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Survey of veterinary clients' perceptions of informed consent at a referral hospital
  1. M. Whiting, BSc BVetMed MA PhD DipECAWBM (AWSEL) MRCVS1,
  2. A. Alexander, BVetMed MRCVS2,
  3. M. Habiba, MBBCh MSc PhD PhD FRCOG3 and
  4. H. A. Volk, DVM PGCAP PhD DipECVN MRCVS4
  1. 1Animal Welfare and Ethics, Department of Production and Population Health, Royal Veterinary College, Hawkshead Lane, North Mymms, Herts AL9 7TA, UK
  2. 2Royal Veterinary College, Hawkshead Lane, North Mymms, Herts AL9 7TA, UK
  3. 3Department of Obstetrics and Gynaecology, University Hospitals of Leicester, Leicester LE1 5WW, UK
  4. 4Department of Clinical Science and Services, Royal Veterinary College, Hawkshead Lane, North Mymms, Herts AL9 7TA, UK
  5. 5M. Habiba also at Department of Health Sciences, University of Leicester, Leicester Royal Infirmary, Leicester LE1 5WW, UK
  1. E-mail for correspondence: mwhiting{at}rvc.ac.uk

Abstract

This retrospective questionnaire study evaluates the perceptions of veterinary clients of the informed consent process and the consent form in a veterinary referral hospital. Replicating a validated perception survey from human medicine, 470 clients at the Queen Mother Hospital for Animals were surveyed on their perceptions during the consenting process through postal survey examining their understanding, experience and recall of informed consent. Of the 165 responses (35 per cent response rate), the majority of clients recalled the process and signing the form; however, half of the clients did not feel in control (51 per cent) or reassured (53 per cent) by the process. There was limited understanding of the purpose of consent, with 45 per cent thinking it removed their right to compensation for negligence and 31 per cent thought the veterinarian could do something different from the agreed procedure. Sixty per cent of clients did not read the form, as they trusted their veterinarian, but 33 per cent of clients felt frightened by the process. This survey highlights the need to understand the process of consent from the client's perspective, and adapt the consenting process to incorporate this into professional communication to ensure that the professional and contractual objectives of consent are met fully.

  • Ethics
  • Law relating to animals
  • Practice management
  • Surveys
  • Veterinary profession
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Introduction

There are limited academic publications on the topic of informed consent in veterinary medicine, and these mostly focus on the professional requirements of consent (Passantino and others 2011), the role of veterinary nurses (Wager 2011, Macdonald and Gray 2014) or concerns regarding abuse of power in the consent process (Yeates and Main 2010, Danks 2014). Although consent is seen as critical to the contract and to the authorisation of veterinary interventions, there have been no studies to date centred on client understanding or their perception of veterinary informed consent. The aim of this study is to provide insight into veterinary client perceptions of informed consent at a veterinary referral hospital.

Informed consent in human medicine reflects the right of patients to autonomous choice, and is often seen as essential to countering paternalism (O'Neill 2003). In addition, consent may have a role in protecting patients against harm and in encouraging medical professionals to act responsibly in their interaction with patients (Heywood and others 2010). The consent process is meant to be empowering to the patient in order to redress the power differential between them and the physician (Schuck 1994). The emphasis on obtaining valid consent may empower patients by placing an obligation on doctors to provide information and explanation. Debate continues about the amount of information disclosure that should be regarded as adequate or sufficient, but the trajectory seems in favour of increase in required disclosure (Parsons and others 2013). Current General Medical Council (GMC) guidance to doctors places consent within a framework of partnership in decision making and sees good partnership as being based on openness, trust and good communication (GMC 2008). Within this context, consent could be seen as affirmation of a patient's decision made with the support of the clinician. Doctors are directed to respect a patient's decision even if this is at variance with the view of the doctors.

The Royal College of Veterinary Surgeons (RCVS) places informed consent as an essential part of the contract between the client and the veterinarian. There are some similarities, but also subtle distinctions in approach and emphasis—for example, around the notions of ownership and contract, and the applicability of tort of battery or guardianship. Contrasting the experience between human and veterinary medicine can further our understanding in these areas.

