Patients and doctors making decisions together GMC Guidance 2008

Consent  What do I need to know?  Why should I worry?  For what can I take consent?  Today: Principles of consent Some practical guidance Some background

Consent  Key points Never do anything against a patient’s wishes Anything you do to a patient needs their consent

Consent  References GMC Booklet ○ uk.org/guidance/ethical_guidance/consent_gu idance/index.asp uk.org/guidance/ethical_guidance/consent_gu idance/index.asp Trust Consent Policy ○ ices/InformationAndRiskmanagement/Consen tPolicy.pdf ices/InformationAndRiskmanagement/Consen tPolicy.pdf

Consent  Implied Consent  Verbal Consent  Written Consent All the same in principle Consent is a process not a signature

Consent  Dangers/difficulties Children Patients with psychiatric illness Patients with “learning difficulties” Patients with confusion etc ○ “Lack of capacity”

Consent  Consent to examination or treatment Patients have a fundamental legal and ethical right to determine what happens to their bodies. Valid consent to treatment is central in all healthcare, from personal care to undertaking major surgery. Seeking consent is also a common courtesy between health professionals and patients.

Consent  What is consent? “Consent” is a patient’s agreement for a health professional to provide care. Patients may indicate consent non-verbally (for example by presenting their arm for their pulse to be taken), orally, or in writing. For the consent to be valid, the patient must: ○ be competent to take the particular decision ○ have received sufficient information to take the decision ○ not be acting under duress.

Consent  For significant procedures It is vital to record the patient’s agreement to the intervention and the discussions which led up to that agreement. This may be done either through the use of a consent form (with further detail in the patient’s notes if necessary), or through documenting in the patient’s notes that they have given verbal consent.

Consent  Consent is not a signature on a consent form. ○ A signature on a form is evidence that the patient has given consent, but it is not proof of valid consent. ○ If a patient is rushed into signing a form, with little information, the consent will not be valid, despite the signature. ○ Similarly, if a patient has given valid verbal consent, the fact that they are physically unable to sign the form is no bar to treatment. ○ Patients may, if they wish, withdraw consent after they have signed a form. The signature is evidence of the process of giving consent, not a binding contract.

Consent  It is not usually necessary to document consent to routine and low-risk procedures, (eg providing personal care or taking a blood sample)  But if you have any reason to believe that the consent may be disputed later or if the procedure is of particular concern to the patient (for example if they have declined, or become very distressed about, similar care in the past), it would be sensible to record their consent.

Consent  Written consent ○ Not needed for most procedures ○ Advisable to obtain it for major procedures e.g. Surgery, major diagnostic procedures ○ You should seek senior assistance if you are unsure of any aspect of the procedure or consent process ○ Should include: A clear and thorough explanation of the procedure The risks, complications & benefits of the procedure The alternatives to the procedure (including no Rx) The consequences of not having the procedure Where to find further information

Consent  Verbal & implied consent Should be handled in the same way ○ But sensibly and taking the context into consideration Make appropriate notes after obtaining consent where you consider it necessary ○ e.g. Performing a LP ○ Not usually needed for inserting an IV cannula

Consent  Taking “delegated” consent Usually the person undertaking a procedure should obtain consent But another person capable of performing the procedure may obtain consent Or It may be delegated to someone who has been trained to take consent for the procedure

Consent  It is your professional responsibility to practice within your capabilities  This applies to both performing procedures and taking consent for procedures  You will receive training to obtain consent for certain common procedures. Your competence for this must be recorded.  If you have not had your competence recorded – you can’t obtain consent for these procedures

Consent  Patient “Capacity” This is the ability to understand the issues being discussed and come to a decision on whether they wish to give consent -For a person to have capacity, he or she must be able to comprehend and retain information material to the decision, especially as to the consequences of having or not having the intervention in question, and must be able to use and weigh this information in the decision–making process. You should start from the presumption that all adult patients have the capacity to take decisions. It is your responsibility to determine that any patient from whom you are obtaining consent has the capacity to give valid informed consent. If in doubt ask for help.

Consent  When to worry about “Capacity”: Children Mental illness Learning difficulties Confusion/Altered levels of consciousness ○ They may have capacity – or may have limited capacity (e.g. OK for simple decisions) ○ You should not attempt to obtain consent to major procedures – seek help

Consent  Just because you disagree with a patient’s decision does not mean they lack capacity  Patients have the right to take illogical decisions  We do not have the right to bully them into doing what we “know” is right.

Consent  In your first few years you will be taking consent from patients all the time – for interventions you perform  You may take consent for more invasive procedures as you become more experienced  You may be trained to obtain consent for procedures which you do not perform  You should read the GMC Guidance and practice in line with your professional responsibilities as a doctor  Do not do what you are not trained to do.