Consent

Question 1

How do we make decisions (3 phases)

Answer 1

Gather information
Recapping and pooling researched information
Weighing things up

Question 2

What affects the quality of the decisions we make

Answer 2

You weren’t competent to make it ie you don’t have the knowledge and skills to make the decision

You were coerced or put under pressure to make the decision too quickly

You were deceived or had information concealed from you

Question 3

What is the ethical basis for consent?

Answer 3

Autonomy

human being have the absolute right to make their own decisions about issues that affect them

the ability to define ones self through the choices we make

ie is strongly linked to identity and the right to self determination and personhood
this is linked to individuals own values and beliefs and as such a impingement on someones autonomy is an impingement on someones sense of self which can lead to sever phycological and emotional reactions

Question 4

What is the role of the doctor in and how can we ensure patients make the best decisions possible?

Answer 4

Patients have the right to be involved in their treatment and care and be supported to make informed decisions. The doctor has the responsibility of facilitating this by providing information

A strong dialogue should be established between doctor and patient to allow exchange of relevant information

Patient need time and support to understand and process information they have received

Doctors must try to found out what matter to the patient so they can share relevant information of preposed options and reasonable alternatives including the option to take no action

Question 5

What was the Montgomery vs Lanarkshire case what was the outcome ruling?

Answer 5

baby had risk of shoulder dystocia and during this babies may suffer oxygen deprivation and cerebral pausly as a result but the risk is only 0.1%

obstetrician told not to tell patient of risk thought caesarean would cause more complications and as a result her baby did end up having cerebral pausly

Doctor should have informed her of the risk
the doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment and of any reasonable alternative or variant treatments

Question 6

What is material risk?

Answer 6

Wether someone in the patients position would see this as a significant risk
Doctor should know from finding out what matters to the patient if they would perceive this as a risk

Question 7

What does delivering material risks and the outcome of the Montgomery vs Lanarkshire case mean in clinical practice?

Answer 7

You must give the patient clear accurate and up to date information based on the scientific evidence about the potential benefits and risk of harm of each treatment option including the option to take no action

It wouldn’t be possible to relay every possible risk of harm or side effect therefore the doctor should tailor the discussion to each individual patient guided by what matters to them and what someone else in the patients position would want to know.

You should deliver this information in a from which the patient understands

Question 8

What makes consent valid?

Answer 8

Must be voluntary and non coerced
Informed
the patient must be competent to make it

Question 9

Is consent always valid once given?

Answer 9

NO can expire

must get consent and asses competence for every clinical procedure and option and continually reassess consent

Question 10

What are the very rare situations that you don’t need consent?

Answer 10

Emergency treatment of unconscious or otherwise incapacitated patient that is clearly not competent to give consent (in this case you act in the patients best interests)

Urgent mental health treatment under the mental health act

Question 11

What is battery?

Answer 11

Touching someone without gaining there consent first

Question 12

What is negligence ?

Answer 12

You obtain consent knowing full well that the patient doesn’t known all the side effects and risks. Patient must prove that they wouldn’t have consented if they had known all the side effects

Question 13

What is the Bauchamp and Childress model

Answer 13

Autonomy
Non-maleficence
Beneficence
Justice

Question 14

What is capacity and what does losing capacity mean?

Answer 14

Prerequisite to autonomy loosing capacity means loosing the ability to decide in accordance with our own values

Question 15

What must someone be able to do in order to have capacity?

Answer 15

Understand the presented information

Recall the information

Weigh up the decision

Communicate that decision

Question 16

How is capacity assessed and how do you approach assesign capacity?

Answer 16

Must assume everyone has the capacity to make decision about there treatment or care and must not assume someone lacks capacity due to there age appearance behaviour any disabilities etc or because they make a decision that you deem to be unwise

Whilst you assume capacity you must asses it!!!
This must be done at all times and for every individual treatment option and over time

Do this by the two stage test

Question 17

What is the two stage test for assessing capacity?

