Informed consent

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Facilitator: Becca
Medics:
Patients: Kyle
Time: 20 mins; 1915-1935
Actual time:
Learning Objectives:
Materials: Chart paper, marker

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Re-establish consent

Facilitator says

Street medics get informed consent for everything we do -- touching someone, asking medical questions, providing first aid. Introduce yourself and get consent before you start patient assessment. Maintain consent throughout the assessment and care process to ensure you're following your patient's wishes. The patient has final say over what happens with his body.

Facilitator says

Injuries and illnesses in protests often involve feeling a loss of control or autonomy:

• Lost control to police.

• Lost control of bodily integrity or function by being injured or ill.

• Lost control of what will happen next .

Facilitator says

Street medics support protesters in recovering their autonomy.

Good consent skills drill: Kyle has a minor scalp laceration and low blood sugar

Facilitator tells patient

Your name is Kyle. You are fully alert and oriented. This morning was the most intense action you've seen. When it calmed down you noticed you were bleeding from a cut on your forehead. You were suddenly overwhelmed and felt really far from home.

You don't realize it, but your overwhelmed and withdrawn feelings are from low blood sugar -- you were so caught up in the action you forgot to eat or drink anything except coffee this morning and you didn't get much sleep last night. You've been smoking cigarettes all day, which disguised your hunger.

Facilitator says

After the medics sent Lisa to the hospital, the wind picked up. The protesters were hanging out and talking about the big action this morning. Our gallant buddy pair noticed this guy they hadn't met before sitting off to the side, really withdrawn. Let's watch the medics establish consent. Pay attention: after you watch, you will practice asking for consent.

Buddy team approaches

a very withdrawn person sitting on the ground.

• Buddies talk to each other, patient, and patient's friends, but not to classroom while they demonstrate.

• Buddies approach at eye level and head on, so Kyle doesn't have to twist his neck to see them.

Patient buddy

establishes and maintains consent.

• Identifies self and buddy by name and certification or role ("I know some first aid").

• Asks: "What can I call you."

• Asks permission to touch, assess, and give first aid.

• Informs Kyle and gives options ("Would you like to move over there against the wall, where we will be out of the wind and the crowd? It might be a safer place to look at your forehead").

Scene and comms buddy

watches the scene in a low-key way (the spotlight is on the patient buddy, not you).

Debrief

Facilitator asks

What did the medics do? Make sure students hit all the high points.

Facilitator explains

why medics asked "What can I call you?" instead of "What is your name?"

Practice: introduce yourself and learn good consent

Facilitator says

It's your turn to practice establishing and maintaining consent.¹ During the roleplay, you can be Stacy, Kyle, or a character of your own devising.

Students

Count off by 1-2.

• 1s ask for consent from 2s.

• 2s ask for consent from 1s -- 1s refuse consent.

Debrief

Facilitator asks

1s: what did you do to establish consent with the 2s?

Facilitator asks

2s: how did it feel to go from being a patient to being a medic?

Facilitator asks

1s: what was your reason for not giving consent?

Refusal

Good reasons to refuse

Facilitator asks

Why might someone say no? Brainstorm and write answers on paper or board.² Dig for responses like these:

• Religious reasons.

• Wants a medic of a different gender.

• Doesn't speak your language well or doesn't understand offer.

• Doesn't believe the problem needs medical care.

• Thinks that you are a cop.

• Thinks that you want money or can't pay for ambulance and hospital care.

• Thinks you are flirting or making a sexual advance.

• Wants to get back to the action or wants to leave the area right away.

• Doesn't want to get separated from friends.

• Fear of spreading or contracting disease.

• Afraid allowing care will lead to arrest -- esp. immigrants.

• Doesn't want to remove clothing or reveal parts of body.

• Believes you are incompetent or unqualified.

• Avoids the modality you use (biomedical/herbal/etc).

• Doesn't like you or trust you specifically.

