Patient Education and Informed Consent

(1)

Obesity Institute, Geisinger Medical Center, Southold, NY, USA

Abstract

The long-term success of bariatric surgery is dependent on patient motivation and the capability of patients to make changes in lifestyle and eating behavior. Bariatric surgery is not curative, but a simple change in gastrointestinal anatomy, which facilitates limitation of calories. The variable results of individual patient weight loss accomplishment and the 10–25 % of patients who struggle with weight loss and weight maintenance are largely a reflection of the inability of patients to successfully change lifestyle and eating behavior. This offers opportunities in patient education and patient selection as more is learned about behavioral and lifestyle factors that may interfere with weight loss success after bariatric surgery. The process of patient-centered informed consent is designed to provide the patient with details of those individual factors, which argue for and against bariatric surgery. The communication of this important information in a manner which patients can comprehend is essential as is the confirmation that the patient does understand the information. Patient education and the informed consent process are complicated by inadequate health literacy skill, a common problem in patients with extreme obesity. Enhanced communication strategies and teaching techniques including audiovisual and multimedia interventions, extended patient discussions, and feedback techniques will help in addressing health literacy issues.

The uniqueness of bariatric surgery makes patient education and informed consent extremely important components of the preparation of candidates for surgery. Bariatric surgical interventions are not curative procedures. They do not eradicate any disease process, but simply create gastrointestinal anatomic changes, which provide patients with assistance in limiting caloric intake and absorption, thus palliating severe obesity and its associated health conditions. All bariatric surgical candidates must understand that they must assume an active participatory role in their obesity treatment in order for bariatric surgery to be successful. This active participation must involve a change in lifestyle and eating behavior as well as compliance with nutritional supplementation and follow-up visits.

Many bariatric surgery candidates and obese individual have unrealistic expectations regarding the weight loss that accompanies bariatric surgery. In one study, candidates for surgery expected to lose an average of 80 % of excess weight and would be disappointed with an average weight loss of 52 % of excess weight [1]. Similar weight loss expectations in excess of usual results were found in another study of patients participating in a variety of weight loss treatments [2]. Patients with extreme obesity who seek bariatric surgery are tired and frustrated with their impaired health and quality of life and look to the bariatric surgery team to solve their health problems and eliminate the need for regular medical care. Many do not accept the fact that they are the most important participants in their own healthcare and that improved health is a function of rational choices. Many have the mindset that their fate is solely related to genetic and environmental factors and that others must resolve their obesity issues.

The importance of active patient participation in the bariatric program should be reinforced throughout the patient education process. The fact that 10–25 % of patients who undergo bariatric surgical procedures will struggle and ultimately fail to achieve long-term weight control is, to a large extent, related to poor patient compliance and inability to make the necessary changes in lifestyle and behavior. In this era of limited access to bariatric surgery, surgical programs must improve their ability to identify and select those patients who understand their involvement and are prepared to participate and be accountable in the healthy life change, for which these procedures can open the door.

Bariatric surgery candidates must understand that that the preoperative evaluation process is lengthy and requires regular education and counseling sessions as well as a thorough medical evaluation. The medical evaluation will establish the magnitude of obesity-related health risks and the safety of anesthesia and major surgery. The complete medical evaluation will include a comprehensive history and physical examination followed by additional specialty consultations as determined by the comorbid disease burden. In addition, professional evaluations from mental health experts will take place to provide information regarding the probability of a healthy outcome following the surgery. At the conclusion of this lengthy process, the patient will participate in summary discussions, where each of these important issues and the relevant findings will be presented to each candidate.

The goal of the process is to provide each candidate with detailed information regarding all factors that might argue for or against bariatric surgery (Table 3.1).

Table 3.1

Patient level factors which must be considered in detail during patient selection for bariatric surgery

Factors influencing patient selection for bariatric surgery
• Anticipated patient-specific health risks with untreated extreme obesity
• Patient-specific health problems that may not be improved or might worsen with weight loss
• Patient-specific risks of bariatric surgery and general anesthesia
• Patient-specific conditions that may influence the final health and weight loss outcome in a positive or negative way
• Patient-specific behavioral factors which might interfere with good outcome

At the conclusion of the summary interview, the patient will be given specific recommendations for obesity treatment, which may include surgical treatment, additional preparation prior to surgical treatment, or alternative treatment. The patient-centered health information, which generates the final recommendation and risk–benefit decision, will be shared in detail with the candidate.

The uniqueness of bariatric surgery is related to the partnership between the bariatric surgery team and the patient, which is essential for a successful outcome. The patient education process, the detailed informed consent process, and the establishment of a partnership based on patient participation and accountability are essential components of the new era of patient-centered, quality- and value-based bariatric surgery, which will result in improved outcomes.

The bariatric team members who participate in the patient education and informed consent process must be aware of the critical importance of making an assessment of the level of motivation as this will be an important component of the patient selection process. Patients with extreme obesity seek bariatric surgery for medical, psychological or lifestyle reasons. Several studies have addressed patient motivation for bariatric surgery, and it appears that health issues in relation to comorbid disease or the prevention of comorbid disease are the dominant motivational factors [3, 4]. The results of the largest study are shown in Table 3.2 [3].

Table 3.2

Results of a survey that included 109 bariatric surgery candidates, regarding the primary reason for considering bariatric surgery