Consent (Adults)

Question 1

what are the three basic phases we go through when we make decisions?

Answer 1

1. Gather information
2. Recall and pool all that information together
3. Weigh things up and may a final decision 🡪 give or refuse consent
   - Patients undergo a similar decision-making process
   - Decision making should be a partnership between the doctor and their patient.

Question 2

the quality of your decision might be adversely affected if:

Answer 2

• You weren’t competent to make the decision
  => weren’t able to understand the concepts involved or the implications of your decisions
• You we coerced or put under pressure to make the decision too quickly
  =>not enough time to gather and weight up information
• You were deceived or had information concealed from you
  => the information that you based your decision on was fictitious/incomplete

Question 3

when/how do patients decide their course of action?

Answer 3

They must decide that they want to go ahead with all stages of the medical
process - give consent.
Decision-making should be viewed as a joint enterprise - a partnership between
doctor and patient

Question 4

what is the decision-making partnership?

Answer 4

You are bringing your expertise - your knowledge, your experience, your insight
into what outcomes are likely to be, and how they can be dealt with
You are presenting alternatives - a range of possible options from which the
patient can choose
The patient brings their own values, beliefs, and their knowledge of their self -
what matters to them, what their priorities are, what they are prepared to accept
Your role is to facilitate the best decision possible for this patient

Question 5

what is autonomy?

Answer 5

The idea that a patient must give consent to a treatment derives directly from the notion of patient autonomy - human beings have the right to make their own decisions about issues that affect them.

Question 6

when do you ask for consent from a patient?

Answer 6

You must take consent from patients for all stages of the medical process
even to examine a patient, always make clear never assume & give patients options to say no.

Question 7

what does autonomy allow for?

Answer 7

Autonomy allows for the maintenance of integrity - following through with the decisions our true self would make.
It allows you to define yourself through your choices
Autonomy gives people the ability to live according to their own values and beliefs (links to identity)
As such, limiting someone’s autonomy is likely to limiting someone’s ability to be themselves and live as an independent self-determining being 🡪 this will lead to a significant emotional reaction
Therefore, medical treatment should seldom proceed without consent
The role of the doctor in the partnership is to help patients make the best possible for themselves.

Question 8

what was used before autonomy?

Answer 8

Autonomy is a recent phenomenon.
Most doctors throughout history favoured beneficence - benevolent concealment/lying to patients about most aspects of their medical care, especially about prognosis.
Based on the idea that doctors have a greater understanding/more information than patients do and so can make a better decision than the patient.
Autonomy is important as doctors don’t know about the patient’s value system and their beliefs. E.g. what they most want out of treatment e.g. better quality of life rather than quantity of life.
It was not until the rise of humanism that autonomy became prominent

Question 9

what is the self-determination theory?

Answer 9

there is now significant psychological evidence to support the importance of autonomy to humans.
Self-determination theory deals with human motivation and links wellbeing, satisfaction and performance to autonomy, competence, and relatedness to human beings around us.

Question 10

what are the GMC’s 7 key principles of consent?

Answer 10

1. All patients have the right to be involved in decisions about their treatment and care and should be supported to make informed decisions if they are able to 🡪 the role as doctor is to support decision making e.g. providing information
2. Decision making is an ongoing process focused on meaningful dialogue. Dialogue should involve exchanging relevant information specific to the individual patient and what they want out of treatment.
3. All patients have the right to be listened to, and to be given the information they need (personalised) to make a decision and the time and support they need to understand it.
4. Doctors must try to find out what matters to patients (values and beliefs of this patient) so they can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action.
5. Doctors must start from the presumption that all adult patients have capacity to make decisions about their treatment and care.
6. The choice of treatment or care for patients who lack capacity must be of overall benefit to them
7. Patients whose right to consent is affected by law should be supported to be involved in the decision-making process

Question 11

explain the classic method of patient doctor interaction

Answer 11

Take a history
recommend treatment (GMC states it is important to now enter a dialogue about different treatments with the decision ultimately up to the patient)
Doctor takes consent from patient (patient passive and doctor is active).

Question 12

what is the shift in consent taking compared to the past?

Answer 12

There is a shift now that consent is not something a doctor take but something a patient gives
Consent is an ongoing process of obtaining what the patient wants from a range of options, this includes the option to do nothing

Question 13

what is the legal basis of consent – based on case law?

Answer 13

duty to provide enough information for the patient to make a balanced
judgement
- should provide alternatives
- should inform of “common or serious” consequences

Question 14

how do you know how much information to give a patient?

Answer 14

Depends on
- What it is you’re proposing to do
- How much information your patient wants

Question 15

when is consent considered invalid?

Answer 15

Consent can also be invalid if certain conditions (below) weren’t met:
For consent to be valid, our decision-making rules apply :
- Consent was given voluntarily (not coerced)
- Informed (adequate information)
- The patient must be competent to make it (must have skills to make it)
- The onus is on the doctor to ensure that consent is valid (not on patient)
- It is also on the doctor to check for free will
- is the patient coming under undue pressure to choose in a certain way? (coerced)
- is there anything that makes this patient particularly vulnerable to coercion?