Previous studies of patient perceptions of consent in human healthcare have highlighted considerable discrepancies between the objective of consent and the patient's perception. In one study, 24 per cent of women undergoing elective surgery and 40 per cent of women undergoing emergency surgery indicated strong agreement with the statement that they had no choice about signing the consent form, and 37 per cent of women undergoing emergency surgery strongly agreed with the statement that they would have signed the form whatever was on it (Akkad and others 2004). Previous studies in human health have reported difficulty in patients retaining the information provided to them during consultations, bringing into the question their capacity to have granted fully informed consent (Dixon-Woods 2001, Mayberry and Mayberry 2001). Some patients consider the consent process to be ritualistic or pressurised. Patients do not always fully read or understand what the consent form says (Akkad and others 2004, Habiba and others 2004). There appears to be a disconnect between patients' experience of consent and the bioethical legal model, which envisages the process as protecting their interests (Akkad and others 2006).

The purpose of informed consent in human and veterinary medicine has many similarities. Guidance on informed consent in the UK is provided by the RCVS (2015), and further explanatory notes are expounded by veterinary associations (e.g. BSAVA 2015). In addition to agreement on the chosen treatment(s), consent in veterinary medicine typically provides reference to agreement on payable fees. However, while this difference can appear striking in the UK, where the National Health Service (NHS) is free at the point of care or in similar healthcare systems, fee for services such as in the UK private care sector is not usually recognised as altering the essence of consent. Self-determination and autonomy are not operational in relation to children, who can provide ‘assent’ and the parent or other legal guardian is called on to provide consent. This contrasts with veterinary medicine, where rights and responsibilities are derived from the notion of property.

A successful consenting process should empower clients by positioning them at the centre of decision making and by reducing the scope for abuse or manipulation of client decisions (Rollin 2002). The implication from the study of Akkad and others (2006), referred to above, is that the role (and perhaps to a lesser extent the legal validity) of consent in veterinary medicine would be brought into question if veterinary clients, like human patients, do not fully understand their rights and the purpose of consent.

This research seeks to provide an insight into client perceptions of informed consent in a veterinary referral hospital. This study is based on an adapted questionnaire, developed in human medicine, to study the experience of veterinary clients of giving consent in connection with treatments for their animals.

Materials and methods

The validated survey used in the study of Akkad and others (2006) was slightly modified to ensure reference to veterinary clients. The survey mainly consisted of five-point agreement Likert scales, and is available as online supplementary appendix 1. The modifications to the survey of Akkad and others (2006) were related to changing words such as ‘patient’ to ‘animal or client’ to ensure the context of the questions remained pertinent to a veterinary hospital. Participants were clients who attended the Royal Veterinary College's Small Animal Referral Hospital, Queen Mother Hospital for Animals (QMHA), London. The inclusion criteria for selected participants were: a visit to the QMHA for the first and only time between January 1, 2015 and June 30, 2015, in order to ensure only one instance of consenting; and admission of their animal for an elective or emergency surgical intervention to the neurology or surgery groups, in order to minimise variation in the consenting process and maintain similarity to the study by Akkad and others (2006). In line with the requirement of the Royal Veterinary College's Animal Welfare and Ethics Review Committee (URN: 2015 1375), clients whose animals died were excluded in order to avoid unnecessary distress.

The data were inputted into Excel (V.15.20) and analysed using Prism GraphPad (V.7.0a). The χ2 test was used to test the statistical significance of observed differences; P<0.05 was considered significant. All results are reported for all respondents except where there is a significant difference in results between emergency and elective clients. A total of 470 clients met the inclusion criteria and were invited to take part in the written postal survey on July 19, 2015 and to return their anonymised answers using prepaid postage before September 19, 2015.

Results

We received 165 responses, giving a response rate of 35 per cent (95 per cent CI 29 to 41 per cent). The characteristics of non-responders could not be determined, as responses were anonymous. Not all respondents answered all questions; the number of completed responses is provided against each question. The responses were from 89 (54 per cent, 95 per cent CI 46 to 62 per cent) elective procedures and 74 (45 per cent, 95 per cent CI 37 to 53 per cent) emergency procedures (two respondents were unsure). As the responses of these groups of elective and emergency clients were similar, their results were merged together where no significant differences were found between them, as specified individually below.

