Consent For Adults

Question 1

3 basic phases we go through when making decisions

Answer 1

Gathering infor
Recalling and pooling info
Weighing up things

Question 2

How would the quality of your decision may be affected adversely

Answer 2

U weren’t competent to make it
U were deceived and info was concealed from you
U were coerced or forced to make a decision too quickly

Question 3

What is a doctors role in the partnership with patient

Answer 3

Facilitate the best decision possible for patient
Bringing expertise - knowledge, experience, insight of outcomes and how they’ll be dealt with
Presenting alternatives - range of options

Question 4

What does the patient bring to the partnership with a doctor

Answer 4

Their own values, beliefs, and knowledge about themselves (their priorities and what they’re prepared to accept

Question 5

What is autonomy

Answer 5

the right of competent adults to make informed decisions about their own medical care

Question 6

What is humanism

Answer 6

Humanism in healthcare is characterized by a respectful and compassionate relationship between physicians, as well as all other members of the healthcare team, and their patients. It reflects attitudes and behaviors that are sensitive to the values and the cultural and ethnic backgrounds of others.

Question 7

Where does autonomy take its roots from

Answer 7

Humanism

Question 8

Where does the idea that a patient must give consent to a treatment derive from

Answer 8

The notion of Patient autonomy

Question 9

What does autonomy entail

Answer 9

Ownership of oneself
Person has the right to determine their experiences
Persons should not be made to do things against their own will or interest
Person should not trespass on another e.g. battery

Question 10

What ideas are autonomy based on

Answer 10

Self determination
Identity
Personhood
Integrity

Question 11

How is autonomy related to someone’s identity

Answer 11

Autonomy an be considered as the ability to define the self through ones choices
Autonomy is the ability to live according to our own values and beliefs
Limiting someone’s autonomy impinges on peoples sense of self and cause emotional reactions

Question 12

Self determination theory

Answer 12

Theory deals with human motivation and links wellbeing, satisfaction and performance to autonomy, competence and relatedness

Question 13

What is autonomy in medical context

Answer 13

Idea that a patient must consent to a treatment derives directly from autonomy
Patients has the absolute right to make their own decisions about what happens to their bodies

Question 14

What is your role as a doctor in terms of autonomy

Answer 14

Your role as a doctor is to empower and enable the patient’s autonomous choices This process is patient-centred, not doctor-centred

Question 15

Autonomy vs beneficence

Answer 15

Historically, some medical practice happened without consent, and most without adequate information
Belief that doctor knew best and should decided treatment
most doctors favoured ‘benevolent concealment’ of most aspects of medical care, even lying to their patients, especially about prognosis

medical humanism became more prominent, so did autonomy (autonomy is a relevantly recent topic)

Question 16

GMC defines 7 key principles of consent

Answer 16

• All patients have the right to be involved in decisions about their treatment and care and informed decision should be supported
• Decision making is ongoing process focused on meaningful dialogue
• All patients listened to and given info and time to support decision
• Doctors investigate what matters to patient so can offer options. Benefits harms and alternatives
• doctors must assume all adult patients have capacity
• choice of treatment or care for patients that lack capacity must benefit them
• patients whose right to consent is affected by law should be supported to be involved in the decision-making process

Question 17

Why can the language we use to describe consent be confusing

Answer 17

People may think of consent as something a doctor takes from a patient, or something a patient gives
But Consent is a dialogue, an ongoing process of ascertaining what the patient wants, from a range of options
This includes the option to do nothing

Question 18

Sidaway vs Bethlem royal hospital governors

Answer 18

As example of case law
Has been superseded by other cases but important because lays down foundations

“A doctor who operates without the consent of his patient, save in cases of emergency or mental disability, is guilty of the civil wrong of trespass to the person; he is also guilty of the criminal offence of assault.” - Lord Scarman

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

Question 19

Doctors duty to the patient

Answer 19

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

Question 20

How much information should you give to the patient

Answer 20

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

E.g. taking bloods vs major surgery

Question 21

What is a material risk?

