Achieving informed consent when patients appear to lack capacity and surrogates.

Obtaining informed consent is a frequent and important part of the practice of orthopaedic surgery. However, the process can be complicated, especially when there are impediments to communication and unusual decisions. An approach that considers each of the elements of informed consent permits the clinician to enhance the role of autonomy in patient decisions while maximizing the probability of achieving successful informed consent. Attending to (and testing when necessary) a patient's capacity to make decisions, ensuring comprehension of the clinical circumstances and proposed intervention and it's risks and benefits, and evaluating the decision-making mechanism are essential steps. A patient's capacity to participate in informed consent at times may be enhanced by selected interventions and may require serial reevaluation to identify the optimal time to discuss the issues. Implied consent has an important but delimited role in emergent circumstances. Prospective elicitation of patient preferences and delineation of surrogate decision makers can substantially enhance the ease and efficiency of informed consent while matching care with patient goals.