A 54 year old businessman is referred from a non-interventional cardiologist to an interventional cardiologist for angioplasty following a diagnostic cardiac catheter. Upon reviewing the films, the interventionist is comfortable that there is a long segment of important stenosis in the dominant right coronary artery that would be amenable to percutaneous coronary intervention (PCI), but is also concerned that there is an important ostial stenosis of the left anterior descending (LAD) coronary artery that is not clearly visualised on the diagnostic film (that does not contain a left anterior oblique (LAO) caudal view). The interventionist arranges to meet the patient in a preadmission clinic and explains to him that more information is required about one of the coronaries before he is happy to commit to PCI and stenting. The patient is therefore consented for “coronary angiogram ± coronary stenting” and signs the form. Four weeks later, the patient is admitted for the elective procedure and upon taking more detailed pictures (including a steep LAO caudal view) the cardiologist demonstrates, as suspected, a tight ostial LAD lesion. He recommends to the patient that he may be better off having coronary bypass graft (CABG) surgery and does not proceed to angioplasty. Later on in the afternoon, the consultant is called by the ward because the patient and his wife are angry that no PCI was undertaken. The consultant is in a meeting outside the hospital, so a registrar is asked to go and explain the management plan again. A referral is subsequently dictated to a cardiac surgeon as an outpatient.
Two months later, the trust received a formal complaint, written by the patient’s solicitor, claiming that he was “shocked” that the PCI did not go ahead and that he was not made properly aware that this was a possibility.
This scenario arises quite simply from a misunderstanding; the patient should have been told clearly that the angiogram was a test to enable the doctor to decide whether or not to go onto an angioplasty, what information the test would provide to enable that further decision to be made, and upon what criteria the further decision would be made. He should have been told of the benefits and risks of each of the procedures and should have been asked to consider and consent to each. If that exercise is undertaken he should clearly understand that he may, or may not, undergo an angioplasty. The consent form was in appropriate terms and suggests he was told all he should be, provided of course that the terms “angiogram” and “stenting” were explained before signing and he was told that the “plus or minus” was put there to reflect the uncertainty of the ultimate nature of the procedure he was to undergo. In circumstances where he subsequently complains, he must have misunderstood. Is that the doctor’s fault? The law imposes an obligation on the doctor to disclose the information in a reasonably comprehensible way; he should take reasonable care to ensure his explanation is intelligible to his patient. However, intelligibility means that the information is in a form capable of being understood; it is not critical that the patient does understand. Provided the doctor has given clear information, which must of course be tailored to the social, emotional, and intellectual abilities of the patient, insofar as it is reasonably possible for the doctor to judge them, it will not be his fault if the patient misunderstands. Having said that, this question is a good example of the dangerous use of interchangeable terms; remember the patient will not know that in this context “PCI” means the same as angioplasty and/or stenting. It is unfortunate that when the patient first became aggrieved a registrar had to be called to explain the management plan again; it would have been preferable for that explanation to be given by the consultant who had performed the procedure as that might have averted the subsequent solicitor’s letter. In the circumstances as they arose, another meeting with the consultant to underline the registrar’s explanation would be ideal.