When Patients Are Not Capable Of Informed Consent

   This is one of my editorials that will irritate the DPMs who equate being a podiatrist with canonization. You guys and gals might want to toss this issue aside or take an extra Paxil or Wellbutrin. Some of the decisions we make and the things we do compel us to take a harder look in the mirror.    We need to be more careful about operating on developmentally delayed, mentally ill and drug addicted patients. Most of these patients are not capable of making an informed decision alone and need the assistance of a competent advocate. This could be a relative, guardian or a social services case manager. The patient’s primary physician should also be involved. In many cases, the patient’s significant other is also impaired. The surgeon must keep that in mind when discussing informed consent.    My partner recently amputated the great toe of a methamphetamine addict. I had declined to repair her bunion several years ago when she arrived at the hospital late and stoned. I counseled her into non-surgical care until she got control of the addiction. She had no trouble locating a willing podiatric surgeon. The double osteotomy was a mistake. The patient went for a stroll on the beach the first week after the surgery. Both osteotomies fell apart and she developed osteomyelitis.    Some will argue that the patient’s non-compliance was the issue and the surgeon was not responsible. The surgeon did write a lengthy letter to the patient, pointing out that her non-compliance caused her complications. He also dismissed her from his care. He sent the letter certified mail and requested a receipt so I guess he covered his butt.    It wouldn’t take a rocket scientist to determine this patient had a significant addiction problem that should have contraindicated elective foot surgery, especially when the patient listed the addiction in her medical history. The surgeon went ahead. The patient lost her toe. It could have been worse. The patient was fortunate to find my partner, who possesses a quality blend of skill and compassion. He stuck his neck out far to help her after the other guy dumped her.    This is not pleasant stuff to contemplate but it happens too often. We as podiatric surgeons need to look at the whole patient and factor his or her mental limitations into our decision making and surgical planning.    A woman with some obvious mental health and prescription narcotic problems recently contacted my office. She went to a well-trained podiatric surgeon with leg pain. He diagnosed posterior tibial tendon dysfunction and performed a FDL transfer. Now the lady has leg pain, foot pain and she is still mentally ill with a narcotic analgesic addiction. You guessed it. The good doc dumped her. She began calling podiatrists at random and found us. We don’t duck these issues so she is about to become our patient. Perhaps the original surgeon could have taken a little time to assess her mental health and drug problems, and might have determined that an elective complex rearfoot procedure might not be in her best interest. Maybe he needed the case for his boards.    I am sure members of the Wellbutrin/Paxil gang are now sitting at their computers firing off letters to the editor to Podiatry Today and a few other podiatry trade magazines, cursing that narrow minded Dr. McCord for saying bad things about podiatrists. Be sure to spell my name right, kids.    People with mental problems do need our care and they often need surgical care. However, one should take the time to involve an advocate. Consider postponing surgical care for those who will self-destruct postoperatively.    Dig out that oath you took when you got your diploma and read it a few times. It spells out our duty to patients. Never mind the indications listed in surgical textbooks for foot and ankle procedures until you have determined the patient is competent enough to make an informed decision and follow through with the postoperative demands.    Some of us have the attitude that mentally impaired patients are responsible and are to be blamed for a poor surgical outcome. I believe we have the ultimate responsibility for our surgical failures when dealing with patients who have mental limitations or addiction problems. If all of the surgeons who carelessly and recklessly operated on these patients quit medicine, the world would be a safer place.    I have a 29-year-old son who is developmentally delayed and has mental illness. I try not to imagine him out in the world on his own without me to help with his important decisions. He has always had good medical care but is vulnerable to physicians who disregard his life situation and limitations. It is just as well that most of those doctors don’t accept Medicaid. Dr. McCord (pictured) is a Diplomate with the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.