While I was researching an assignment for my latest class, I ran across an article about informed consent and physical therapy. The article stated that in a patient centered environment, consent must be granted for any procedure or activity that is outside normal interaction. It further stated that complete information about what was about to happen must be provided before asking permission. In other words, before we touch someone for treatment, we must not only ask permission for therapy, but also for the specific planned intervention. Since the patient or decision maker is considered autonomous, that person should be allowed to decide about all interventions.
That stopped me cold. I have always believed that once the consent to treatment form is signed the patient has consented to be cared for. The patient must be asked if therapy is desired because it can be refused. I never even thought about in relation to every single treatment I provide. If I want to do something new or a little different, I will explain it and make sure the patient is comfortable with what I want to do. Sometimes a patient will only agree to walk in the room or doesn't want therapy at a specific time. To me, those are examples of patient autonomy.
Informed consent arose from unethical use of human subjects in medical experiments. Over time it evolved into patient rights. Obtaining permission for each intervention makes sense when talking about invasive or risky procedures. It doesn't make sense when talking about ROM exercises. If I had stopped to think about it, I would have thought overall permission for therapy would be granted at the time of the evaluation when the POC was discussed. I describe what I plan to do but not specifically how. That's practically impossible with PT. Patient status changes from day to day. What was appropriate one day might not be the next. As long as my patient progresses, I'm going to process therapy. I can't predict exactly how that will occur.
I looked into it a little further. There is still debate about what is considered informed consent. For awhile the accepted standard was what another physician would reasonably say. That doesn't really work because few people outside the medical field have that level of understanding of medical terminology. Now the focus is on explaining in terms the patient can understand. That's better, but it doesn't take into account who is doing the actual explaining. A physician or experienced therapist who has done the intervention many times will present the information differently than an inexperienced new graduate or resident. If the new graduate can't answer all the questions, is it still informed consent?
This is even more significant in a place such as Houston where a large number of the population has a language barrier. Frequently non-English speaking patients will agree rather than ask questions if they don't understand. A good example is explaining weight bearing status to a non-English speaker who may be hard of hearing or slightly confused. I've had Spanish-only patients get up and move around when they were in severe pain because they didn't know they had a choice. I usually find out after I ask a Spanish-speaking therapist to find out if the patient is OK because the patient looks uncomfortable. If I have to get specific consent to each treatment and there isn't a translator available that patient probably won't receive therapy. It wouldn't be ethical.
This is a huge gray area that I hadn't previous considered. According to the APTA Code of Ethics and Standards of Care, our current practice is adequate. Both of those documents bind the PT to do what is best for the patient while considering the patient's individual needs and desires. That's good. It will probably remain adequate since few people outside the therapy field are even aware of the differences in what we do. There is also minimal risk to therapy and the evidence is still out in many cases on what is the best treatment. It would be a different story if the choice was between something very effective but a high fall risk and something less effective with no fall risk.
The things I read were published within the last few years. The topic appears to be relatively new to discussion. It may take on more significance as we move to direct access and Vision 2020. Autonomous practice will require more disclosure and more specific consent. Therapists in private practice will need to have some kind of consent to treat form to cover them legally. This might not be anything right now but I don't think it will go away.