ORIGINAL RESEARCH


Psychiatrists’ Documentation of Informed Consent

Debbie Schachter, MD, MSc, FRCPC1, Irwin Kleinman, MD, FRCPC2


Objective: The present study was undertaken to determine current attitudes and behaviour toward informed consent for antipsychotic medication and documentation of the informed consent process in patient charts.

Method: Thirty psychiatrists treating a minimum of 10 patients on antipsychotic medication were selected from teaching and nonteaching hospitals. Clinicians completed questionnaires on their behaviour and attitudes regarding documentation of informed consent and antipsychotic medication. Physicians’ charts were reviewed to ascertain documentation.

Results: Psychiatrists reported sometimes documenting the informed consent process. The chart review revealed that, on average, each psychiatrist had documentation in 23% of charts. Physicians who either were affiliated with a teaching hospital or spent more time reading medical journals were more likely to document the informed consent process.

Conclusions: Physicians who use antipsychotic medication as a treatment in their practice are not routinely documenting the informed consent process in patient records. Physicians should pay more attention to this aspect of record keeping because it is their only record of the consent process.

(Can J Psychiatry 1998;43:1012–1017)

Key Words: informed consent, documentation, antipsychotics

Informed consent is obtained before initiating any medical treatment and reflects our respect for the fundamental autonomy of the individual (1,2). The elements of consent include that it be specific, informed, and voluntary and that the patient be capable. For consent to be informed, P a person must receive information that any reasonable person in the same circumstances would require to make a decision (3). Information should refer to the nature of the treatment; the benefits, material risks, and side effects of the treatment; and the alternatives, including the option of no treatment. Physicians who fail to inform patients about material risks of treatment can be found negligent in their practice of informed consent (4,5).

Tardive dyskinesia (TD) is estimated to affect 20% to 25% of patients on long-term antipsychotic medication and to be irreversible in as many as 50% of adults (6,7). TD has received considerable attention in the medical, legal, and ethical literature (8). In keeping with the principle of patient autonomy, it is important that patients be informed about TD as part of the informed consent process for antipsychotic medication (4,6). The American Psychiatric Association’s (APA) Task Force Report on Tardive Dyskinesia has recommended that patients be informed about the benefits and risks of antipsychotic medication, including the risk of TD (6,9).

A physician who fails to inform patients about the risks of treatment, including the risk of TD, may, therefore, be considered negligent (4,10). In several cases, physicians have been successfully sued for failure to inform patients about the risks associated with antipsychotic medication. The issue of informed consent for antipsychotic medication is particularly complex for several reasons. First, empirical data suggest that patients informed about the benefits and risks of medication do not always recall what they were told (11–14). Among guardians of individuals with mental retardation, the average recall of information about TD was only 43% (11). In another study, although the informed consent process increased knowledge, it was felt that patients did not learn the information necessary to make an informed decision (13). Kleinman and others increased patient’s knowledge about antipsychotic medication using a structured informing process (12). However, some patients did not recall having been informed. In addition, psychopathology at the time of the informed consent process affects patients’ ability to learn information about antipsychotic medication, with patients who have more psychopathology learning less than those with less psychopathology (15).

Documentation of the informed consent process may therefore be a physician’s only record that a patient was informed about the benefits and risks of medication. There is, then, a need for physicians to document somehow that patients were informed about the benefits and risks of antipsychotic medication (8,16,17). The APA has recommended that physicians record that the indications for and risks of maintenance antipsychotic medication have been reviewed with the patient and/or relatives (6,18).

There has been controversy concerning the appropriate method to document that patients have been informed about the benefits and risks of long-term antipsychotic therapy. Some attorneys and authors advocate the use of written consent forms, arguing that the risk of TD represents a significant risk and that, therefore, written informed consent is necessary (19). They feel written consent is indicated when patients with TD need continued maintenance antipsychotic medication or in patients who require antipsychotic medication for periods of longer than 1 year.

In contrast, the APA argued that written informed consent forms were unnecessary, because they are not routinely used in nonexperimental therapies and might introduce a potentially detrimental and adversarial quality to physician–patient relationships (6). Further, signed consent forms do not necessarily ensure adequate disclosure. Courts are interested in what was disclosed (17,20), and legal actions against physicians have occurred in the presence of signed consent forms (17). Some psychiatrists and institutions have developed checklists or forms to facilitate physicians’ documentation of the informed consent process for antipsychotic medication (21,22). However, while community centres and professional associations may develop clinical guidelines, this does not always translate into clinical practice (23–26). In a review of records in Ohio, a state with legislation on documentation, in a centre where a checklist consent form was introduced to facilitate documentation, only 40% of charts were deemed acceptable by the investigators (22).