Question 16

according to the GMC, what info should be given to the patient?

Answer 16

You must give patients clear, accurate and up-to-date information
The following information should be given to patients:
- Patient’s should be aware of any material risks
- Patients should be aware of common risks e.g. common side effects and what to do if they occur.
- The effect of the patient’s individual clinical circumstances on the probability of a benefit or harm occurring.
- Risks of harm and potential benefits that this patient would consider significant for any reason (based on their values and beliefs)
- Patients should be aware they can say no
- Patients should be aware of reasonable alternatives

All information must be made as accessible as possible (make sure they understand what you are saying in terms of complexity and if required get a translator)
It wouldn’t be reasonable to share every possible risk of harm, potential complication or side effect.
Instead, you should tailor the discussion to each individual patient, guided by what matters to them, and share information in a way they can understand.

Question 17

define material risk

Answer 17

a risk with grave consequences regardless of the frequency it occurs

Question 18

how does a doctor make the judgment on whether a risk is material?

Answer 18

Doctor makes a judgement on whether a risk is material by asking:
- Whether a reasonable person in the patient’s position would attach significance to the risk or
- If the doctor knows (or should know) that this particular patient would attach significance to the risk
- It is the Doctors duty to know or find this out
- Aligns with GMC guideline that doctors should know about their patient’s value system and beliefs and therefore what is valuable to them - nice alignment of law and GMC guidance.

Question 19

explain a case example where patient was not informed of the risks of operation

Answer 19

Patient had an operation to relieve pain but developed paralysis as a complication.
She was suing for damages as she had not been informed of this risk (less than 1%) suing saying her consent was invalid as she did not have all the information.
Refused damages as the risk was not common enough.
But this ruling did solidify the idea that you must obtain consent as a must before performing a procedure

Question 20

explain the Montgomery vs Lanarkshire (2015) case

Answer 20

Question 21

is consent always valid?

Answer 21

Consent can expire after a prolonged time, or if the situation changes (dynamic process) e.g. if patient gave consent to be put on the waiting list don’t assume when their turn comes up that they still have the same desire.

Question 22

what are the exceptions to consent?

Answer 22

There are some situations where you cannot get consent, and cannot postpone until you can
e.g. emergency treatment of an unconscious or otherwise incapacitated patient
e.g. urgent mental health treatment under the Mental Health Act
In these situations, you should act in the patient’s best interests.
If you have information about what they would want in this situation (e.g. advance directive, or advance statement) then you should use this

Question 23

explain the ‘therapeutic exception’

Answer 23

There are situations where it is conceivable that giving the information necessary to get informed consent would cause ‘significant psychological harm’ to the patient.
It has been argued that this is a situation where informed consent is not in the patient’s interests
HOWEVER - While court rulings have repeatedly mentioned that such circumstances may exist, they have never upheld this in any specific case - should not use as an exception or reason to not give information
If a patient is so fragile that such knowledge might put them at risk, they probably lack capacity to consent to care

Question 24

Is consent always necessary?

Answer 24

Sometimes doctors will use the concept of implied consent, eg. for aspects of
examination, or minor procedures
However, you should never assume the patient understands what you are about to
do
It is best practice always to ask

Question 25

how does coercion impact validity of consent?

Answer 25

If a decision is unduly influenced by someone else, it is not truly that of the patient
If they are only consenting to the treatment under duress, the consent may be
invalid
You must be extremely careful not to compromise patients’ autonomy by
attempting to influence them too much
How much is too much will also depend on the person, and your relationship with
them

Question 26

what does coercion depend on?

Answer 26

This depends on whether the information is accurate, and whether it can be
confidently known.
If this is a true statement, then this is a warning - and one you have a duty to make
If it is an exaggeration to persuade the patient to take the doctor’s preferred
treatment option, it is a form of medical coercion
The best course is to steer clear of persuasion altogether. Provide information,
and if asked, your opinion

Question 27

who can consent on behalf of a child?

Answer 27

Those with parental responsibility can consent on behalf of children who have not
yet achieved competence
Mothers have parental responsibility for any children they have given birth to
Fathers have parental responsibility if they are named on the child’s birth
certificate, or are married to the child’s mother
Fathers can also apply for parental responsibility through the courts
Adoptive parents gain legal parental responsibility
Social care authorities can also have parental responsibility for children

Question 28

can parents refuse treatment for their child?

Answer 28

Generally, only one parent needs to provide consent for a child’s medical
treatment, you do not need both to be present
One parent cannot veto a treatment they disagree with if the other parent provides
consent
However, doctors are discouraged from going against the expressed wishes of a
parent, especially if there is no clear benefit to the child for the treatment

Question 29

what happens when both parents deny consent but doctors think procedure is best interest of child?

Answer 29

If both parents refuse to consent to treatment on behalf of a non-competent minor,
and the medical team believes the treatment to be in the child’s best interests, the
team can apply to the courts to provide the consent that the parents will not
The court will consider the parents beliefs as part of their deliberations, but they
have a clear duty to safeguard the best interests of the child
Children’s Act 1989 s1 (1) : duty to maintain the child’s welfare as paramount
Human Rights Act 1998 (s2 - right to life)