…silence is consent…

Written by Anna Karsten

Quick question: are your patients really aware of their medical status, the truth of the condition that they are in? Your answer might be that they are supposed to know and that is correct, but do they? I have come across a number of patients that do not really understand why they are in hospital other than they are sick or hurt. However, one specific case lingers in the back of my mind when dealing with this topic.

The consent of the governed is not consent if it is not informed – Edward Snowden

It was a 16-year old male that got stabbed to his chest on the Friday night and I attended to his care the Monday morning. He developed two pneumothoraces  and one haemopneumothorax, additional to that one of the stab wounds extended into his right ventricle of his heart. The injury to the ventricle had to be repaired and the doctor performed a median sternotomy.  As I was about to conclude the session with the patient, he asked me why they – the doctors – had to cut his chest open. I was dumbstruck as I did not really think about asking him about it, to be honest. I was more focused on his physical condition and neglected his emotional state. I had to think hard about my answer. I began with inquiring what he remembered of the night he got stabbed and brought to hospital. He told me that he did not really remember much. I had to sit down next to him and subtly break it to him that when he got stabbed not only his chest got injuries but his heart as well. And due to the heart injury the doctors had to operate to repair it to prevent complications and possibly save his life. The tears ran down his cheeks as he began to cry. I comforted him with the fact that he is “okay” now and alive, on his way to recovery. The question kept bugging me, and I thought to myself :”this is enough”. I also want an answer now: who’s responsibility  is it to inform patients of their actual medical condition?

Taking into account the injuries mentioned above, it can be understood why he is so traumatised, especially after hearing about the heart injury – that, in fact, one of the vital organs of the body. A pneumothorax, as defined by O’Toole (2013), is the infiltration of gas/air into the pleural space, causing a lung collapse. In this patient’s case, his pneumothoraces were a result of the stab wounds that permitted the entry of air (O’Toole, 2013). A haemopneumothorax on the other hand is the accumulation of both air and blood in the pleural cavity (O’Toole, 2013) and in this patient’s case caused by the stab wounds and the bleeding of tissues. This was managed by putting in ICD’s to drain them. The heart was repaired via the route of a median sternotomy. A median sternotomy involves an incision of the sternum and is then opened to perform heart surgery, where after it is sutured with steel sutures (O’Toole, 2013).

Not informing a patient of these conditions and procedures bring me to patient consent and openness/transparency. Batho Pele requires health professionals to provide their patients with good information regarding the services available to their disposal AND allowing patients to ask questions and responding to them honest and frankly. The patients rights charter ensures that patients need to give consent for any medical or related treatment, protecting both patient and professional. With regards to obtaining minor consent, the process is slightly different to this of an adult (HPCSA, 2008). According to the HPCSA guidelines, children aged 12 years and older are legally competent to decide on medical treatment only (Child Care Act). However, in an emergency where there is no time to contact the legal guardians, health care practitioners consider what is in the best interest of the child and proceed their management (HPCSA, 2008).

The video below discuss the difference it made in a patient’s life after she actually gave well informed consent:

Treating patients that are not fully aware of their medical condition is difficult because part of my job description is education. How can I educate a person if there is no foundation for me to build further on? Going back to varsity and seeking help with regards to this, I was told that it is not my job to break bad news and counsel patients. And I fully understand this, but again, I can’t flourish in my job if another does not do their job. So what do I have to do? Just leave the patient in pain, rejection, depression? No, I will just have to put on my big girl pants and start adulating in my profession. I have to consult the doctor and involve a social worker possibly.

Looking back at the incident and all of the others that followed, I had to make difficult decisions at times. Not only were some doctors not willing to help me in this cause, but I had to consult my clinicians for referrals to social workers because “students are not competent enough to refer patients”. With that being said, I might have made a small difference in one or two wards in one hospital, but it was a start. A start of getting professionals to take responsibility for their profession and what comes with its job description. It was the beginning of patients being able to say: this is my life, my health and I know what is going on!

