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Acupuncture Today
December, 2008, Vol. 09, Issue 12
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Another Ethics Situation: Consent

By Laura Christensen, MA, LAc, MAc

Recently, a patient told me that she did not want to continue with the Rolfer to whom I had referred her. I believe this patient needs Rolfing, as she is developing her third case of frozen shoulder.

I want to be sure that we use all the modalities that will help, in addition to acupuncture. After her first visit, she said that she appreciated the Rolfing and thought it was really what she needed, but that something had happened at the session that made her very uncomfortable and she might not go back. This made me very concerned.

She had liked the Rolfer, but at the end of the session, the practitioner had begun doing something other than Rolfing without asking her. The patient thought it was reiki. I happen to know that it was not, but the point is that the Rolfer switched treatments without informing the patient or getting her permission. The practitioner did not explain what the additional procedure was or why she thought it was needed at that time. As a result, the patient felt that she had been given no choice in the matter, and no longer trusted the Rolfer and therefore planned to stop the Rolfing.

What the Rolfer did not know was that this patient has a history of many frightening medical interventions, which made her feel vulnerable to, and violated by, medical professionals. She was sensitized to the issue of consent; she had good reason to be.

During her session with me, I carefully interviewed the patient about her experience, expressing my concern and support of the patient's misgivings. I encouraged the patient to call the Rolfer to discuss her experience, so that she could continue with the therapy. She never called; and thus will not have the Rolfing that I think she needs.

Now, this Rolfer happens to be one of my best friends; I have known her for nearly 20 years. In fact, it is because of her insistence that I resumed my practice of acupuncture after a nine-year hiatus from the field. I have experienced the energy work that she does, and believe it is safe, useful and helpful in most cases.

Handling this scenario brought some interesting challenges for me. In speaking with the patient about the situation, I recognized that I might be tempted to explain the behavior of the Rolfer and the energy work that was done, and defend my friend - but I chose not to. I realized that doing so would make my patient feel awkward and perhaps interfere with her ability to trust me. This patient is quite self-aware and sensitive, and I knew she would quickly surmise the difficult situation if I came to my friend's defense. Additionally, this would put me in a position of using the practitioner/patient relationship to serve my needs, which is always inappropriate.

This was another wake-up call for me about how people feel when we do something to them without discussing it first and getting consent. As acupuncturists, we like to seamlessly integrate ancillary modalities like moxa, electric stim, auricular treatments, cupping, tuina and others. We see the need for an ancillary therapy as we go, and proceed to add it to the treatment - sometimes without stopping what we are doing, demonstrating or explaining the method (discussing risks and benefits), and getting explicit consent from the patient.

For example, with things like auricular electrical stimulation, we consider the modality pretty harmless, painless, and non-threatening, especially compared to needles and moxa. However, our patients might not feel the same way. Almost every time I use an ear machine, I tell the new patient what I am doing; but in the occasional case that I forget to show it to them, explain, and get their permission, they will usually ask, "Now what are you doing?" I apologize, proceed to explain and get consent, and they are always fine with it (so far.)

As I stated in an earlier column, a teacher of mine said that if you go to a medical doctor you will either be poisoned, cut or burned. By the same token, it seems to me that when our patients come to us, we are either going to stab them, burn them or electrocute them. Really, folks - they feel threatened by us at a primal level, and we must always keep this in mind when introducing a new therapy. I have often thought about making a PowerPoint presentation about ancillary modalities for my patients to watch early in their care with me, to save the time and "speaking qi" that it takes to explain every new thing I may do at a treatment.

For the benefit of our businesses, our profession as a whole and the image of acupuncture in the public eye, we must be as assiduous, if not more so, than other health care professionals about explaining therapies and getting consent. Even more importantly, we must give our patients control and choice about their health care. This need is demonstrated by the many cases in which people believe they are injured and attempt to find a remedy by making an official complaint, or even suing the practitioner.

Then there is the question of just how much detail we need to go into explaining the ancillary method, how it works (who really knows, anyway), and the risks and benefits compared to other options. I think most of us choose how to do this based on our assessment of the patient's interest, paranoia and willingness to trust our judgment, as well as the characteristics of our relationship with them.

I am not sure every acupuncturist would think we have to have a separate signed consent form for every ancillary therapy (legal advisors would certainly disagree), but each of us should certainly have some kind of structure in place for the performance and documentation of this process. Even if it is just a conversation - document it.

Consent could be as simple as saying something like, "Now that I've explained what I am planning to do, are there any other questions? Shall we go ahead then?" Or "Is it OK if I just go ahead with the [modality] then?" Or "Does it seem like you are OK with that?" And remember to always document that the conversation took place.

Come to think of it, does your dentist get your written consent beforehand for every different procedure they do? Does your dental hygienist do so? Does your doctor do so? Your physical therapist? Perhaps they do so nowadays more than in the past, but I don't recall seeing or signing anything like this at any of my visits to the above. I guess they assume that you have been to the dentist before and know what will be done.

As for the doctor, do they fully inform you about all of the risks and benefits of each medication they recommend? How about when you have an extremely minor procedure such as having a skin tag removed? Will they sit down, take the time to explain what they will do, including all the risks, and have you sign a consent before they quickly yank off those little guys? The consent process might take five minutes, while the procedure takes 15 seconds. Interesting.

Despite what other health care practitioners may be doing, as practitioners of the mysterious art of acupuncture, we must be very aware of these dynamics. By doing what I have indicated, we can help our patients trust us, they will have a good impression of our professionalism, and they will be more likely to stay in treatment long enough to get the full benefit of our methods. And we can reduce the risk of patients making complaints to our boards.

This event with my patient and my Rolfer friend has been painful to go through, but it ended up being very helpful for me, because it led me to think again about our consent process with our patients.

Click here for previous articles by Laura Christensen, MA, LAc, MAc.


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