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Urinary Catheters: A One-Point Restraint?
- Sanjay Saint, MD, MPH;
- Benjamin A. Lipsky, MD; and
- Susan D. Goold, MD, MHSA, MA
- Veterans Affairs Ann Arbor Health Care System; Ann Arbor, MI 48109-0429 (Saint) Veterans Affairs Puget Sound Health Care System; Seattle, WA 98108-1597 (Lipsky) University of Michigan; Ann Arbor, MI 48109-0429 (Goold)
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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IN RESPONSE:
We appreciate the letter by Dr. Munasinghe and colleagues and their contribution to this field (1). We are, however, unclear about what they mean by “informed consent with full disclosure.” If they are recommending that patients receiving nonemergent indwelling urinary catheters should be required to sign a consent form, we disagree. Such a policy is less likely to have the desired effect than it is to serve as a deterrent to doctors' placing or ordering urinary catheters. Whether the deterrent would decrease inappropriate use without compromising appropriate use is a matter for empirical investigation. One could extend Munasinghe and colleagues' argument to intravenous catheters and even to certain medications that can have adverse effects (for example, aminoglycosides and amiodarone), thereby making the practice of medicine even more bureaucratically unwieldy. Furthermore, patients and research participants often view the informed consent form as a formality even when they can understand it (2). We agree with other observers that true consent is a dialogue, not a signature (3).
If Dr. Munasinghe and colleagues mean that patients should understand the risks and benefits of, alternatives to, and rationale for placing a catheter, this is the current standard for any clinical intervention, albeit one that is frequently not met. Requiring “informed consent with full disclosure” merely restates what should already be the case. For the case of urinary catheters, the problem may be that physicians, unaware of the extent of the risk involved, may not be motivated or able to communicate this information to patients. A previous study indicated that the problem is less with the inappropriateness of initial insertion and more with inertia: Use of urinary catheters is not discontinued when it is no longer needed (4). Thus, other organizational efforts, such as automatic stop orders, are likely to be more effective (5).
Good medical practice requires explaining all clinical interventions and their rationale to patients, including disclosure of risks, benefits, burdens, and alternatives. We are not in favor, however, of requiring written informed consent for patients undergoing urinary catheterization. Improved use of these catheters will more likely be accomplished by automated systems that aid providers to remember and rethink the need for these helpful and harmful devices.
Sanjay Saint, MD, MPH
Veterans Affairs Ann Arbor Health Care System; Ann Arbor, MI 48109-0429
Benjamin A. Lipsky, MD
Veterans Affairs Puget Sound Health Care System; Seattle, WA 98108-1597
Susan D. Goold, MD, MHSA, MA
University of Michigan; Ann Arbor, MI 48109-0429
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
