SHE Pod Season 2 Episode 12: Camilla Scanlan on Consent for Neurosurgery and Traumatic Brain Injury

9:52PM Nov 1, 2021

Speakers:

Kathryn MacKay

Camilla Scanlan

Keywords:

consent

bethany

chapter

adam

traumatic brain injury

camilla

person

severe disabilities

people

patient

case

substitute decision maker

brain

advanced directive

brain injury

traumatic brain injuries

attending physicians

decision

medical

surgery

Hello, and welcome to the SHE Research Podcast. I'm your host Kate MacKay and today I'm joined by Camilla Scanlan to discuss her chapter, Consent for Neurosurgery in Cases of Traumatic Brain Injury. This is co-authored with Cameron Stewart and Ian Kerridge. And this chapter appears in a book entitled Traumatic Brain Injury. Hello, Camilla.

Hello Kate, nice to see you.

Nice to see you. Thanks for joining me.

My pleasure. Thank you for your interest in my chapter.

Oh, absolutely. It was fascinating to read. So to kick us off, how about, you could describe to the listeners the kind of case that you present in the chapter that sort of helps to situate the topics that we'll get into around consent and brain injuries?

Sure. The case that I present in the chapter is hypothetical, but it is... the features of it are very, very realistic. So I think, perhaps before I outline the case, maybe I can outline the cohort of people that are most affected by traumatic brain injury.

Yes, please.

So brain injury occurs across a number of different disease types and experiences. And it can be mild, moderate, or severe. So the sorts of injuries we're talking about, can come from a person having an aneurysm, bleed, or a stroke. What this chapter is specifically aimed at is people who have very traumatic brain injuries, and that's most often from a violent situation, or an accident of some sort. From the statistics, we know that young men are particularly prone to traumatic brain injuries because of their risk taking behaviour. So the sociological evidence tells us that young men in particular hegemonic masculinity and are likely to do more risk taking events, then women or people of an older age, and the statistics show this up. Two out of three, acquired brain injuries have been acquired before the person is 25 years old. And three out of four of those people are men, more so this is the cohort that we're really looking at, when we're thinking about severe traumatic brain injury. Right? When a person receives a traumatic brain injury, one of the problems is that there's very little space within the cranium. So the brain, all it can basically do is what's called contra crew, which is moved back and forth and shake about a little bit. So the injury becomes very acute in the brain, not only from the position of the injury itself, but how the brain can respond. The most dangerous traumatic brain injury, or the one that has most catastrophic outcomes, is a brain injury to the front of the brain because that frontal brain part is called the executive decision making area. So that's why a blow a severe trauma to the front of the brain can have all sorts of disabilities resulting from it. So these disabilities can be cognitive. It could be motor skills, and that might include resulting paralysis, emotional changes in the person and functional changes. So that can be so that the person is no longer able to toilet themselves or each may dress or they may lose vision. They may lose balance Nimita hearing from the emotional perspective, they may become very irritable, and they may lose the ability to control their temper. So we're looking at some very significant downstream effects of traumatic brain injury. Perhaps I could not introduce you to the case. Yep. So this is the story of Adam and Bethany. And there are a young couple. They have a two year old toddler. And Bethany has recently recently given birth to a two month old baby. Bethany has begged Adam to stop riding his motorcycle. But he finds it very difficult to give up. It's something he absolutely loves. He adores the exhilaration, that feeling of freedom as you lean into a corner neuron straightaway. So it's been very difficult for him to oblige. And then one evening, Bethany's worst fears are realised, when the police visit her home to tell her that Adams been involved in a very serious bike accident.

It would appear that as he was riding along a wet road, and it recently rained, that his bike may have hit one of the light reflectors on the road. The bike has aquaplaned and has landed straight into a tree, with Adam taking the full force of the impact on his head. The police believe that he probably would have been travelling about 70 kilometres an hour on impact. Adam was unconscious when the paramedics arrived, and he's been taken to a large teaching hospital. He still hasn't regained consciousness. So Bethany arrives at the hospital to find Adam, in a very frightening stage, he's unconscious, he's got tubes, monitors, all sorts of things going on. And this is terrifying for the medical team have performed urgent screens and X rays and images and found that he has a hematoma, a clot on one side of his brain, and that is stopping blood circulate to another part of his brain. So this is quite, it has a very bad prognosis. The medical team has decided before Bethany arrives, that surgery could save his life, if it was performed fairly quickly. But with their experience and expertise, they feel quite sure that even if they are able to save his life, that he will be left with severe disabilities. It's impossible at this point for the medical team to say how severe what exactly those those disabilities are, other than based on their experience, there will be severe disabilities. Because the medical team have already ascertained that surgery could assist Adam could save his life, they're prepared to offer that option to Bethany. So this is where we now need to think about consent and the role that consent pairs. We know that legally, ethically and professionally, surgery can't be performed unless there has been concerned for it to go ahead. And this relies or relates to respect for patient autonomy. There are three elements of consent. One is the first one is that the person giving consent has to have The capacity, the mental capability of giving consent. The second element is that consent has to be voluntarily made, it can't remain under undue duress. And the third element is that the person has to have been provided with what's called material information. So information that would be material to that person. So by that, it's meant that it would be relevant to that person's situation and to his or her decision making capacity. We know, however, that Adam is unconscious. So clearly, he cannot make these decisions on his own, or can't make these decisions at all. So the law then makes allowances for a substitute decision maker to be able to make decisions in the case of when the person him or herself lacks capacity.

