Saturday, March 19, 2011

364. Informed Consent and Against Medical Advice (AMD) - to get it in writing

Sometimes, I do not record in writing my advices to the pet owner to treat the dog or hamster and do not record that prognosis is poor. This is not a good practice as in litigation, the judges want to see the written word.

In one case reported in the Straits Times on March 18, 2011, I was shocked to read about a very experienced surgeon from the Singapore General Hospital being suspended for 3 months on one of the 3 charges of not giving INFORMED CONSENT. The 3 judges believed in the complainant and said that the case records and brochure put up as defence by the doctor did not mention the risks of pain, bleeding and infection being told to the patient. Definitely, the brochure did not mention the risks. Therefore, the judges decided to suspend him for 3 months for not giving informed consent. The patient had had abdominal pains after surgical removal of his piles in 2006. The rectal area was infected post-operation.

I was shocked because this surgeon provided excellent services to me when I underwent colonscopy by him. Excellent bedside manners. Efficient and competent. His nurses assured me that he would not take a long time to do the colonscopy as he is experienced. I was given a sedation by a lady, probably a nurse. She inserted another syringe (probably with saline) to give me the full dose. I just slept. No pain or groginess after colonscopy. It was as if I had a nap. I asked the doctor what injection it was and he did tell me.

In between reading the lines in the newspaper report (mentioned twice), it seemed that there was a warning to doctors to provide a higher standard of care and that means informed consent for everything and proper writing down of advices and risk given. I have an informed consent form for every tasks and procedure nowadays and read to the pet owner the content.


The owner wanted me to treat his dog rather than Dr Vanessa and this is because I had treated his other dog for the past years. Dr Vanessa also had owners who just wanted her to treat their dogs or pets.

The puppy had pale gums but not white. It had passed smelly bloody diarrhoea for 2 days but no vomiting. Just give an injection and medication and send home? This would be the standard treatment.

No blood test, no X-ray and no IV drip? This case was not to be taken lightly as the puppy had passed smelly bloody diarrhoea for 2 days. I advised hospitalisation for 2-3 days. The owner insisted on taking the dog home in the evening, after IV drip and treatment. Some owners don't like dogs to be hospitalised and some don't like to pay more than necessary.

"Let the dog go home," I said to Dr Vanessa. "If the dog dies at home, the owner had been told that the dog needed to be hospitalised to give the IV drip." I ought to record in writing as I was the main vet handling the case and would be hauled up to court even though I did this case with Dr Vanessa. But I did not record this done. Nor did I record my prognosis of 50:50.

This would be a serious mistake if the puppy died of bleeding and infection and dehydration. Therefore, I have to be more careful to write "AMD". Family members might sue me, though the owner might not. Dogs are family. Times have changed. All doctors and vets have to be much more careful as litigation takes up a lot of time.

X-Ray - "Lots of gas in the large intestines with a lot of fine particles like soil," I discussed with Dr Vanessa. She was not really convinced but this is OK as each vet has his own opinion. The owner did not tell me that the dog had gone to the East Coast beach the day before diarrhoea and had eaten lots of sand. He told me and apologised for the omission the 2nd day when he took the dog back accepting my advice (dog panting, lethargic, did pass non-smelly stools in a soft lump, could eat). I said that the dog had no diarrhoea due to the drugs given. The intestines, being bleeding needed time to heal and the food intake irritates the gut.

Blood test from Day 1 showed:

haemoglobin 12.6 (12-18)
Red cell count 5.3 (5.5-8.5)

total WBC 17.9 (6-17)
Neutrophil 49.16% Abs 8.80
Lymphocytes 31.40% Abs 5.62
Monocytes 10.17% Abs 1.82
Eosinophils 8.66% Abs 1.55
Basophil 0.67% Abs 0.12

PCV 0.34 (0.37-0.55)
MCHC 37 (32-26)
Platelets 241 (200-500)

The owner accepted the advice to hospitalise the puppy for 2 days. Should be able to recover and go home well. Many vets read blood test as one single event. Actually, one should read it as a starting of a disease process. In this case, the intestines have bleed seriously and dehydration and bacterial infection had gained a foothold. Not so bad, but enough to cause the dog to pant (in pain and in infection) and lethargy. Without IV drip, I think it would just pass away due. In this case, there would be a failure to record advices given to the owner as to hospitalisation and IV drip, X-ray and blood tests if these procedures were not done. All bets are off if the puppy dies. It is a very emotional experience for the family and many question the competence of the vet. Litigation would be in their mind.

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