DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
OBTAINING CONSENT
- For a competent patient, go to CONSENT WITH CAPACITY
- For a patient without capacity, go to CONSENT WITHOUT CAPACITY
INTRODUCTION
- The three guidelines on consent outline assessing and informing adult patients (aged ≥18 yr), so they can give valid consent before undergoing a clinical procedure
- The greater the associated risks, the more stringent the consent process
- make comprehensive notes in the medical records
CAPACITY
- Adult patients are assumed to be competent unless it is proved otherwise
- if patient able to understand, retain and weigh up information needed to make decision and is able to communicate this decision back to you, assume competence
- unexpected decisions do not prove that a patient is incompetent, but may indicate the need for further information or explanation
- patients may be competent to make some healthcare decisions, even if not competent to make others
Assessing capacity
- Assessing capacity is a core clinical skill and does not necessarily require specialist input (e.g. psychiatrist)
- You should be able to draw reasonable conclusions about a patient’s capacity during your dialogue with them
- In complex cases where you believe that you are unable to make a judgement, seek specialist input from psychiatrists, neurologists, speech and language therapists or liaison nurses
- A person has capacity if they can:
- understand information relevant to the decision in question
- retain that information
- use the information to make their decision
- communicate a decision
- If you believe that a patient may lack capacity to decide, assess their capacity using the test set out in the Mental Capacity Act, summarised in next section
Capacity assessment
- Does the person have an impairment or disturbance in the functioning of his/her mind or brain?
- If the answer to this question is ‘yes', has the impairment deprived him/her of the capacity to make this particular decision?
- In order to answer the second question, can the patient:
- understand information about proposed treatment, its purpose and why it is being proposed?
- retain information for long enough to make an effective decision?
- use or weigh that information as part of the decision-making process?
- understand the benefits, risks and alternatives?
- understand the consequences of his/her refusal?
- communicate his/her decision (whether verbally, using sign language or other means)?
Any doubt or disagreement whether the patient has capacity
- An application to the court MAY be necessary
- Seek advice
CONSENT
When
- Consent is required before an adult is:
- examined, treated and cared for
- Consent must be given before commencing a procedure or treatment other than in exceptional circumstances, such as:
- life-saving procedures and emergencies
Expressed consent
- Must be obtained for any procedure carrying a 'material risk'
Written
- Expressed consent is usually given by signing a consent form which does not in itself prove that consent is valid but may contain helpful prompts to share key information
- can be given orally with written documentation supporting the oral discussion
- need not necessarily be spoken, but clear and interpretable (e.g. hand squeeze) and given free from duress
- The law requires explanation of all 'material risk'
- Record expressed consent in patient's clinical records
- a consent form alone is not enough and is not a substitute for a meaningful dialogue tailored to the individual patient’s needs
Implied
- Assumed when, following explanation of the proposed procedure/treatment, patient indicates willingness to proceed by co-operating, for example:
- extending arm to have blood taken
- Good practice to document the actions/conversation around implied consent
REFUSAL OF TREATMENT
- Consent must be given voluntarily
- not under any form of duress or undue influence from healthcare professionals, family or friends
- A competent adult has the right to refuse treatment
- even if the decision seems irrational, it is ethically wrong to persuade him/her otherwise
- his/her refusal is binding
- If the patient refuses, ensure s/he clearly understands the implications of refusal e.g. that it may result in death
- A patient can withdraw consent at any time and has the right to stop treatment at any stage
- if there is any doubt, check that the patient still wishes to proceed
Pregnancy
- A competent pregnant woman may refuse treatment, even if this would be detrimental to the fetus
- Where a fetus is placed in danger as a result of a mother's refusal of treatment, seek advice
- it may be appropriate to revert to the Court of Protection
Exception to voluntary consent
- The only exception is treatment for a mental disorder in a patient detained under the Mental Health Act (MHA)
- involve the mental health liaison team
- does not preclude the individual from giving or withholding consent to treatment for physical conditions
- assess the patient's capacity to consent as above