Legal status of consent

All 165 respondents recalled the consent procedure, and the vast majority (98 per cent, 95 per cent CI 96 to 100 per cent) recalled signing the consent form. Hospital records show that all those approached to participate provided a signed consent. Sixty eight per cent (95 per cent CI 61 to 75 per cent) of participants (n=161) believed that signing the consent form was a legal requirement, and nearly half thought that only the owner of the animal may sign the form (45 per cent, 95 per cent CI 37 to 53 per cent, n=162). Nearly half the participants (45 per cent, 95 per cent CI 37 to 53 per cent, n=161) were unaware that signing the consent form did not remove their right to compensation for negligence, and a third of the participants (33 per cent, 95 per cent CI 26 to 40 per cent, n=161) either did not know or thought it was not permissible to change their mind once the form had been signed. The majority of participants (92 per cent, 95 per cent CI 88 to 96 per cent, n=160) believed the consent form was also their agreement to pay for the treatment, but nearly a third (31 per cent, 95 per cent CI 24 to 38 per cent, n=159) thought that the veterinarian could do something different from the consented procedure (beyond life-saving treatments). Only 7 per cent (95 per cent CI 3 to 11 per cent, n=155) were not sure what the consent form meant they had agreed.

Time to read the form

Almost all participants (96 per cent, 95 per cent CI 93 to 99 per cent, n=164) were satisfied with the amount of time offered to them to consider the procedure before consenting. Nearly two-thirds of participants (64 per cent, 95 per cent CI 57 to 71 per cent, n=163) had a partner or friend with them when making a decision, although only one-third (32 per cent, 95 per cent CI 25 to 39 per cent, n=158) thought that this was important to them. A quarter (25 per cent, 95 per cent CI 17 to 33 per cent, n=105) felt too worried to read the form, and a fifth (21 per cent, 95 per cent CI 13 to 29 per cent, n=105) felt the form was too long or was a standardised agreement (11 per cent, 95 per cent CI 5 to 17 per cent, n=105). Two-thirds (95 per cent CI 59 to 73) of participants did not read the form completely because they felt the veterinarian had already explained everything, and 60 per cent (95 per cent CI 53 to 68 per cent) felt it was not necessary because they trusted the veterinarian. Participants preferentially read the part of the consent form that was handwritten in front of them (67 per cent, 95 per cent CI 60 to 74 per cent, n=161), with 43 per cent (95 per cent CI 35 to 51 per cent, n=158) choosing to read all the standardised form.

Emotional state at consenting

During the consenting process the majority of participants did not feel under pressure (87 per cent, 95 per cent CI 82 to 92 per cent, n=157), but one-third felt frightened (33 per cent, 95 per cent CI 26 to 40 per cent, n=159) and nearly half felt responsible if things went wrong (48 per cent, 95 per cent CI 40 to 56 per cent, n=159). The consenting process was neutral in making the clients feel in control (51 per cent, 95 per cent CI 43 to 59 per cent, n=158) or reassured (53 per cent, 95 per cent CI 45 to 61 per cent, n=155). The majority of clients did not feel relieved by signing the consent form (74 per cent, 95 per cent CI 67 to 81 per cent, n=155).

Participant preferences for informed consent

The participants were questioned about the information they wished to have before signing the consent form; these are summarised in Table 1. The majority wished to be presented with alternative treatment options, expected prognosis and the potential risks. The majority also valued the ability to ask questions about the procedure and this corresponds with their desire to understand what was being agreed through the consent process. About a third of participants (95 per cent CI 26 to 40) did not feel it necessary to have time alone to make a decision, a fifth (95 per cent CI 14 to 26) did not need the veterinarian to read through the form with them, and 16 per cent (95 per cent CI 10 to 22 per cent) did not find value in the veterinarian checking the client's level of understanding.

TABLE 1:

Client preferences for informed consent

With regard to financial commitments, the majority (95 per cent, 95 per cent CI 92 to 98 per cent, n=162) of participants wished to be forewarned of the costs entailed, valuing this as important or very important, and to have those costs explained to them. The majority (92 per cent, 95 per cent CI 86 to 98 per cent, n=158) also expressed concern for being prewarned about the cost of aftercare following the procedure.

Importance of the consent form

Finally, participants were questioned about the importance of the consent form separate to the consenting process (Table 2). The discussion about the intervention led to 90 per cent (95 per cent CI 85 to 95 per cent, n=162) of participants feeling adequately informed to confidently sign the consent. Only 6 per cent (95 per cent CI 2 to 10 per cent) did not feel sufficiently informed, yet these participants still proceeded to sign the form. Half (95 per cent CI 42 to 58) the participants felt the consent form adequately made their wishes known, but the majority (86 per cent, 95 per cent CI 81 to 91 per cent) felt the consent form made what was agreed clear to them. A very small minority of participants (2 per cent, 95 per cent CI 0 to 4 per cent) regarded signing the consent form of no importance and thought it was not a valuable use of time, while one in ten clients valued the consent form for making them specifically aware of the risks of the proposed procedure.

