3.3 Consent Issues Flashcards
History
A 16-year-old girl with learning difficulties is put on the operation list
for dental corrective surgery (surgery due to last 1 to 2 hours). You are asked to pre assess this patient.
What are the causes of learning
difficulties?
The underlying problems in these children may include
neurological disability,
developmental delay,
behavioural disorders,
autism,
and mental health or
personality problems.
What are the issues with this case?
- Poor dental hygiene.
- Uncooperative and communication may be challenging.
- Higher risk of infection like hepatitis B,
especially in institutionalised individuals.
- Higher risk of infection like hepatitis B,
- Other medical conditions and physical abnormalities may co-exist, such
as epilepsy, reflux, and cardiac anomalies.
- Other medical conditions and physical abnormalities may co-exist, such
- Consent issues.
What is capacity?
How will you assess capacity in this patient?
A capable (or competent) person is one who has reached 18 years of age
and who has the capacity to make decisions
on their own behalf regarding treatment.
In England and Wales competent young people of 16 or 17 years of age
can give consent for any surgical, medical, or dental treatment; it is not
necessary to obtain separate consent from the parent or guardian.
The Mental Capacity Act 2005 governs the treating of an incapable person.
occasionally in some cases the Act permits medical treatment to be given
without the patient’s consent, as long as it is in their best interests and has
not been refused in a valid and applicable advance directive (living will) or
advance decision.
In adult:
Every adult is assumed to be capable. The default position, therefore, is that
all adults have capacity until they are proven otherwise. No other person can
consent to treatment on behalf of any adult, including incompetent adults.
Any treatment, investigation, or physical contact with the patient undertaken
without consent may amount to assault.
But treatment may be given if it is in their best interests, as long as the
requirements of the Mental Capacity Act 2005 are adhered to.
In children:
Only people with ‘parental responsibility’
are entitled to give consent on
behalf of their children.
Parental responsibility is defined in the Children Act (1989)
as “All the rights, duties, powers,
responsibilities, and authority which by law a parent
of a child has in relation to a child and his property”
(Children Act 1989, section 3).
What are the consent and parent-guardian issues in adolescents?
‘Consent’ is a patient’s agreement for a health professional to provide care.
Patients may indicate consent nonverbally, orally, or in writing.
Parent-guardian:
The mother has an automatic right to parental responsibility. The father
has an automatic right only if he was married to the mother at the time of
birth, although he can acquire parental responsibility by court order or by
agreement.
In some circumstances, another person may have acquired parental
responsibility (e.g. a legal guardian, adoptive parent, or a social worker).
Age:
- If a person under 18 years of age refuses treatment that is deemed
essential, then the patient can be made a ward of the Court and the
Court may order that an operation may be carried out lawfully. - If a young person of 16 or 17 years of age is not competent to give
consent, then the consent of a parent should be sought, unless
immediate treatment is required to prevent death or permanent injury. - If a child under the age of 16 years achieves a sufficient understanding of
what is proposed, he or she may consent to treatment.
The child must be Gillick competent.
What is Gillick competence?
This term is used in medical law to decide whether a child
(16 years or younger)
who has achieved sufficient understanding of what is being
proposed is able to consent to his or her own medical treatment,
without the need for parental permission or knowledge.
However, in cases where a competent child
has refused or resisted medical treatment,
the courts have upheld the right of the parents
to consent for the child’s treatment up to the
age of 18 years.
Lord Scarman’s test
Lord Scarman’s test is generally considered to be the test of ‘Gillick
competency’.
He required that a child could consent if he or she fully
understood the medical treatment that was being proposed.
Fraser guidelines
Fraser guidelines are concerned only with contraception and focus on
the desirability of parental involvement and the risks of unprotected sex in
children younger than 16.
Who are iMcAs?
The IMCA service is provided for any person aged 16 years or older,
who has no one able to support and represent them,
and who lacks capacity to make a decision about either:
- a long-term care move
- a serious medical treatment
- adult protection procedures
- a care review
What are the different types of
consent forms you have come
across?
Form 1: For adults or competent children
Form 2: For parental consent for a child or young person
Form 3: For cases where the patient will remain alert throughout the
procedure and no anaesthetist will be involved in their care
Form 4: For adults who are unable to consent to investigation or treatment
What problems might you encounter while anaesthetising her in the anaesthetic room?
Difficult rapport and aggressive and combative behaviour at induction
requiring sedation.
Premedicants like midazolam reduce anxiety at induction
of anaesthesia and reduce postoperative behavioural disturbances.
Parent-guardian presence at induction and in the recovery area is necessary
to eliminate separation anxiety.
Starvation status may not be adequately followed by the patients.
What are criteria for offering
GA in a day-care dentistry?
The General Dental Council and the Royal College of Anaesthetists
guidelines state that general anaesthesia for dentistry should only be
administered for:
- Situations in which it would be impossible to achieve adequate local
anaesthesia and complete treatment without pain
- Situations in which it would be impossible to achieve adequate local
- Patients who, because of problems related to age/maturity or physical/
learning disability, are unlikely to allow safe completion of treatment
- Patients who, because of problems related to age/maturity or physical/
- Patients in whom long-term dental phobia will be induced or prolonged
Further reading
- Patients in whom long-term dental phobia will be induced or prolonged