Gurian and others, in a survey of elderly patients admitted to a teaching hospital’s inpatient psychiatric unit, found documentation in only 8 of 28 charts (27). All 8 instances of documentation involved refusals of treatment. Consistent with their documentation, only about one-half of the physicians at the teaching hospital reported that they occasionally documented the informed consent process. Lacro and others attempted to improve documentation through a quality assurance project (28). Immediately after introducing a consent form, 39% of patients on long-term antipsychotic medication had signed consent forms.

The finding of low rates of documentation in the presence of either legislation or hospital guidelines has important implications for actual physician practice in situations where there are no externally directed guidelines and where physicians are free to document as they feel is indicated. In these situations, it is unclear to what extent physicians are actually documenting the informed consent process.

Further, it is unclear why some physicians are not documenting the informed consent process. The factors that influence physicians’ behaviour in terms of documenting the informed consent process are largely unknown. Even when practice guidelines disseminate widely accepted information, factors other than knowledge have been suggested to influence physicians’ behaviour (23). Factors postulated to influence behaviour include physicians’ education, personal physician characteristics, practice characteristics, community economic factors, and administrative influences (26). Attitudes of physicians to documentation of the informed consent process may influence behaviour, and these have not been well studied. In the APA survey of psychiatrists, 11% of psychiatrists favoured a written procedure, while 70% did not (9).

This study was undertaken to determine current attitudes and behaviour of Canadian psychiatrists toward the documentation of the informed consent process for antipsychotic medication. The physician characteristics associated with more documentation and/or more favourable attitudes to documentation of the informed consent process are examined.

Method

Subject Selection

Thirty psychiatrists were selected, divided equally between teaching- and nonteaching-affiliated hospitals. No more than 6 psychiatrists were selected from any 1 hospital. To be eligible to participate in this study, clinicians needed to treat a minimum of 10 patients on antipsychotic medication in their practice. Informed consent for participation in this study was obtained from all physicians.

Procedure

Clinicians completed mailed questionnaires on their behaviour with respect to informing competent patients or relatives of incompetent patients about antipsychotic medication and documenting the informed consent process and their attitudes toward documenting the informed consent process. Physicians were subsequently interviewed. For each physician, the charts of the 10 most recently seen patients taking antipsychotic medication were reviewed to see whether they had documented the informed consent process.

Instruments

Self-Report Questionnaire

Face validity of the questionnaire was determined by showing it to 9 experienced psychiatrists and 10 experienced general practitioners. The questionnaire was divided into 3 sections: 1) behaviour scale addressing information provided to patients about the benefits and risks of antipsychotic medication, 2) items related to self-report of documentation of the informed consent process, and 3) items related to attitudes toward documenting the informed consent process. The behaviour scale was developed to summarize current practice as it pertains to providing information regarding the benefits and risks of antipsychotic medication to patients or relatives of incompetent patients. Items addressed providing information on the reasons for medication, the alternative treatments, the name of the medication, dosage of medication, and the side effects associated with antipsychotic medication. Items of behaviour were scored using a 5-point Likert scale (5 = always, 4 = almost always, 3 = sometimes, 2 = almost never, 1 = never). The overall score is a sum of the individual item scores.

Items dealing with documentation of the informed consent process were also answered using a 5-point Likert scale (5 = always, 4 = almost always, 3 = sometimes, 2 = almost never, 1 = never).

Attitudes toward documentation of the informed consent process were assessed using a 5-point Likert scale. Positively keyed attitudinal items were scored as follows: 5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, 1 = strongly disagree.

Results

Demographic Characteristics

The mean age of the psychiatrists was 44.8 years (SD 8.3), and 80% were male. On average, they graduated from medical school in 1972 (SD 8.87 years), spent 67 hours (SD 53) every year in formal continuing medical education activities, and spent 12.3 hours (SD 10.11) each month reading medical journals.

Self-Report of Disclosure and Documentation

Table 1 shows the frequency with which psychiatrists endorsed informing patients about the benefits and risks of antipsychotic medication. While all psychiatrists routinely discussed the reasons for antipsychotic medication, only two-thirds routinely disclosed the risk for TD to patients. Table 2 shows the frequency with which psychiatrists endorsed documenting the consent process with competent patients or relatives of incompetent patients. No psychiatrist obtained written consent when prescribing antipsychotic medication to competent patients.

