What are the implications of treating a ureteral stone without explicit patient consent?

Legal and Ethical Implications of Treating Ureteral Stones Without Explicit Consent

Treating a ureteral stone without explicit patient consent is a breach of patient autonomy and may constitute assault, battery, or negligence, potentially leading to legal action against the physician. 1

Legal Implications

The legal consequences of treating without consent are significant:

• Assault or battery claims may arise from touching a patient without consent or approaching them with medical instruments, regardless of the outcome 1
• Negligence claims are more common, based on the argument that had proper warning been given, the patient would not have agreed to the treatment and complications would have been avoided 1
• Courts may find a physician negligent even if the patient would have undergone the treatment had they been warned, reflecting the legal importance placed on respecting patient autonomy 1
• Human rights violations under Articles 3,8, and/or 9 of the European Convention on Human Rights might be invoked when consent is not obtained 1

Exceptions to Explicit Consent Requirement

There are only three legitimate exceptions to obtaining explicit consent:

1. Emergency situations where treatment is immediately necessary to prevent death or serious harm 1

   • For obstructed kidneys with signs of infection or sepsis, especially in patients with single kidney or chronic renal failure, urgent decompression is considered emergency treatment 1
   • However, this only justifies the immediate decompression procedure (stent or nephrostomy), not definitive stone removal 1

2. Patient has explicitly waived the right to receive information 1, 2

3. Therapeutic privilege in rare circumstances where discussion of risks would pose a serious threat to the patient (e.g., risk of suicide) 1, 2

Professional and Ethical Considerations

The professional and ethical standards are clear:

• Respecting patient autonomy is central to the doctor-patient relationship 1
• Physicians have an ethical obligation to inform patients about what will happen to them and what to expect 1
• The American Urological Association (AUA) guidelines emphasize proper technique and informed decision-making for ureteral stone management 3
• Emergency physicians have a duty to respect patients' right to accept or refuse recommended healthcare 1

Specific Considerations for Ureteral Stone Management

When managing ureteral stones without explicit consent:

• Blind basketing (stone extraction without endoscopic visualization) should never be performed due to high risk of ureteral injury 3, 4
• Complication risks that should have been disclosed include:
  • Ureteral injury (3-6% of cases)
  • Ureteral stricture formation (1-5% of cases)
  • Urinary tract infection (2-4% of cases)
  • Sepsis (2-4% of cases) 3

Practical Guidance for Clinicians

To avoid legal and ethical issues:

1. Document thoroughly any emergency circumstances that necessitated proceeding without consent
2. Obtain consent as soon as feasible for any non-emergency follow-up procedures
3. Involve surrogate decision-makers when patients lack capacity 1
4. For emergency decompression of obstructed stones with infection, document the rationale for urgent intervention 1
5. Defer definitive stone removal until proper consent can be obtained 1

Medicolegal Risk Mitigation

The risk of legal action increases when:

• The procedure was not truly emergent
• Alternative, less invasive options were available
• Complications occur that were not disclosed
• There was time to obtain consent but it wasn't sought
• The patient had previously expressed refusal for similar procedures 1

Remember that even in emergency situations, physicians should, to whatever extent time allows, inform the patient about the treatment being provided and should not violate the explicit refusal of treatment if the patient possesses decision-making capacity 1.