Answer 17

Stage 1 is there an impairment of or a disturbance in the functioning of the person’s mid or brain?
If so
Stage 2 is the impairment or disturbance sufficient such that the person lacks the capacity to make a particular decision?

Question 18

What must be assessed therefore when assessing capacity?

Answer 18

That they understand the information

That they are able to retain information

Patient has the ability to weigh up the information and actively engage in the decision making process by weighing up the pros and cons and relating them to one another and coming up with a conclusion

Able to communicate the decision

Question 19

How do you ensure that the patient understands the information

Answer 19

make sure is it presented in the most accessible way don’t assume prior knowledge (e.g. that they know what life in a care home would be like)

Question 20

What is meant by the patients ability to retain information hen giving consent?

Answer 20

They can they retain enough information for a sufficient amount of time in order to make a decision at this pint in time

Question 21

What is meant by the patient ability to Weigh up the information when assessing capacity and how is this assessed?

Answer 21

Capacity to be able to engage in the decision making process and be able to see the pros and cons and how they relate to each other

Does not mean the patient has to reach a rational conclusion or one that you agree with

Easier to asses if you know what matters to your patient ie there value system

Question 22

How do you asses wether the patient has the ability to communicate their decision how can you facilitate this

Answer 22

facilitate communication by:

reproducing the manner by which they usually communicate

provide all the necessary tools and aids to allow communication

support/ presence of any relevant carers or friends/relatives that can help communicate patients decision

Question 23

What can impair capacity

Answer 23

impairment of or disturbance in the functioning of the person’s mind or brain?
Also includes extreme pain or overwhelming emotional states e.g. needle phobias

meaning person lacks the capacity to make a particular decision

Question 24

Can a patient demand a treatment?

Answer 24

No capacity does not five the patient the right to demand a treatment that the doctor does not feel is medically indicated or in the patient’s best interests
Patient autonomy must be weight against what is objectively best for them beneficence and the fair distribution of resources justice

Question 25

What are the 6 things you need to ask yourself if the patient lacks capacity?

Answer 25

Can it wait
is the loss of capacity temorpary can the decision be temporally postponed

What would be best in general

What would be best for this specific paitn based on their own value system and are there any risks they wouldn’t be willing to take? are there outcomes they would value above others

can you get any mor information e.g. relativels carers who many know what the patin would want has the patient left any instructions such as advanced statement that gives a significant other ability to make decisions on their behalf or advanced decisions that refuse specified treatments in specified circumstances

Is there anyone else who has the right to make a decision
lasting power of attorney

Is there total lack of information court of protection external help to establish a independent mental capacity advocate

Question 26

What is the difference between competence and capacity?

Answer 26

Competence is used exclusively to denote whether or not a person under 18 years of age can make a decision about their health.
Should not be used for anyone above 16 as this is then termed capacity

Question 27

What is Gillick competence?

Answer 27

Children under 16 can consent if they have sufficient understanding and intelligence to fully appreciate what is involved in a proposed treatment including its purpose, likely effects risks and chances of success and the availability of other options

Question 28

What are the Fraser guidlines

Answer 28

They are only related to whether someone under 16 can be prescribed contraceptives without parental knowledge
and have now been extened to include STI’s and termination of pregnancies

Young person must have sufficient maturity and intelligence to understand the nature and preposed implication of treatments

They cannot be persuaded to tell their parents or allow the doctor to tell them

They are likely to begin or continue having sexual intercourse with or without contraceptive treatment

Their physical or mental health is likely to suffer unless they receive the treatment

The treatment is in the young persons best interests

Question 29

What if the child is not gillick competent?

Answer 29

You must ask for parental consent
usually sufficient to have consent from one parent if parents cannot agree and disputes cannot be settled informally you should seek legal advice

Question 30

Can a child refuse treatment?

Answer 30

Just because child can consent to treatment don’t mean they can refuse it

refusal by a young person can be overruled by a person who has parental responsibility over that young person

if one with parental responsibility overrules a competent child you legally can carry out the treatment however you should consider the harms of breaking the child’s right to self determination and autonomy.