Table 1.  Percentage of psychiatrists (N = 30) indicating
the frequency with which they inform competent patients
of various items



Item

Always or almost always
(%)


Sometimes
(%)

Never or almost never
(%)

Reasons for antipsychotic medication

100

0

0

The brand or generic name of medication

90

7

3

The dosage of the medication

87

13

0

The consequences of not receiving the medication

97

3

0

Akathisia

77

23

0

Dystonic reactions

67

30

3

Rigidity

83

17

0

Tardive dyskinesia

67

27

6

Constipation

64

33

3

Dry mouth

77

23

0

Table 2.  Percentage of psychiatrists (N = 30) indicating the frequency of various behaviours



Behaviour

Always or almost always
(%)


Sometimes
(%)

Never or almost never
(%)

Document in the chart that a competent patient was informed about risks and benefits of antipsychotic medication

13

60

27

Obtain written consent when prescribing antipsychotics to competent patients

0

0

100

Document in the chart that a relative of an incompetent patient was informed about risks and benefits of antipsychotic medication

44

28

28

Obtain written consent from relatives when prescribing antipsychotics to incompetent patients

28

8

64

Documentation in Charts

The chart review revealed that, on average, each psychiatrist had documentation in 23% of charts. There was a moderate correlation between self reports of documentation and actual documentation as determined by chart reviews (r = 0.39, n = 30, P < 0.04). Physicians who stated that they always or almost always documented the informed consent process tended to overestimate the frequency evidenced by the charts. For cases in which consent was obtained from the patient, psychiatrists who reported always or almost always documenting the informed consent process had documentation in 32% of charts (N = 3), those who reported sometimes documenting the process had documentation in 28 % of charts (N = 18), and those who reported never or almost never documenting the informed consent process had documentation in 7% of charts (N = 6). For cases in which consent was obtained from a relative, psychiatrists who reported always or almost always documenting the process had done so in 60% of charts (N = 1), those who reported sometimes documenting in 6% (N = 3), and never or almost never documenting the process in 0% of charts (N = 3).

Relationship Between Actual Documentation and Informing Behaviour

There was no significant association between actual documentation and the total amount of information provided to patients on the self-report questionnaire (r = 0.007, n = 30, not significant) or the amount of information provided about TD (r = 0.13, n = 30, ns).

Correlates of Documentation Behaviour

There was a significant difference in the percentage of charts with documentation between physicians with teaching- and nonteaching-hospital affiliations (t[28] =  2.5, P < 0.018). Physicians from teaching hospitals were more likely to document in charts (mean = 0.34, SD 0.28) than were physicians from nonteaching hospitals (mean = 0.12, SD 0.19).

There was no significant gender difference in the percentage of charts with documentation (t[28] =  0.21, ns). In bivariate analyses, the percentage of charts with documentation correlated significantly with the number of hours spent reading medical journals; physicians who spent more time reading medical journals were more likely to document in charts than were those who spent less time reading (r = 0.45, n = 30, P < 0.013). There was no significant correlation between percentage of charts with documentation and age (r = 0.25), number of hours spent in formal continuing medical education (CME) activities (r = 0.21), and the time since certification (r =  0.26).

In a linear regression analysis, with percentage of charts with documentation as the outcome variable, the following variables were considered as potential predictor variables: gender, number of hours spent reading medical journals, time since certification, hospital affiliation, and number of hours spent in formal CME activities. The final regression equation explained 26% of the variance in scores and was significant (F[2,26] = 6.03, P = 0.007). Hospital affiliation (t[1,26] = 2.11, P = 0.04) and number of hours spent reading medical journals (t[1,26] = 2.26, P = 0.03) were significant predictors of documentation. Physicians from teaching hospitals compared with those from nonteaching hospitals had more documentation in charts, and physicians who spent more time reading medical journals were more likely to document in charts. There was no interaction between hospital affiliation and time spent reading medical journals.

Attitudes Toward Documentation

Table 3 shows a summary of psychiatrists attitudes toward documentation of the informed consent process for antipsychotic medication. Most respondents felt that informed consent for antipsychotic medication should be recorded in charts and did not think that the process needed to be audio- or videotaped or that signed consent forms were necessary. Physicians thought signed forms may increase patients’ anxiety and might be detrimental to the patient–physician relationship.

