montgomery and informed consent: where are we now

leading to a recruitment crisis. lead the patient to a decision that is not in their best interests, as was true for the Montgomery case. Limited professional guidance exists on the sharing of medical imagery on these platforms. Paradoxically, its ruling supporting the principle of autonomy could be justified only by disregarding the individual patient's actual choices and characteristics in favour of a stereotype. Montgomery, who has diabetes and is just over 1.5 m (5 feet) tall, was not told of the risk of shoulder dystocia and the possibility that her baby might suffer serious harm.A graduate in molecular biology whose mother and sister were GPs, Montgomery raised concerns with the consultant obstetrician Dina McLellan that she might not be able to deliver vaginally. Training and educational materials. Two years on, Sarah Chan and colleagues discuss the consequences for practising doctors The Montgomery v Lanarkshire case of March 20151 drew fresh attention to informed consent. doi: 10.1136/bmj.j2224. The case was made that as the consultant had not discussed the risk of shoulder dystocia, the potential significant consequences of it occurring and the alternative option of a Caesarean section that negligence had occurred as far as consent is considered; Mrs Montgomery was not able to make a fully informed decision without full information on all the options. The court held that McLellan should have informed Montgomery of the risk and discussed with her the option of a caesarean section. These issues are not always pursued, but, obstetric litigation practice has noticeably changed, making, professional training and clarity with respect to guidelines an, Looking at some of the cases in which the Montgomery ruling, has been considered tells us about its interpretation to date. The claimant alleged that the trust was negligent, in failing to advise of this possibility. Mrs Montgomery was around five feet tall, and was also diabetic, which often results in a larger foetus. GMC guidance says that. 2017; 357:j2224 (ISSN: 1756-1833). Conclusion There were 171 claims in otology, 24 per cent of all otolaryngology claims, with a potential cost of £24.5 million. Firstly, I argue that using animal-derived medical products on patients without their informed consent undermines respect for their autonomy. a researcher in bioethics and was responsible for subsequent drafting. It is suitable for both claimant and defendant advisors and will cover the key points which arise in these complex and demanding cases. BMJ. These “emergencies” might be exempt from. Healthcare policy should cover, for, example, which treatments should be available and how consent, treat patients according to their interests, which might include, A second concern was that the ruling would encourage, “defensive medicine,” shifting the focus from helping the patient, to protecting the doctor. The paper highlights the inadequacies of the current model in gaining consent for IR procedures. patients often had urinary and sexual dysfunction post-operatively.Conclusions Her obstetrician had not disclosed the increased risk of this complication in vaginal delivery, despite Montgomery asking if the baby’s size was a potential problem. cases have succeeded on a Montgomery basis, understand that others have settled before litigation ever started, or was concluded, as the claims were unanswerable in the light, proportion of cases of obstetric negligence raised since, Montgomery involve consent in addition to standard complaints, of substandard care. There is a substantial incidence of complications after P.E. Ed) 1988;296:839-40. doi:10.1136/bmj.296.6625.839pmid:3130937. 2 0 obj <>/ProcSet[/PDF/Text]>>/TrimBox[0 0 595.2760009766 841.8900146484]/Type/Page>> The full implications of the case are undoubtedly still unknown. Background Byrne DJ, Napier A, Cuschieri A. But doctors should have already been, following GMC guidance, which highlights the importance of, Finally, doctors criticised the focus of patient autonomy over, medical paternalism. This paper examines the UK Supreme Court decision in Montgomery v Lanarkshire Health Board, which deals with consent and information disclosure in medical treatment and care. Effective communication, team working, documentation, training and education as well as robust risk management strategies can help improve patient care and reduce medico-legal claims. The Montgomery case in 2015 was a landmark for informed consent in the UK. Purpose <> Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK; MRC Centre for Reproductive Health, University of Edinburgh. Intrapartum fetal distress, shoulder dystocia and complications of vaginal birth after caesarean section account for the majority of obstetric litigation. Despite the challenges discussed above, much can be gained from a shift towards a more person-centred perspective when it comes to what counts as valid consent. Overall complications varied from 18 to 63% with the most common being persistent perineal sinus (9–40%) or surgical site infection (wound—2 to 30%; intra-abdominal collection—3 to 24%). Conclusion AU - Wojcik, Wojtek. Information overload is unlikely, given that information should be tailored to the patient. must be fit for purpose. In the era post Montgomery vs Lanarkshire Health Board. Nadine Montgomery was a woman with diabetes who gave birth by vaginal delivery. Chan SW; Tulloch E; Cooper ES; Smith A; Wojcik W; Norman JE The law now requires a doctor to take “reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.” endobj After the Montgomery case, the so called Bolam test, which asks whether a doctor’s conduct would be supported by a responsible body of medical opinion, no longer applies to the issue of consent. Montgomery and informed consent: where are we now? This coding scheme was then increasingly refined into key themes and allowed parallels to be made within and between cases. Other parts of the consent form relating to need for blood transfusion and the need for further procedures were also examined. ET is a medical student at the University of Edinburgh and was primarily, responsible for research and initial