INFORMATION SHEET FOR CANDIDATE:

You are the evening resident in the emergency department

of a major city hospital when a 25 year old patient, John, is
brought in by ambulance. He was the passenger involved in
a motor vehicle crash and was trapped in the car with
severe injuries to his right leg. The emergency services had
to cut the car to free him. The MICA crew at the scene had
placed two 16 gauge iv cannulas, started iv fluids and had
given him small increments of morphine iv for pain relief.
His vital signs are stable, he is conscious (GCS 15), his
right lower leg has multiple compound fractures to tib. and
fib., as well as the talus and some foot bones with severed
nerves and arteries (not bleeding).
The orthopaedic team have decided that he most likely will
have to have a below knee amputation and you have been
asked to obtain consent from the patient.

YOUR TASK IS TO:

Obtain consent from the patient and answer questions from

the patient and / or the examiner
HOPC: John is a healthy bricklayer being the passenger in a Laser, driving home from a
work related meeting. He remembers the crash and everything since quite well. He can’t
feel his right lower leg and has little pain at present.

FHx., PHx.: unremarkable

SHx.: married, 2 children, financially secure. John is a high level athlete and just
undergoing trials for inclusion into the Victorian rowing team. Non smoker, occasional
alcohol, no drugs or medications. NKA.

PROCEDURE:
1. Explain the extent of injuries in laymen’s terms to the patient with all the surgical
possible procedure like debridement, suturing of soft tissues, nerves and arteries and
fixing bones together (plastic, orthopaedic and micro-surgery etc.).
2. Outline that his injuries look very grim. However, the surgeons will try to save his
limb and do everything to restore life to the tissues but it might not be possible to
repair all the damages and it could be that in the operation major parts of the tissues
are found to be not viable or ‘dead’. This would necessitate an amputation, most
likely below knee which should heal very well and nowadays it can be managed very
well with prosthetic devices like he might have seen in the para-olympic games.
3. The major risks of not amputating in such a situation are:
 Dying tissues with production of toxins poisoning the body leading to
multiple organ failure
 Major infection localised, gas gangrene or spreading through the whole body
(sepsis)

PROGRESS: John asks detailed questions about the operation, why it is necessary, if
there are any alternatives and in the end he actually states that he does not agree to an
amputation under any circumstances.

CONSENT:
Informed consent to a treatment, investigation or procedure is required and enforced
under Australian law. The underlying principle is the high importance of individual’s
rights and autonomy.
Consent should be given freely without any coercion or time pressure by a competent
patient! The patient has to understand not only the Rx/Ix or Mx but also the relevance
to the specific case, e.g. a finger injury may be more significant to a pianist vs. a market
gardener!
It must be in writing, signed by the patient and witnessed by a doctor.
Risks (anything, if known to a reasonable person, s/he would attach significance to),
complications, alternatives and the likely outcome need to be specified for the proposed
Rx, Ix or Mx..
You have to prove that the patient understood your advice! Competence is determined by
the patient’s age (!e.g. minors), and intellectual, physical, sensory, neurological or mental
capacity to make a legally binding decision. The patient has to have has to have the
cognitive capacity (SOUND MIND) to understand the medical condition, the options for
treatment, the risks and what may happen if no treatment is given.

Informed consent does not apply to emergency situations (implied consent)

If the health professional decides that a patient is not competent to consent to treatment,
either because of limited cognitive capacity or insufficient understanding, or next of kin
are not available or able to give consent, contact the guardianship board of the Victorian
Civil and Administrative Tribunal (VCAT). Next of kin can give consent if there is no
dispute about a treatment or procedure, if there is any disagreement, VCAT needs to be
involved.
If a person, appointed under a medical enduring power of attorney, seems to be not acting
in the best interest of the patient, VCAT should be approached to have the person’s
authority cancelled and to have a guardian appointed.

PROGRESS:
The patient still refuses to give consent to the amputation and you have to inform the
registrar or consultant over the phone.
You should discuss the possibility that in this case the competency of the patient could be
influenced by:
1. influence of narcotic analgesics
2. shock