TABLE 2:

Importance of the consent form to the client

Clients were not clear about the purpose of the consent form, with two-thirds (95 per cent CI 59 to 73) viewing it as disempowering and instead giving control to the veterinarian. The clients were not in agreement on the purpose of the consent form, as about a third (95 per cent CI 26 to 40) viewed the form as mainly there to protect the veterinarian, and about a fifth (95 per cent CI 14 to 26) thought the form preferentially protected the hospital. Over a quarter of clients (95 per cent CI 18 to 32) did not believe the form helped with patient safety or with the prevention of mix-ups in the operating theatre.

The only significantly different result between participants in the emergency and elective groups was in the importance of being presented with different treatment options (Table 3). Significantly more participants placed importance on receiving information about alternative treatment plans for elective procedures (95 per cent) compared with those with animals having emergency interventions (79 per cent) (P=0.001).

TABLE 3:

Importance of alternative treatment plans

Discussion

Veterinary professional regulators regard informed consent as an important part of the process of instigating an intervention or therapy on a client-owned animal. The RCVS state it is an essential part of the contract formation between the veterinary practice and client (RCVS 2015); it is also valued by veterinary regulators in other European jurisdictions (Magalhães-Sant'ana and others 2015). The view of clients themselves on the process of consent, and on signing consent forms, has not previously been investigated. This survey supports the importance of informed consent for veterinary clients, with 74 per cent placing value on the process of consent. Only 2 per cent regarded it as a ‘waste of time’. Although it has been suggested that the term ‘informed consent’ ought not to be used in veterinary medicine and that seeking consent on the day of the procedure was inappropriate (Anon 2010), the data presented here suggest that all participants, including those with animals undergoing emergency surgery, viewed consent positively.

There are similarities in the findings of this study and the previous study on human medical consent (Akkad and others 2006). The majority of veterinary clients (86 per cent) and human patients (71 per cent) felt the consent process explained the planned procedure to them in a way they could understand. Similarly, the large majority of veterinary clients (95 per cent) and human patients (77 per cent) felt that the consent procedure enabled an adequate explanation of the risks associated with the proposed intervention. One of the important objectives of the consent process is to empower the patient/client to make their decision. In human medicine, a minority (32 per cent) of patients felt that they retained control of the proposed procedure. An even smaller minority (13 per cent) in this study reported feeling in control of their choices. Similar to the study by Akkad and others (2006), we found an apparent disconnect between the veterinary client's experience of the consent process and the view within the bioethical and legal model. The similarities between the perceptions found in human medicine and in veterinary medicine demonstrate that it may be valid to transpose to the veterinary field the lessons learnt in human medicine on trying to obtain informed consent. Similarly, any advancements made in the veterinary field with regard to improving client perceptions of informed consent may likewise be transposed to the human medical field.

Informed consent has a dual purpose in veterinary medicine: it has both the professional connotations of the consenting process found in human medicine and the contractual purpose of agreement of work between the professional and the client (RCVS 2015 s11.2). These two purposes are expanded in the RCVS Supporting Guidance, where the professional component requires that ‘a range of reasonable treatment options are offered and explained, including prognoses and possible side effects’ (s11.2f), ‘clients must always be aware of the risks’ (s11.2i) and ‘the client is made aware of any procedures to be performed by practice staff who are not veterinary surgeons’ (s11.2k). The contractual component is stipulated in the section of the Supporting Guidance where clients should be offered ‘realistic fee estimates based upon treatment options’ (s11.2g) and they should be informed ‘of any escalation in costs once treatment has started’ (s11.2i). For both of these components it is important that practice staff ‘recognise that the client has freedom of choice’ (s11.1l). This financial and contractual element of consent differs from that found in human healthcare in the NHS, and requires the consentee to consider additional information of a nature different from medical consequences. Such duality, although necessary in the context of a private enterprise, can become an additional stress burden, which confounds the consenting process.

While in the UK there is no salient difference in professional responsibilities associated with gaining informed consent between the NHS and private healthcare, it should be noted that, in other jurisdictions, a notion of ‘informed financial consent’ has been developed to cover the complexity of the competing agreement documents (HADSCO 2012). Still, the financial aspect of the consent form in veterinary medicine marks a clear departure from consent in human healthcare. One proposition is that the two become separated.