Table 3.  Percentage of psychiatrists (N = 30) indicating attitudes toward documentation



Statement

Agree or
strongly
agree
(%)



Neutral
(%)

Disagree or strongly
disagree
(%)

Informed consent process for antipsychotics should be recorded in the chart

70

17

13

Informed consent process for antipsychotics should be audiotaped or videotaped

7

3

90

Patients should sign consent forms for nonsurgical medical procedures

43

27

30

Signed consent forms may increase patient anxiety

70

13

17

It takes too much time to document in the chart that the risks and benefits were explained to the patient

27

13

60

Consent forms for medication may be detrimental to patient–physician relationships

40

27

33

Signed consent forms for antipsychotics are unnecessary

73

17

10

Patients should sign consent forms for surgical procedures

93

7

0

Signed consent forms for medications with serious side effects are necessary

40

30

30

Correlation Between Attitudes to Documentation and Actual Documentation

There was no significant correlation between scale score measuring attitudes to documentation and percentage of charts with documentation (r = 0.096). There was no significant correlation between scores on any of the individual items composing the documentation scale and percentage of charts with documentation (r = 0.16 to r = 0.36). The highest association was between percentage of charts with documentation and those who felt documentation should be recorded (r = 0.36, n = 30, P = 0.052).

Discussion

Although almost all psychiatrists reported explaining some of the potential benefits of and reasons for antipsychotic medication to patients or relatives of incompetent patients, written documentation was not occurring routinely. Documentation of the informed consent process was present in approximately one-quarter of the charts. These low rates of documentation are at the lower range of those reported by others (22,27). There are several explanations for the low rates observed in this study. First, this may reflect the absence of specific provincial guidelines on documentation in Ontario where the study was undertaken. Second, this may be explained by the lower rates of malpractice litigation in Canada compared with the United States, where the earlier studies were conducted.

We had hypothesized that psychiatrists who were aware of the medicolegal necessity of informing patients about TD would be more likely to both inform patients about this side effect and make some notation or documentation about this in patient records. We were unable to support this hypothesis. Documentation was not associated with either the total information provided to patients or information provide specifically regarding TD. This suggested that documentation was not necessarily associated with awareness of the medicolegal necessity of informing patients about TD. Further, only hospital affiliation and reading of medical journals was associated with documentation of the informed consent process. Physicians who read more journals or are affiliated with teaching settings may be more aware of the need to document the informed consent process or more conscientious in both record keeping and the reading of medical literature. These findings are consistent with those of Benson, who noted that physicians who read more journals disclosed more information to patients (29). Physicians affiliated with teaching hospitals were more likely to document in charts than nonteaching hospital affiliated physicians. We do not know whether there were differences in the hospitals’ policies regarding documentation of the informed consent process. Neither gender, age, nor number of hours spent in CME) were associated with documentation behaviour. This is consistent with CME not being related to quality of care or charting practices among Ontario family physicians (30,31). This, however, contradicts findings that CME is effective (32) possibly because randomized trials for CME effectiveness look for outcome specific to CME intervention. In studies of charting practices, there may be no association between CME and documentation or care, since one is looking at overall CME, rather than CME related to documentation.

The finding that neither gender nor age correlated with differences in documentation behaviour differs from other findings on age and gender effects on physician documentation behaviour. In a study of effect of demographics on minimal standards for either care or documentation, younger physicians performed better than older physicians (31). In addition, an audit of Ontario family physicians’ charts revealed younger physicians and women had better charting practices (33). In the latter study, the criteria for charting consisted of only legibility, basic registration data, allergies, notations for assessments and medication prescriptions. There was no examination of documentation of informed consent process. Another possible explanation for the differences in the studies is that the present study had a small sample size and would, therefore, have the power to detect only large effect sizes. It may be that with a larger sample, smaller differences would be detected.

In terms of understanding other determinants of behaviour, while 70% of physicians felt the informed consent process should be recorded, virtually no physicians endorsed audio- or videotaping the informed consent process. This is consistent with the findings of the APA survey (9). While 40% of psychiatrists thought signed consent forms were necessary for medications with serious side effects or for nonsurgical procedures, almost three-quarters did not feel they were necessary for antipsychotic medications, which suggests that they view these medications as not having serious side effects. Psychiatrists thought signed consent forms could increase patients’ anxiety or be detrimental to patient–physician relationships, in agreement with some of the concerns raised by others in the literature (9).

