5. Whether any information is put in writing. For example, does the patient have access to brochures that describe the generic condition with usual questions and answers? Did the physician write a note or letter to the patient, or a letter to the general physician with the stated expectation that the latter would review it with the patient? Did the doctor make a note in the patient’s chart? Is there a protocol in writing for the physician to follow and was it followed?
6. Whether the time spent with the patient is realistic in terms of enabling the patient to hear, understand, and evaluate. Was the information communicated in the language most likely to be understood and on more than one occasion, to reinforce the seriousness and to give the patient a chance to ask questions that did not occur to the patient in the anxiety of the original disclosure?
7. Whether the patient is dependent on family members for assistance in decision-making. Could the treatment (or lack thereof) result in impaired cognitive abilities? In either case, involvement of the family is not a courtesy; it is a necessity. If others are involved, does their recollection of events coincide with the doctor’s? The more obviously the patient is dependent on such people, the more importance should be attached to 1-6 above in the context of those others.
8. Whether the patient or family express spontaneous surprise when the event, allegedly described in advance as a material risk, unfolds.

Problems, comments, and observations

• The cases describe an advancement in a patient’s right to accept or refuse medical treatment. Doctors must now explain the medical options in terms or language that a patient can understand. There is a greater onus placed on doctors to make inquiries into whether the patient understands the medical advice or at least to be aware of signs suggesting that a patient may not have the literacy skills to understand. These same lessons may help us with parties to administrative tribunals.