Does your patient need a PhD to read your consent form? It is the night before surgery. The patient is asked to sign a consent form. He just glances at the page of small type, then quickly signs his name.

When patients sign consent forms for surgery, how much do they understand? Not a great deal, according to a study recently reported in the New England Journal of Medicine.’ A day after signing consent forms, only 60% of the 200 cancer patients in the study understood the purpose and nature of the procedure they had consented to. Only 55% could correctly list even one major risk or complication. Only 40% had read the form carefully, and most thought the consent form protected the physician’s rights.

Does this surprise you? How well do you think the surgical patients coming to your OR understand the operation they are about to undergo? Do you think they are aware of the major risks or complications? What kind of form does your hospital use? Is it complex? Or simple and understandable?

The authors of this study believed that con- sent forms are too complex and difficult for many patients to grasp. This verdict was con- firmed by another study published in the same New England Journal.2 Grundner analyzed five different surgical consent forms using readability tests. He found that four of the five forms were written at the level of a scientific joumal and the fifth at the level of a specialized academic magazine. All of the forms he studied had at least one sentence that was

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more than 50 words, and some had sentences with 70 or 80 words. That long a sentence is hard to read. By comparison, the average sen- tence length in this paragraph is 20. These forms have been constructed-and that’s probably the right word-by committees of lawyers and physicians. Although they can understand the forms, probably few patients can.

Grundner believes few consent forms could pass readability tests. The implications, he says, are that thousands of persons may be undergoing surgery on the basis of inadequate consent. The solution he suggests is simple. Analyze consent forms for readability, and re- write those that are excessively difficult. When he analyzed the consent forms, he used the Fry Readability Scale and the Flesch Readabil- ity Formula. There is also a Fog Index, which reveals how foggy or obscure writing is.

As an example, I ran a Flesch readability test on a paragraph above, and it came out 57.9, which means it is, by Flesch’s scale, some- where between standard and fairly difficult to read. I must have smart readers. According to the Fog Index, you need 12.8 years of educa- tion to read the same passage. A sample selected from a previous editorial yielded a Fog Index of 13.3 years. If the baccalaureate becomes a requirement for entry into nursing practice, I may have to write longer sentences.

Get out your calculator and try one of the readability tests on your consent form, or for that matter, other communications you use for patient teaching. What about written post- operative instructions you give patients at dis- charge or when they go home from day surgery? See whether your patients need col- lege degrees to understand what you are try- ing to tell them. Remember, too, that patients

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Flesch readability score4 Select a 1 00-word sample at random. Count the number of words in each sentence, then divide by the number of sentences to determine average sentence length. Then count the number of syllables in the 100-word sample. Now get out your calculator, and use this formula to determine readability: Multiply the average sentence

length by 1.01 5 Multiply the number of syllables

per 100 words by .846 Add the two figures Subtract from 206.835 Reading ease score is A zero score is practically unreadable, 40 is difficult, 65 is standard, 75 is fairly easy, and 100 is easily understood by any literate person.

are often under stress, which further interferes with their ability to comprehend material.

As William A Regan, JD, points out in this month’s legal column, obtaining the patient’s informed consent is a responsibility shared by the physician and the nurse. Clearly, the physician’s responsibility is to tell the patient about the proposed procedure, its benefits and risks, and alternative treatments. But the nurse-both the operating room nurse and unit nurse-makes sure the patient’s level of un- derstanding constitutes informed consent. In her preoperative assessment and teaching, the operating room nurse usually asks the pa- tient what he understands about the proce- dure. If he needs more information, she sees that he gets it from the appropriate person. It is

Fog Index Take a sample of at least 100 words. 1. Determine the number of words per

sentence. 2. Determine the number of words of three

syllables or more per 100 words. 3. Add results of steps 1 and 2. 4. Multiply that number by .4.

This will give you the approximate number of years of education required to read the sample.

the operating room nurse who checks that the consent form has been properly signed. These responsibilities can extend to making sure forms are easily understood by most patients.

The keys to readability are short sentences and words that aren’t packed with a lot of sylla- bles. The way to revise your forms to make them more understandable is to rewrite them with shorter sentences and simpler words. Also, avoid jargon. Many words commonly used in the hospital don’t mean a thing to the patient. Don’t let your lawyers tell you the form has to be complicated to be legal. Tell them it has to be understandable to be legal.

There are good sample forms available. One is by the American Medical Association, 535 N Dearborn St, Chicago, 111 60610. The same form can be found in George Annas’s excellent book, The Rights of Hospital Pa- tients.

Consumers have protested against the gobbledegook on insurance forms and legal documents and demanded that they be written in readable language. Patients’ understanding is essential to informed consent. That should apply to the form as well as to what the physi- cian says. Doesn’t your patient deserve a form he can read without a PhD?

Elinor S Schrader Editor

Notes 1. Barrie R Cassileth et al, “Informed consent-

why are its goals imperfectly realized,” New Eng- land Journal of Medicine 302 (April 17, 1980) 896- 900.

2. T M Grundner, “On the readability of surgical consent forms,” New England Journal of Medicine 302 (April 17, 1980) 900-902.

3. George J Annas, The Rights of Hospital Pa- tients (New York: Avon Books, 1975) 70-71.

4. Rudolf Flesch, The Art of Readable Writing (New York: Collier Books, 1962) 229.

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