On Teaching Cardiac Catheterization Redux: Explaining Informed Consent

In the August 2014 CLD Editor’s Corner¹, I wrote at the beginning of the academic year, “I am reminded that it’s not easy to teach cardiac catheterization.” Six years later, I again appreciate that everything in the cath lab is new to our trainees. This is my 37th year teaching fellows, residents, technologists, nurses, and industry representatives about cardiac catheterization. I continuously marvel at the blank slate of the new fellow’s open mind and how these high achievers struggle with the apprenticeship style of learning.

Every procedure with a new fellow is time-consuming and sometimes exciting. From the book “House of God”, the quote, “show me a fellow who only doubles my work, and I’ll kiss his feet” has never been truer, but should not be taken as a negative. Our job as teachers is to provide the environment and method to train superior fellows, nurses, and technologists. I’m sure everyone in the cath enjoys seeing the incorporation of new information for the fellow and, of course, new nurses and technologists. The satisfaction of transmitting knowledge to hungry minds is a reward in itself. For example, this week we did several interesting cases using a recently implemented left distal radial approach² for a coronary artery bypass graft patient. Two patients had wide ascending aorta dilations needing aortic replacement, and another patient with renal failure, coronary disease, aortic stenosis, and subacute pericardial tamponade needed a pericardiocentesis. In this latter patient, the fellow and I did a right and left heart cath, and aortic stenosis hemodynamic evaluation prior to and again after pericardiocentesis.  I still love doing cardiac catheterizations and helping our trainees, young colleagues, and cath lab team members ‘up their game’.

This week, my newly assigned first-year fellow showed up to the cath with an eager smile and bright look. I asked him, “Did you see the patient? How did you explain what we were going to do before obtaining consent? What did you tell him about the risks of the procedure?” As in my earlier editor’s page¹, I emphasized that seeing the patient means more than just getting a history and doing physical exam. It means appreciating (“seeing the circumstances”) of the patient and their family, ascertaining their psychosocial IQ, and giving them the security of our professionalism and crystal-clear communication at a level they can understand in a time of stress.   

Obtaining Consent: A Simple Explanation

Speaking with any patient should be done in a language the patient can understand: simple, direct, with no medical terms or technical language. While this sounds easy, many times we use our daily vernacular, the everyday idioms of work. Doctors and staff speak a technical jargon, using slang or abbreviations that are understood only to one another, but not to the uninitiated. Moreover, the medical literacy of the layperson is highly variable. It cannot be assumed they will know anything about the heart, let alone the techniques of angiography and percutaneous coronary intervention.

Consent is usually obtained by the principal physician operator.³ During our fellows’ initial experience, I try to do their first patient consent together. To summarize what happens, we first introduce ourselves, then I ask a few questions of the patient to ascertain their understanding of why we were asked to perform the catheterization and find out if any new symptoms have appeared since they saw their referring doctor. We then describe the procedure in clear, simple terms (usually keeping the language to a fourth-grade level), explaining what steps will take place, what information each step will produce (“pictures of the arteries and pumping chamber”), and what the  information will do to help the patient’s doctors better manage the patient’s conditions.   

We next move to explaining the risks for both routine cardiac catheterization and, if appropriate, ad hoc PCI. Again, we use simple, non-medical language. We tell the patient there are serious risks, but fortunately these are very rare. Major risks include stroke, myocardial infarction, and death occurring in 1 person in about 1000 (do not use 0.01%). It is worth noting that a recent paper from the Mayo Clinic⁴ said that these risks were even more uncommon, about 1 to 5 in 10,000, and that deaths after catheterization were due to co-morbidities of critically ill patients in shock or who have postsurgical complications. Minor risks include allergic reaction, bleeding, hematoma, and rarely, infection. Many hospital consent forms have very detailed descriptions enumerating every possible complication for legal purposes. Some hospitals require the consent form be given to the patient and family, and provide sufficient time for them to read it before the physician’s request to sign the form. For PCI, a detailed discussion is needed that states the options for medical therapy, stenting, or coronary bypass surgery in advance of the procedure. Table 1 lists what is needed on a consent form.

Sometimes after hearing more about the procedure, a few patients may not want to go forward. As always, the final decision to undergo any medical procedure is always the patient’s decision. If the patient is reluctant, anxious to the point of tears, or cannot cooperate with simple instructions, the procedure should be deferred until the family and referring physician speaks to the patient. A reluctant patient should never sign the consent.

Did We Do a Good Job Explaining the Consent? What Do Patients Recall After Explaining the Procedure?