Responsing to refusal (quick lecture)

Facilitator says

³

• Ask yourself how sick or injured you think the person is.⁴ Ask yourself why you want to offer care -- if it's about your ego, let it go. If it's about the person's safety or well-being, you can continue to try for consent.

• Clarify who you are and what your purpose is.

• Reflect to the person what you see: "you're bleeding" or "you have a thousand-yard stare." The person might not be aware that he's in bad shape, and this check-in can help.

• Offer/find another medic.

• Let him define the problem and attend to his self-identified needs.

• Find his friends and explain the situation (only if you have a damn good reason for breaking confidentiality).

• Find a safe space to move with the person or make the scene you are in safer (get rid of media, create a perimeter using other protesters).

• Use his language to communicate.

• Help him consider the risks and benefits of not getting care.

• Be clear that you will not force him to to anything.

• Get an ambulance.

• Commiserate with his stated fears or dislikes.

• Assure him that you are a volunteer and do not want money.

• Clearly state that you are not a cop. You don't like cops.

• Respect his "no."

If you accidentally do something without consent

Facilitator says

• Be accountable.

• Apologize clearly.

• Use body language or distance to respect boundaries.

• Maintain the same standards as before -- nothing without informed consent.

Facilitator says

If you can't resolve the situation, offer to find another care provider and give a way to hold you accountable (your name, collective, contact info for another person from your collective, etc).

Introduction to medical ethics

Informed consent

Facilitator says

This phrase means: a reliable adult patient agrees to receive care after being informed of the risks and benefits of each intervention.

Facilitator says

The American Red Cross suggests these steps to establishing informed consent -- as you have noticed, we go further, but this is a good foundation):

• Identify yourself.

• State your level of training.

• Ask if you can help.

• Explain what you observe.

• Explain each thing you plan to do.

Implied consent -- asking forgiveness instead of permission

Facilitator says

We don't use the word "unconscious" (consciousness is for doctors, philosophers, and politicians to debate, not us). We use terms based on what we can readily observe -- like "unresponsive," which means the person appeared unable to respond to you.

If someone can't give informed consent because he's unresponsive, consent is "implied" -- law and convention assume that if he could communicate his wishes, he would accept help that he would consider to be in his best interest.

Facilitator says

When operating under implied consent:

• Explain every touch, movement, and change in the scene to the unresponsive person. If he suddenly "comes to," he can orient and give a clear yes. If he doesn't regain the ability to communicate but can hear and feel, you're less frightening.

• Ask yourself, "If I was in his situation, would I want this care?" "If he was alert and oriented, would he want this care?"

• If a patient makes clear requests that pertain to his care before becoming unresponsive, do your best to honor verbal advance directives and communicate them to the next part of the care chain, in writing if necessary.

Consent to assess and render first aid to minors

Facilitator says

It is generally hospital policy to require parental consent for care of people under 18. This is a reasonable policy,⁵ but it does deny minors full autonomy. Follow your best ethical sense.

• When giving first aid to minors, be especially conservative with your interventions -- you can always educate and encourage self-care.

• You may choose not to ask the patient's age. If he's old enough to be at a protest without a parent, you might assume he's old enough for you to respect his judgment.

• If a child is at a protest with a parent and is sent to a hospital, find the parent.

• If you believe a person may get discriminatory treatment in a hospital because of his age, you might try to accompany him through the system as an advocate.

Sum up and yell

Facilitator says

As a medic, you rehumanize situations that were dehumanizing and restore consent where it was lost. Take special care to allow people control of their own bodies and personal space. This is more than a legal issue -- it is a political and ethical issue.

Facilitator says

When talking to a patient

• Be confident. Keep a medic face on if you can.

• Ask permission to do each new thing. Explain what you are doing. People hate surprises.

• Warn when something will hurt or look scary.

• Pay attention to language, facial expressions, and other indications of how the person feels.

Big yell!

Students:

On the count of three, yell what you would want to say upon seeing a gory, messy scene. Feel it in your gut first.

Facilitator says

Say it now so you won't say it in the street.