This study had several limitations. First, the sample was not representative. However, because care was taken not to overselect physicians from a particular hospital or site, the sample may, in fact, be representative. Second, because of the small sample size, there was limited power to detect small effects for continuous variables or moderate effects for categorical variables.

Conclusion

Psychiatrists had favourable attitudes toward documentation in charts, but they do not endorse audio- or videotaping the informed consent process or using written consent forms. They had low rates of actual documentation and overestimated their own behaviour. Since psychiatrists’ behaviour did not reflect their attitudes, periodic chart reviews might heighten physicians’ awareness of their own charting practices. The development of checklists or other tools might also facilitate charting the consent process. Finally, the results of this study need to be replicated using a larger, representative sample to ensure that the practices reported in this study generally reflect those of all psychiatrists.

Clinical Implications

Limitations

Acknowledgements

This research was funded by theNational Health and Research Development Program, Grant No 6606-4226-57P and Grant No 6606-5304-301. The authors thank Dr Jack Williams for his collaboration in this project. The authors thank Catherine Turchon, Marta Chydzij, and Maggie Toplak for their assistance.

References

1. Beauchamp TL, Childress JF. Principles in biomedical ethics. 4th ed. New York: Oxford University Press; 1994.

2. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: a new practical approach to ethical decisions in clinical medicine. 2nd ed. New York: Macmillan; 1986.

3. Reibl v. Hughes [1980] 2 SCR 880.

4. Wettstein RM. Legal aspects of neuroleptic-induced movement disorders. In: Wecht CH, editor. Legal medicine. New York: Praeger; 1985. p 117–79.

5. Wagner KD, Pollard R, Wagner Jr RF, Shifren MD. Medical liability claims and lawsuits filed against the University of Texas system involving adult psychiatric patients. Bull Am Acad Psychiatry Law 1994;22:459–69.

6. American Psychiatric Association. Tardive dyskinesia: a task force report of the American Psychiatric Association. Washington (DC): American Psychiatric Association; 1992.

7. Kane JM, Smith JM. Tardive dyskinesia: prevalence and risk factors: 1959 to 1979. Arch Gen Psychiatry 1982;39:473–81.

8. Brabbins C, Butler J, Bentall R. Consent to neuroleptic medication for schizophrenia: clinical, ethical, and legal issues. Br J Psychiatry 1996;168:540–4.

9. American Psychiatric Association. Task Force Report 18, Tardive dyskinesia. Washington (DC): American Psychiatric Association; 1979.

10. Appelbaum PS, Schaffner K, Meisel A. Responsibility and compensation for tardive dyskinesia. Am J Psychiatry 1985;142:806–10.

11. Jaffe R. Informed consent: recall about tardive dyskinesia. Compr Psychiatry 1981;22:434–7.

12. Kleinman I, Schachter D, Koritar E. Informed consent and tardive dyskinesia. Am J Psychiatry 1989;146:902–4.

13. Munetz MR, Roth LH. Informing patients about tardive dyskinesia. Arch Gen Psychiatry 1985;42:866–71.

14. Robinson G, Merav A. Informed consent: recall by patients tested postoperatively. Ann Thorac Surg 1976;22:209–12.

15. Schachter D, Kleinman I, Prendergast P, Remington G, Schertzer S. The effect of psychopathology on the ability of schizophrenic patients to give informed consent. J Nerv Ment Dis 1994;182:360–2.

16. Canadian Medical Protective Association. Consent: a guide for Canadian physicians. Ottawa: Canadian Medical Protective Association; 1989.

17. Vaccarino JM. Consent, informed consent and the consent form. N Engl J Med 1978;298:455.

18. American Psychiatric Association. Tardive dyskinesia: summary of a task force report of the American Psychiatric Association. Am J Psychiatry 1980;137:1163–72.

19. Sovner R, DiMascio A, Berkowitz D, Randolph P. Tardive dyskinesia and informed consent. Psychosomatics 1978;19:172–7.

20. Chafe SMJ. Controversial legal consent in clinical medicine. Annals of the Royal College of Physicians and Surgeons of Canada 1992;25:109–11.

21. Benjamin S, Munetz MR. CMHC Practices related to tardive dyskinesia screening and informed consent for neuroleptic drugs. Hospital and Community Psychiatry 1994;45:343–6.

22. Munetz MR, Peterson GA. Documenting informed consent for treatment with neuroleptics: an alternative to the consent form. Psychiatr Serv 1996;47:302–3.