drafting of the manuscript; SWC is. Her baby, Sam, was born with serious disabilities after shoulder dystocia during delivery. The role of the BDJ is to inform its readers of ideas, opinions, developments and key issues in dentistry - clinical, practical and scientific - stimulating interest, debate and discussion amongst dentists of all disciplines. Medicines and medical devices containing animal-derived ingredients are frequently used on patients without their informed consent, despite a significant proportion of patients wanting to know if an animal-derived product is going to be used in their care. Although the rates of obstetric complications differ among high birth weight infants delivered by caesarean section compared to. Nadine Montgomery, a woman with diabetes and of small stature, delivered her son vaginally; he experienced complications … All studies reporting post-operative morbidity, mortality or functional outcomes in patients who had P.E. There is also a significant economic burden for the healthcare provider. Provenance and peer review: Not commissioned; externally peer, Published by the BMJ Publishing Group Limited. Today’s patients can expect a more active and informed role in, treatment decisions, with a corresponding shift in emphasis on. Osteoarthritis (OA) of the knee is an important cause of morbidity and significantly affects quality of life. As most women in TPTL ultimately deliver at term, they must weigh this likelihood with their own personal considerations, and responsibilities. Montgomery and informed consent: where are we now? endstream 10.1136/bmj.j2224 1 The judgment concerns Nadine Montgomery, a woman with diabetes whose son was born with serious and permanent disabilities after a shoulder dystocia during delivery. One such attempt in Scotland has, so far. application/pdf It might be time, four years on from Montgomery, to consider this question again. Although the trial judge found the Defendant to be in breach of duty by reason of its failure to inform the Claimant of the risks that the mesh repair would present in the event she became pregnant, the Claimant lost at trial on the issue of causation. Nadine Montgomery, a woman with diabetes and of small stature, delivered her son vaginally; he experienced complications owing to shoulder dystocia, resulting in hypoxic insult with consequent cerebral palsy. A retrospective analysis of 100 patients who experienced a complication related to an IR procedure was performed. Others have raised, questions about the implications for the legal treatment of, clinical judgment, suggesting that it represents “a radical move, away from English law’s traditional respect for clinical, Doctors at the coalface have received little official direction on, how their practice should change in light of the ruling. Aims By Sarah W Chan, Ed Tulloch, E Sarah Cooper, Andrew Smith, Wojtek Wojcik and Jane E Norman. which had been law since at least the mid 1980s. Secondly, it risks causing non-trivial psychological harm. decision making involves a nuanced negotiation of information. But this is a false dichotomy—the idea of, a fully autonomous patient making choices completely, independent of the doctor’s input does not reflect the complex, reality of medical decision making, nor does the caricature of. before the decision. So doctors must now ask themselves three questions: BJOG An International Journal of Obstetrics & Gynaecology. Results ... A valid consent process requires sufficient and understandable information to be conveyed that is relevant to his or her decision [19]. The majority of studies identified in this review utilised small sample sizes and observational design, thereby hindering valid assessments of the impact of delivery method on the mortality of this population. A search of electronic databases was conducted and supplemented with investigation of the references cited in the original articles. Conclusion The ruling overturned a previous decision by the House, established that, rather than being a matter for clinical judgment, to be assessed by professional medical opinion, a patient should, be told whatever they want to know, not what the doctor thinks. All studies that reported surgical outcomes for patellofemoral instability in the presence of patella alta were included. The, doctor might think that disclosure of certain information could. Qualitative interviews were undertaken as part of the EQUIPTT study (REC: 17/LO/1802) using a semi-structured interview schedule. : Montgomery v Lanarkshire Health Board * [2015] UKSC 11, New law on consent will overload seriously ill patients, Doctors should not cherry pick what information to give patients, court rules, How Montgomery is reconfiguring consent in the UK, Montgomery and implications for clinical practice, Mode of delivery and birth outcomes of macrosomic infants. The test of materiality is whether a reasonable person in that particular patient’s position would be likely to attach importance to the risk, or whether the doctor is—or should reasonably be—aware that that particular patient would be likely to attach importance to it. 1992. Finally, almost six years after the Judgement in Montgomery vs Lanarkshire Health Board, the GMC have published their updated Decision Making and Consent Guidance (coming into force November 9th 2020) (1) It is to be hoped that this will have a positive impact on the horrendous rise in the number of claims brought against the NHS for instances where informed consent has not … endobj Montgomery v Lanarkshire Health Board[2015] UKSC 11. Patients are not always aware of the facts of their treatment after. But, allocation of health resources should be tackled systematically, rather than individually. The pooled relative risk (RR) of having no patellofemoral dislocation and no patellofemoral apprehension or subjective instability postoperatively was 51.80 (95% CI, 20.75-129.31) and 48.70 (95% CI, 17.22-137.71), respectively. endobj For permission to use (where not already, This is an Open Access article distributed in accordance with the Creative Commons. DOI identifier: 10.1136/bmj.j2224. Two years on, Sarah Chan and colleagues discuss the consequences for