Cognitive functioning and informed consent

Providing information and obtaining informed consent are routine aspects of preoperative care. For informed consent to be obtained, the relevant information must be provided by the surgeon to the patient. There must be evidence that the patient has understood the rationale, risks, and benefits of the surgery, the potential alternative treatments, and the risk of not proceeding with surgery. The decision about the surgery must be made voluntarily and without coercion. Patients may need this information to decide whether to choose more or less radical surgery, weighing the possibilities for cure against potential adverse effects of surgery. Breast surgery is an important example in which cosmetic and body image concerns of women have led to more conservative surgical approaches, especially in cases where there is little evidence that more aggressive surgery is associated with a higher cure rate.

The psychiatric consultant may be called in to evaluate the patient's capacity to give informed consent. The presence of a major psychiatric disorder, such as schizophrenia, does not necessarily mean that informed consent cannot be obtained, unless the altered mental state affects the individual's understanding of their condition and/or the proposed treatment. In most jurisdictions the emergency treatment of incapable persons is permitted as an exception to the requirement for consent, unless the clinician has reason to believe that the person would refuse such treatment if he or she were capable. (6) When there is not an emergency, substitute consent must be obtained on behalf of individuals who are incapable of providing informed consent. The legal requirements for substitute consent vary in different countries.

Significant cognitive impairment may be associated with impairment in the capacity to provide informed consent. This capacity requires that a patient be able to understand information relevant to the treatment being recommended, and to appreciate the reasonably foreseeable consequences of a decision to accept or to refuse such a procedure. Obtaining informed consent is not only a legal and ethical requirement, but can be a process of great importance to the surgeon- patient relationship. In some cases, treatment refusal reflects breakdown in the relationship between the surgeon and the patient rather than an informed decision to reject the recommendation for surgery. Attention to this relationship and the provision of additional information may help to relieve this difficulty so that an informed decision can made. In other cases, treatment of a major psychiatric illness, such as a psychotic disorder, may restore the patient's capacity to provide consent.

The capacity of patients to provide a coherent history and account of their symptoms is also an important aid in the assessment of the indications for surgery. Impairment in this capacity may be due to associated cerebral disorders, such as Alzheimer's disease. Patients with evidence of cognitive impairment prior to surgery are at increased risk of developing dementia or delirium in the postoperative period. Neuropsychological testing may be indicated prior to elective surgery when there is concern about the degree of cognitive impairment, and/or to establish a baseline prior to surgery.

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