So Camilla, just to kind of clarify for the for the listeners, I think the it sounds like the main dilemma, if we can put it that way that Bethany faces is that the treating team has said that surgery on Adam is could be appropriate, because it might save his life rather than being a futile treatment. So they are offering the surgery because it could actually be life saving in this case, but it will come at some sort of cost, and it may be a very large cost. In fact, it could be quite severe disablement. So Bethany is put in the position of needing to make this decision about whether or not she's going to basically consent on Adam's behalf?

Yes, that's correct. Yeah. And there, there are two ways that she could do this. The law allows for the substitute decision maker to be making the decision using so in this case, Bethany says she can use her own judgement to objectively and subjectively decide what is in the best interest of Adam. Alternatively, the law says that the substituted judgement can be what Adam would have decided. So hearing, we have another thorny issue. And that is that on a number of occasions, in the past, Adam has said that he would not want to live with a severe disability. Now, that statement was made publicly, when I say publicly in front of friends and family on a number of occasions, just as a matter of conversation, he hasn't written an Advanced Directive, it would be unusual for a young man to have made an Advanced Directive. But even if an Advanced Directive is made, it's very hard at time A, to predict how you're going to be feeling at time b, when circumstances could be quite different. So he now has two children. So maybe his view would be very different about whether he would want to live or go on living with disability with as was a better option for him.

So in the chapter, I take it that the chapter doesn't set out to try to solve this because this is such a thorny issue. And I really, I mean, this, like you said, this kind of cases, drawn from fact from real cases. So it's not even an example that's, you know, out of this world, it's one that people encounter. And, yeah, I just have so much compassion for people in that scenario. But so, So solving this issue sort of isn't what you're setting out to do. So I wonder, what did you hope to establish in the chat What were you trying to do in the chapter I

wanted to clarify that there are a number of things that happen in the consent process. And first of all, is that consent is a process. It's not a quick and easy fix when you need to have something done. And it's certainly not the signing of a piece of paper. It's an ongoing process. And it has a number of functions. It allows for the respect of patients or autonomy. And that's its primary function, I would say. So it allows for the person to provide authorization for procedure to go ahead. Probably a secondary function is that it requires the provision of material information. So this has to come from the attending physicians, it's their responsibility to make sure that the material information has been provided to the decision makers, and that the decision makers can understand it, and that they are sufficiently sufficiently cognitive, so that they can understand what the proposal is, and what would happen if they didn't have the treatment, the person has to be able to be cognizant sufficiently to retain the information, and then to be able to weigh that information as part of the decision. And then it has to be able to communicate that decision to others. So in this chapter, we see that not only is consent looking to that primary function of respecting the patient's autonomy, and the secondary function of the duty of the attending physicians, to provide information, there is a third opportunity. And this is the creation of the opportunity to develop relationships between the medical healthcare professionals, and the person making the decisions. That relationship should be one of needs to be and will ultimately have to be one of trust and understanding. So the decision maker be that the patient or a substitute decision maker needs to ultimately trust that the healthcare professionals will be doing whatever they believe is in the best interest of the patient, if consent to actively trade is what the decision maker designs. So this is something that hasn't been discussed very much previously, about this need for trust and understanding and how that comes to relationships between the patient or patient's significant others and the healthcare professionals.

Hmm, interesting. So the chapter is kind of adding that into into the mix of what the point of consent is, yes,

yes. What process of consent is yes.

That's really interesting. We're nearly out of time here. So I guess, I would like to ask you, what are the primary takeaway messages that you hope people will read Will will glean when they read your chapter and I wonder if it's related to that one?

It is very much related to that one, Kate? Yes, this book is targeting people who have an interest in traumatic brain injuries. And that's a broad group of people. It includes patients who have previously had a traumatic brain injury who are negotiating in their new life as a result of that. It's aimed at healthcare professionals, but also aimed at the circle, the significant others of the patient. So hopefully, it can highlight this area of the third arm or the third function of the process of consent and to hammer home. The idea that consent is very much Your process and it needs to be worked through.

Fascinating. Well, thank you so much for speaking with me about the chapter Camilla.

My pleasure.

Thank you everyone for listening to this episode of the SHE Research Podcast. You can find Camilla's chapter linked in this episode's notes along with the transcript of our conversation. SHE Pod is hosted by me, Kathryn Mackay and produced by Madeline Goldberger. You can find our other episodes on Spotify, Radio Public, Anchor or wherever you get your podcasts of quality. Thanks again for listening. Bye.