A Narrative Review of Surgical Consent in Older Populations: Complexities and Potential Solutions

Maintaining best practice around surgical consent is a core competency, yet in caring for older patients, it can be particularly challenging to meet these standards. Our research question was: In the context of obtaining surgical consent for older people, what are the barriers to, and enablers of, best practice? A literature review was undertaken, using RAMESES (Realist And Meta-narrative Evidence Syntheses) methodology, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eight studies were identified by searching PubMed, Embase, Medline and CINAHL databases, supplemented by reference list searches. Four major themes with subthemes emerged: 1. Complexities: (i) Factors affecting decision-making capacity; (ii) Patient Comprehension; (iii) The doctor-patient relationship and barriers to autonomy; (iv) Ethical issues at stake; 2. Gaps between theory and practice: (i) Lack of proper documentation; (ii) Patient resistance resulting in coercion and restraint; (iii) Proper practice in the emergency context; 3. Reasons for gaps between theory and practice: (i) Lack of knowledge and training: physician misconceptions; (ii) Guesstimates of cognition don't work; (4) Potential solutions: (i) Promoting patient autonomy; (ii) General communication strategies; (iii) Person-centred education step. Notwithstanding a limited yield, this review has identified several pitfalls and practical strategies for promoting human-rights and autonomy; avoiding coercion and restraint in this complex setting.