Several publications report poor recall of patients for the explanations of medical procedures. Eran et al⁵ performed an enlightening although discouraging study. Two hundred patients were given explanations before an angiogram using a specifically “consent-trained” group of physicians and an untrained group of physicians. Patients were questioned on their recall of described complications. Neither patient group did well on recall (35% of inpatients and 36% of outpatients could not recall logical complications such as bleeding when asked). We should remember that despite our best efforts to be clear and simple, patients are often overwhelmed and cannot retain what is explained. This result also explains why many patients may say that “the doctor never told me about that…” despite documentation to the contrary.

With this in mind, after meeting the patient and family, and explaining the procedure, we should have a brief “teach-back” moment. Ask the patient what they just learned to can see if what you said to the patient was understood. In this way you can ‘see’ the patient again in a new light. The same issues with retention of information occur after the fellow and I talk to the patient and his or her family about the results. We provide a simple graphic illustration with a diagram of the angiography to help further explain our recommendations (Figure 1). We then return to the lab to complete notes and orders, review the angiograms and hemodynamics, and recap what we learned. Then, we do it all again for the next patient. This repetitive process is the fellow’s path to becoming an independent operator at the end of his fellowship.    

A Word on the “Learner’s Speed”

Teaching the necessary steps before, during, and after the procedure is a continuous process. The repetitive steps of radial or femoral access, coronary catheter advancement, performance of angiography and ventriculography, and hemostasis are discussed and demonstrated with increasing detail on each repetition. Like all new learners, some get it quickly and some don’t. The experienced teacher knows this, and adjusts his or her style to the speed of the learner. I learned this years ago when I was trying to teach my two-year-old daughter, Anna Rose, about numbers. I expected she would learn it quickly and at my speed, because I thought I was such a good teacher. She sure showed me. The learner will learn at his or her own speed, at all times, and truly test the teacher’s patience and skills.

How to Consent for Ad Hoc PCI

(This topic was originally discussed in “Conversations in Cardiology: Who should get the consent for cardiac cath in your  lab?”³).

The consent for a procedure which is performed by a diagnostic invasive cardiologist and then handed off to an interventionalist for ad hoc PCI is another problem. It is hoped that the patient’s new operator will be added to the consent or better yet, be part of the initial consent process. Consent for the diagnostic and possible ad hoc PCI should include the PCI operator (if known) before going forward with the PCI. Consent for cath and PCI can obtained by the diagnostic physician, but is not ideal without specifying a PCI operator.

Emergency Consent

In emergency situations, it may not be possible to speak to the patient to obtain consent (the patient is unconscious or unable to communicate) or, because of a critical clinical problem with potential for loss of life or limb, there may not be time to obtain a patient’s informed consent. In this setting, many hospitals permit a two-physician rule, with both physicians verifying the procedure’s necessity, reporting to the hospital administrator on duty, and proceeding with the life-saving intervention.

The Bottom Line

Understanding the patient’s experience is key to providing excellent care. It is important for all of us to be sure the patient and family understand the procedure, its risks, benefits, and anticipated findings, in order to help the patient face future decisions. Explaining in simple, clear language with repetition and ‘teach back’ will go a long way to a well-informed and satisfied patient, meeting our ethical, professional, and clinical obligations.

Disclosures: Dr. Morton Kern reports he is a consultant for Abiomed, Abbott Vascular, Philips Volcano, ACIST Medical, Opsens Inc., and Heartflow Inc.

1. Kern MJ. On teaching cardiac catheterization: ‘seeing’ the patient. Cath Lab Digest. 2014 Aug;22(8):4-6. Available online at https://www.cathlabdigest.com/articles/Teaching-Cardiac-Catheterization-%E2%80%98Seeing%E2%80%99-Patient. Accessed September 17, 2019.
2. Kern MJ. A light bulb goes on – my first use of the distal radial artery for the left arm approach.  Cath Lab Digest. 2019 June;27(6):6-11. Available online at https://www.cathlabdigest.com/content/light-bulb-goes-my-first-use-distal-radial-artery-left-arm-approach. Accessed September 17, 2019.
3. Kern MJ, et al. Conversations in Cardiology: Who should get the consent for cardiac cath in your  lab? Cath Lab Digest. 2018 March;26(3):6-8. Available online at https://www.cathlabdigest.com/article/Who-Should-Get-Consent-Cardiac-Cath-Your-Lab. Accessed September 17, 2019.
4. Al-Hijji MA, Lennon RJ, Gulati R, et al. Safety and risk of major complications with diagnostic cardiac catheterization. Circ Cardiovasc Interv. 2019 Jul; 12(7): e007791. doi: 10.1161/CIRCINTERVENTIONS.119.007791.
5. Eran A, Erdmann E, Fikret ER. Informed consent prior to coronary angiography in a real world scenario: What do patients remember? PLoS One. 2010; 5(12): e15164. Published online 2010 Dec 20. doi: 10.1371/journal.pone.0015164