23. Battista RN, Ruiz EA, Endicott AN. From science to practice: The evolving art of communication. In: Dunn EV, Norton PG, Stewart M, Tudiver F, Bass MJ, editors. Disseminating research/changing practice. London: Sage Publications; 1994. p 21–31.

24. Davis DA, Taylor-Vaisey A. Translating guidelines into practice: a systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. Can Med Assoc J 1997;157:408–16.

25. Kennedy NJ, Sanborn JS. Disclosure of tardive dyskinesia: effect of written policy on risk disclosure. Psychopharmacol Bull 1992;28:93–100.

26. Lomas J. Teaching old (and not so old) docs new tricks: effective ways to implement research findings. In: Dunn EV, Norton PG, Stewart M, Tudiver F, Bass MJ, editors. Disseminating research/changing practice. London: Sage Publications; 1994. p 1–18.

27. Gurian BS, Baker EH, Jacobson S, Lagerbom B, Watts P. Informed consent for neuroleptics with elderly patients in 2 settings. J Am Geriatr Soc 1990;38:37–44.

28. Lacro JP, Sewill DD, Warren K, Woody S, Harris MJ, Jeste DP. Improving documentation of consent for neuroleptic therapy. Hospital and Community Psychiatry 1994;45:176–8.

29. Benson PR. Informed consent: drug information disclosed to patients prescribed antipsychotic medication. J Nerv Ment Dis 1984;172:642–53.

30. Dunn EV, Bass MJ, Williams JI, Borgiel AEW, MacDonald P, Spasoff RA. Study of relation of continuing medical education to quality of family physicians’ care. Journal of Medical Education 1988;63:775–84.

31. McAuley RG, Paul WM, Morrison GH, Beckett RF, Goldsmith CH. Five-year results of the peer assessment proram of the College of Physicians and Surgeons of Ontario. Can Med Assoc J 1990;143:1193–9.

32. Davis DA, Thomson M, Oxman AD, Haynes RB. Evidence for the effectiveness of CME: a review of 50 randomized controlled trials. JAMA 1992;268:1111–7.

33. Borgiel AEM, Williams JI, Bass MJ, Dunn EV, Evensen MK, Lamont CT, and others. Quality of care in family practice: does residency training make a difference? Can Med Assoc J 1989;140:1035–43.


Résumé

Objectif : La présente étude a été menée afin de déterminer les attitudes et comportements courants à l’égard du consentement éclairé aux médicaments antipsychotiques et de la documentation du processus du consentement éclairé dans les dossiers des patients.

Méthode : Trente psychiatres traitant au moins 10 patients à l’aide d’antipsychotiques ont été choisis dans des hôpitaux d’enseignement et autres établissements. Les cliniciens ont rempli un questionnaire sur leurs attitudes et comportements à l’égard de la documentation du consentement éclairé et des antipsychotiques. Les dossiers des médecins ont été examinés pour s’assurer de la présence de la documentation.

Résultats : Les psychiatres déclarent documenter parfois le processus du consentement éclairé. L’examen des dossiers révèle qu’en moyenne, chaque psychiatre a de la documentation dans 23 % des dossiers. Les médecins affiliés à un hôpital d’enseignement ou qui consacrent plus de temps à la lecture de revues médicales sont plus enclins à documenter le processus du consentement éclairé.

Conclusions : Les médecins ayant recours aux antipsychotiques dans leur pratique n’ont pas l’habitude de documenter le processus du consentement éclairé dans les dossiers des patients. Ils devraient toutefois y accorder plus d’attention, étant donné qu’il s’agit de la seule preuve du consentement éclairé.

This paper was presented at the 48th annual meeting of the Canadian Psychiatric Association, Calgary, Alberta, 1997.

Manuscript received January 1998, revised, and accepted May 1998.

1Assistant Professor, Department of Psychiatry and Public Health Sciences, University of Toronto, The Centre for Addiction and Mental Health, Clarke Division, Toronto, Ontario.

2Assistant Professor, Departments of Psychiatry and Family and Community Medicine, University of Toronto, Mount Sinai Hospital, University of Toronto Joint Centre for Bioethics, Toronto, Ontario.

Address for correspondence: Dr D Schachter, Clarke Institue of Psychiatry, 250 College Street, Toronto, ON  M5T 1R8

Can J Psychiatry, Vol 43, December 1998