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 A survey on current practice of informed consent process in surgical specialties of a tertiary teaching hospital center: What is the state of play?


 Background

Informed consent is essential in current medical practice and should be a global standard to be sought at all instances when doctors interact with patients. The aim of this study was to evaluate compliance to the guidelines of the Portuguese health entity regarding the correct filling process of informed consent.
Methods

A prospective observational survey was conducted upon arrival of the patient at the operating room of a tertiary teaching hospital center in Portugal, in march 2021, to verify the presence of informed consent in the clinical process. A sample of 202 clinical files was randomly collected.
Results

 Only 47% of the patients had the informed consent document in the clinic process and only 45% of the total clinical files had the informed consent signed by the patient. Merely 21.8% of the informed consents respected all the items recommended by the guidelines of the Portugal health entity. Most of the surgical informed consent (SIC) had only basic information and only a lower percentage had reports about the surgical procedure, information regarding the treatment, possible consequences of a missed treatment or complications and possible treatment alternatives. Those results didn’t conform to the standard regulations of the Portuguese health guidelines regarding SIC.
Conclusion

Even though improvements in SIC were attained in recent years, our study suggests that the implementation of SIC is still suboptimal in surgical practice. It is important to raise awareness for the obtention of SIC by the healthcare team, because complete information before an invasive procedure is an ethical requirement.