. doi: 10.1002/bjs.9719. Epub 2015 Feb 23.

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