practising doctors Results By way of conclusion, and by way answer to the question first posed: where are we now? Debates series on the ethical and legal impact of the Montgomery case. He did not, seek treatment immediately because he had not been advised, of the risk of deep vein thrombosis or pulmonary embolism or, of symptoms that might indicate these. Clinical triage of women in threatened preterm labour (TPTL) could be improved through utilising the QUiPP App, as symptoms alone are poor predictors of early delivery. But what are the implications for doctors’ practice, 2017;357:j2224 doi: 10.1136/bmj.j2224 (Published 12 May 2017), supported a doctor’s duty to disclose relevant, We (ESC) have noticed that a considerable, East Kent Hospitals University NHS Foundation, Farrell AM, Brazier M. Not so new directions in the law of consent? critical revisions, ethical analysis, and part of the legal research; ESC, WW, and JEN are clinicians and were responsible for conceiving the, idea for the manuscript, critical revisions, and obstetric medicolegal. Having previously dealt with countless manuscripts containing a vast amount of clinical trial data, he would have been expected to be capable of logically and rationally analysing every bit of medical information. the Montgomery ruling, depending on their nature and timing, but complications of labour (such as sudden and profound fetal. If the Montgomery ruling intended to herald a new era of informed consent in UK clinical practice, the implementation on the ground has been slow and patchy. Given recent healthcare scandals in the National Health Service (NHS), the Supreme Court's legal recognition of the importance of recognizing patient autonomy in disclosing risks about medical treatment and care is a welcome development. This virtual classroom seminar will consider the issues arising where informed consent to treatment may be an issue. What You Will Learn. Montgomery and informed consent: where are we now. Methods A more comprehensive consent process making use of all available resources is essential. would make little practical difference to clinicians. advice; AS is a barrister and QC in both Scotland and England. 1988;296:839-40. doi:10.1136/bmj.296.6625.839pmid:3130937. ; however, there is no evidence describing QoL pre- and post-P.E. A large proportion of the population seek medical attention for this condition. If she mentioned the risk to mothers with diabetes generally, she said in evidence, they would opt for a caesarean section, and “it’s not in the maternal interest for women to have caesarean sections.”Montgomery lost her case at the outer house of the Court of Session after the judge decided that no warning was necessary because in most cases shoulder dystocia was dealt with by “simple procedures” and the risk to the baby of serious disability was “tiny.” Her appeal to the inner house failed.But the Supreme Court justices said that shoulder dystocia was a major obstetric emergency and the contrast with the tiny risks to the baby and mother from an elective caesarean was “stark.” If it were left to doctors to decide what information to give to patients, the justices said, that would sanction differences in practice attributable not to different schools of medical thought but to “divergent attitudes among doctors as to the degree of respect owed to their patients.”In more recent cases the courts of England and Wales, in line with the supreme courts of Canada and Australia, have asserted the right of patients to determine what happens to their own bodies. But, doctors must judge what is appropriate for each patient and how, their exercise of judgment might be assessed by the courts. 2017-05-12 Examining Montgomery v Lanarkshire Health Board, UK law on consent finally embraces the prudent patient standard, R.I.P. false Update on the UK law on consent], in this case on appeal which refused the amendment. A total of 11 studies with 546 knees were included. We have, heard anecdotally that some hospitals are in the process of, updating their procedures on informed consent, but few have, completed this. XEP 4.9 build 20070312; modified using iText 5.0.3 (c) 1T3XT BVBA; modified using iText® 5.1.3 ©2000-2011 1T3XT BVBA More fundamentally, it fails to appreciate the nature of professional expertise. In all three populations, the attractiveness of surgery, relative to radiation therapy, was substantially greater when the treatments were identified rather than unidentified, when the information consisted of life expectancy rather than cumulative probability, and when the problem was framed in terms of the probability of living rather than in terms of the probability of dying. The aim of this study was to identify how often complications relating to Interventional Radiology (IR) procedures were discussed with the patient prior to the procedure. This is in line with the modern approach of patient-centered shared decision making after the Montgomery ruling, which redefined the standard for informed consent and disclosure. Three final themes emerged from the data incorporating 10 sub-themes, ‘Seeking help’, ‘Being “assessed” vs making clinical decisions together’, and ‘End result’. So the Montgomery principles have been, known—or should have been known—by doctors for many, Since the Montgomery ruling, several attempts have been made, to introduce a consent based claim to cases that were under way. Montgomery ruling Informed consent is a fundamental principle of health care: anyone receiving medical treatment must agree to undergo that treatment. Competing interests: We have read and understood BMJ policy on, declaration of interests and declare the following interests: AS. Descriptive labels of the coding scheme were applied to the raw transcript data. patients compared to the normal population across various QoL measures and P.E. bmj.com Obstetrics is a specialty that is widely perceived to be associated with a high risk of litigation. To pool the outcomes of surgical management for patellofemoral instability in the presence of patella alta and to determine whether the outcomes differ for different surgical techniques. 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