We need to teach our patients as part of our patient education drive the following:



Health Professionals Council of South Africa,. (2008). Guidelines for good practice in the health care professions: informed consent (booklet 9). Pretoria: HPCSA. Retrieved September 29, 2016 from http://www.hpcsa.co.za/downloads/conduct_ethics/rules/generic_ethical_rules/booklet_9_informed_consent.pdf

Health Professionals Council of South Africa,. (2008). Guidelines for good practice in the health care professions: national patients’ rights charter (booklet 3). Pretoria: HPCSA. Retrieved from http://www.hpcsa.co.za/Uploads/editor/UserFiles/downloads/conduct_ethics/rules/generic_ethical_rules/booklet_3_patients_rights_charter.pdf

Mosby’s Medical Dictionary. (2013).M. T. O’Toole (Ed.), St Louis, MO: Elsevier/Mosby

Russo, R. (2007). Informed Consent [Video file]. Retrieved September 29, 2016 from https://www.youtube.com/watch?v=OhOiSGcbbps

The Department of Public Service and Administration, South Africa. (2014). The Batho Pele Vision [Presentation]. South African Government. Retrieved September 29, 2016 from http://www.dpsa.gov.za/documents/Abridged%20BP%20programme%20July2014.pdf


4 Replies to “…silence is consent…”

  1. Hi Anna,

    Your blog post was very thoughtful and interesting. I like that you kept questioning yourself and trying to find answers to your questions. I was also in a similar situation to yours. However, I tried my best to be empathetic and listen to m patient. I also tried to inco-operate batho pele principles (openness and transparency and also courtesy). Your blog relates well to a case you experienced.

    More on what you can improve on:

    Content: Good. Your information showed insight into the topic. You can improve this post by researching articles e.g. different scenarios that health professionals face and how they responded in terms of informed consent.You addressed human rights topic quite well.

    References: Satisfactory. Some of your in-text references are incorrect according to the APA guideline. I suggest that to improve on this follow APA guidelines. You also need to make use of journal articles. Your reference list is good.

    Structure: Satisfactory. The writing conformed to the structure and guidelines. You can improve on your grammar and sentence structure e.g. do not start sentences with ‘AND’ because it is a conjunction. Your spelling was correct in this blog post.

    Argument: Good. Your argument was good. Please can you find articles to back up your argument to make it strong.

    Technology: Satisfactory. You had a good cover image but no other images related to your blog post. You lacked other resources e.g. images and articles. You need to capture the reader’s attention with these resources. You can also add more links to videos rather than only having one video on the blog.

    Overall impression of blog post:

    Your blog post was satisfactory. I hope my comments will benefit you now and in the future. I am sure your blog post will be much better with the feedback I gave you now.

    Well tried Anna! All the best with the rest of your posts.


  2. Hi Anna

    I liked reading this post because it is too often that I find myself in the same situation where patients do not even understand or know what is the reason for their hospital stay. I liked the use of your rhetorical questions. I had a patient who did not speak English but spoke french. The doctor made no attempt to communicate with this patient but had referred a fully functional patient to me without an attempt at observing the patient. I had to think creatively and use google translate in my attempt to communicate to a patient who was unsure of why he was in the hospital. Remember these instances where people tell you that you are “incompetent” while is the greater picture you are educating their patients.

    Please check your APA referencing style, I liked that your post was concise and the media clearly brought across your message.


  3. Anna

    Once again, easy to read and you write as if you’re engaging with the readers which is nice. References were good, just double check APA style (although I understand if the literature you used doesn’t allow perfect APA style in texts).

    Good use of media.

    Again, small grammar errors but still well written. My only question is how exactly does the title relate to the blog? Silence is consent? consent to what? Or is it meant to be sarcastic? Also there is no need for the … at the beginning of the title as the last … is enough for the intended effect.

    Good article, I liked reading it and I am 100% behind you on this topic.



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