The consenting process is not mere passive information transfer from veterinarian to client. It forms the basis for a contract of agreed work between the parties. Therefore, it is important to ensure that the client understands the various, including the legal, dimensions of the document they are about to sign and that they fully understand the rights and responsibilities that stem from it. In human medicine, being made aware of alternative treatment options is an important stage in informed consent, and, arguably, the duty to inform a patient of risks associated with a procedure ‘will not be discharged unless she is made aware that fewer, or no risks, are associated with another procedure’ (Birch 2008). Participants in this study valued being presented with alternative treatment plans.

While only 7 per cent of respondents did not understand what the consent form meant for them, the majority appreciated it as representing a business contract and an agreement to pay for the proposed treatment. Over two-thirds of respondents incorrectly assumed that the written consent form was a legal requirement. More alarmingly, one-third of respondents did not appreciate that they could change their mind or incorrectly thought that the veterinarian could do something different from the consented procedure. This demonstrates that the clients who were surveyed had a limited understanding of their rights associated with the ownership of their animal. It also suggests the need to increase client awareness of the purpose of the consenting procedure. Furthermore, this point may indicate that the number of complaints relating to consent received from clients within a practice may be an under-representation of the actual grievances felt.

Limitations of this study

This survey was undertaken at a single referral teaching hospital. This may mean that the consenting process may be more emphasised because of the hospital's status. This may have elevated the client's perception of the importance of the process beyond what they may experience elsewhere. However, the similarity in responses to the previous human studies indicates that this may not be a limitation. A follow-on study is being generated to determine the differences in client perceptions found in primary care. One limitation is the modest response rate, but this was in line with expectation in this type of research. The exclusion criteria for participants were set to rule out clients who may have experienced multiple instances of informed consent within the hospital. It is not clear if the view of this group will be different, but the decision was made in order to enable a degree of uniformity. We did not plan this research to take account of the clients’ features such as their educational or occupational background. We excluded clients whose animals had died, but this was necessary in order to avoid causing them undue distress. The retrospective aspect of this study may introduce a recall error, but the delay between consenting and survey was only six months. Some questions had fewer responses than others; this was due to the survey allowing the respondents' freedom to choose not to respond to any particular question.

Proposal to improve the consent process

The findings suggest that improving the consent process in veterinary medicine requires a revised approach that takes into account client perception and experience. This echoes the conclusion of Akkad and others (2004) in relation to human health. The process of obtaining consent entails a special form of communication that involves a particular form of emotional engagement at a critical time, and in veterinary medicine this is balanced against a financial commitment and ‘willingness to pay’. Several studies have evaluated the veterinarian and client communication (Cornell and Kopcha 2007, Coe and others 2008). This study provided a depth of understanding of client's perceptions of the process. Notice should be taken of clients' expressed preferences to have time alone or to consult friends and family. This survey has highlighted stressors that may affect decision making. A third of clients felt frightened at the time of consent. Thus, further research is necessary to investigate how veterinarians may seek to alleviate fear and anxiety, where possible, before embarking on consent.

Veterinarians ought to avoid undue influence on clients’ choice. Care must be taken to draw the distinction between clinical facts and professional judgements. Directing client decision at the time of consent can give rise to professional concern (Yeates and Main 2010), but knowledge may be used to guide the client to an appropriate decision. This survey reveals that clients are influenced by the discussion around the consent procedure and not just what is written on the consent form. It appears that improvement is needed in explaining the role of consent in order to ensure that the client is able to express their wishes and to enable an active role in decision making.

A major finding from this survey is the lack of understanding of the legal status of consent. This may be compounded by the inclusion of financial transaction within the same document, and a consideration may be that the two aspects be dealt with separately.

Conclusion

This is the first reported study into veterinary clients' perceptions of the informed consent process as undertaken at a veterinary hospital. The survey did reveal important parallels with the findings from human medicine. There is scope for shared learning, where similarities or differences can enhance our depth of understanding. It is apparent that some aspects of the current process are not perceived by clients as fulfilling the objectives envisaged in the bioethical model, a problem that is shared between human healthcare and veterinary medicine. Communication is likely to remain a key factor in the client's perception of the consenting process, and further studies are needed to determine the specific details of how this may be improved. This research enabled us to draw some proposals that may help improve the process.

References

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Footnotes

  • Provenance: not commissioned; externally peer reviewed

  • Correction notice This article has been corrected since it was published Online First. This title has been changed from ‘A survey of veterinary clients' perceptions of informed consent at a referral hospital’ to ‘Survey of veterinary clients' perceptions of informed consent at a referral hospital’ to conform to house style.

  • Twitter Follow Martin Whiting at @mwhiting81

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