The relevant and comprehensive information about invasive surgical procedures is important for every patient. Recently it has become an important part of medical practice and often a legal necessity for surgical procedures.1,2 The concept of patient consent evolved from a judgement in the US supreme court during 1914 and it became a part of international law following World War II with the basic concept that patient consent is mandatory prior to performing any invasive procedure.3,4 The term ‘informed consent’ means the process whereby patients are provided with all the necessary information about health care and subsequent treatment plans. It has many benefits including patient cooperation, thus minimizing surgical complications and increasing the chances of successful defence against possible medico-legal cases.5 The legal aspects of consent are based around the rights of the patients to make their own decision and the ethical aspects of the concept of the shared process of decision making.6 Thus, shared decision making allows both patient autonomy and physician responsibility. In the socioeconomically developing countries like Nepal, it is less likely that patients will be involved in the decision making process about the management plans of their health conditions. In fact they prefer that the involved physician should decide the treatment.

Patients undergoing eye surgeries are concerned of their visual improvement, time taken to improve the vision and the overall risks of visual loss.7 In recent years, eye surgeries have evolved with shorter surgical procedures and better outcomes. So, the patient's expectations are also high. Managing unrealistic patient expectations are paramount in reducing the medico-legal risk associated with these procedures.8 The appropriate pre-operative counselling will not only help to strengthen the patient–doctor relationship but also protect the doctor against medico-legal risks. So, we designed this study to determine what patients want to know when their surgery is advised and to assess their knowledge, attitude and curiosity towards the informed consent.

All forty two patients who were invited to participate responded to the questionnaire (response rate: 100%). Mean age of patients was 53.48±6.41 years and 64.3% were female. Eleven patients (26.2%) had undergone prior surgery for either eye diseases or other systemic conditions. More than half the patients (57.1%) had no formal education. Only 19% had either higher secondary education or professional degree. Disease treated and visual acuity pre and post operatively are presented in Tables 1 and 2. Final visual acuity was improved in all the patients.

It is a general legal and ethical principle that a valid informed consent is obtained before starting treatment.10 In the western countries, treating a patient without valid consent may invite to a civil or criminal offence.11 Before signing consent form, patient should be well informed of the benefits, risks and complications of the intended procedure as well as alternative treatment options.12 Many factors such as access to information, emphasis on patients autonomy and medico-legal considerations have become part of the process of informed consent.

In the present study, the most important information desired by patients pre-operatively was the nature of illness, reason for operation and the chances of success of the operation. These findings are similar to a study by Pimentel et al. carried out in patients with cancer who reported that most of patients wanted to know as much as possible about their illness and treatment.13 Explaining all the desired information to the patients before surgery helps to establish a trustful relationship.12 In our study we observed that patients preferred to abstain from taking part in the management decision regarding their care. This observation is similar to that of Kiss et al.14 Higher number of illiterate patients in our study could have led to this observation because these patients are more likely to let their physician make decision regarding surgery. We observed that more males wanted to know about the surgical doctor. This could be because of the male dominated society where the family head (senior male) makes the decision regarding all the family members. This leads the doctor to act in a paternalistic way in our society where doctor decides everything for the better management of patient.5 In contrast, in developed countries, it is now accepted that a competent individual may go as far as to refuse any treatment even if as a result the may die.15

Most of our patients (69%) did not want to know about any complications prior to the surgery which is in contrast to a study where patients wanted to know about the important complications of their Ear, Nose and Throat (ENT) surgery.9 Kang observed that 35.6% of their patients did not want to know about the complications and risk of surgery, which is similar to our observations. It is understandable that different patients with different anxiety levels and interest would express different degrees of acceptance or tolerance to how much information they would want to know prior to undergoing surgery.11 It is postulated that providing information about risks and complications causes undue and unnecessary anxiety.16 This might be the reason behind our observation where only a few patients wanted to know all the details about their surgery and the complications. Our results show that preoperative anxiety was affected by the thought of operation success, complications and anaesthesia. It is well mentioned that patients tend to be more interested to know about what will happen to them during surgery and the outcome rather than understanding their surgical condition.11

Most of our patients (83%) were satisfied with the surgical outcome. Multivariate analysis was used to explore which factors influence patients’ satisfaction. Of the patient variables, better final visual acuity and occupation (housewife) were strongly associated with the satisfaction. The reason might be the adequacy of the visual performance in daily activities. However, selection bias leading to higher number of housewives in the study group may have lead to this observation.

The majority (61.9%) of our patients were not sure if they could withdraw the surgery at any time if they wished so which is similar (74%) to the observation made by Kang.10 From the ethical point of view, the consent will be valid only when the patient feels that it would have been possible to refuse and change their mind. It is possible only when patients understand the meaning and the significance of consent. Many patients (69%) thought that to sign the consent form was equivalent to agree for surgery. It reflects that these patients allow doctor to determine the treatment without blaming them of the possible adverse effects. Few (16.7%) patients considered the consent form as a medico-legal document which is, in fact, true from the doctor's perspective.17

To conclude, in this study most of patients were happy to let doctors decide their treatment. Many of patients wanted to know about the disease process, treatment involved and the success rate of surgery. Most of patients did not know what actually consent meant and why they were signing it. The success of the operation, the anaesthesia and a long list of complications tended to provoke anxiety. However, it must be recognized that most of patients want to know what their treatment involves. Although, some might be anxious, it should not mean that they do not need information. The information helps patients to cope with the treatment and helps to achieve better surgical outcome.

The authors declare not to have any conflicts of interest.