Answer 21

Established by Montgomery and lankshire case

The test of materiality:
- whether a reasonable (average) 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

Doctor needs to learn about patient and what matters to them so they can decide what information to highlight

Question 22

GMC guidance on informing patient correctly

Answer 22

You must give patients clear, accurate and up-to-date information, based on the best available evidence, about the potential benefits and risks of harm of each option, including the option to take no action.

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 23

How do decide what information/ risks to disclose to patient based on GMC

Answer 23

● Recognised risks of harm that you believe anyone in the patient’s position would want to know
● 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.
● Any risk of serious harm, however unlikely it is to occur.
● Expected harms, including common side effects and what to do if they occur.

Question 24

Summary of consent

Answer 24

You must take consent from patients for all stages of the medical process
Your role is as a decision-making partner with your patient
You must disclose material risks, and alternative options (including no treatment) All information must be made as accessible as possible

Question 25

Is consent always necessary

Answer 25

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 26

In what situations can u not gain consent from patients

Answer 26

• eg. emergency treatment of an unconscious or otherwise incapacitated patient
• eg. urgent mental health treatment under the Mental Health Act

Question 27

How should you decide what to do when patient cannot give consent

Answer 27

In these situations, you should act in the patient’s best interests.
If you have information about what they would want in this situation (eg. advance directive, or advance statement) then you should use this

Question 28

Is consent always valid

Answer 28

Consent can expire - after a prolonged time, or if the situation changes
Consent can also be invalid if certain conditions weren’t met, or if it was given in the wrong way.

Question 29

Doctor needs to ensure consent is valid by

Answer 29

Ensuring patients decision made under free will

• is the patient coming under undue pressure to choose in a certain way? e.g. by family/ friends
• is there anything that makes this patient particularly vulnerable to coercion? e.g. abusive relationship, they’re young, financially dependant on someone else

Question 30

How does coercion undermine autonomy and how may a doctor influence this

Answer 30

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 31

Beauchamp and Childress definition of coercion

Answer 31

“Coercion … occurs if and only if one person intentionally uses a credible and severe threat of harm or force to control another”

Question 32

What is a threat of harm (referring to childress) in medical context

Answer 32

a threat of harm might be the withdrawal of treatment, or that if refused now the treatment will not be offered again later

Question 33

When is a statement given to a patient a “threat of harm”
E.g. “If we decide to watch and wait, the situation is likely to get worse. In six months time, the treatment would be unlikely to be successful.”

Answer 33

This depends on whether the information is:
- accurate
- 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 34

What is medical coercion

Answer 34

If it is an exaggeration to persuade the patient to take the doctor’s preferred treatment option, it is a form of medical coercion

Question 35

What is Undue influence

Answer 35

Persuasion that falls short of coercion but still influences patient during decision making
Where decision isn’t the patient but is actually someone else’s decision

Consent under undue influence cannot be accepted

Question 36

What is Parental consent

Answer 36

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 37

What is parental refusal

Answer 37

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 38

What happens if both parents refuse treatment on behalf of non competent minor

Answer 38

If 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

Question 39

What acts apply to parental refusal if refusal is not beneficial to child

Answer 39

Children’s Act 1989 s1 (1) : duty to maintain the child’s welfare as paramount
Human Rights Act 1998 (s2 - right to life)

Question 40

How is the law involved in consent

Answer 40

Consent has legal implications

Uk has 2 forms of law:
- Enacted through parliament (legislative)
- CASE LAW - Based on legal precedent. rulings made by judges in similar cases (most based on case law from previous patients suing)

Question 41

What is the Montgomery vs the Lanarkshire case 2015

Answer 41

The obstetrician chose not to tell the patient about the risk of shoulder dystocia, and unfortunately her baby suffered from oxygen deprivation causing cerebral palsy
Mother sued because HCP didnt give patient enough information
The Supreme Court ruled that the doctor should have informed her of this risk.
“The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks (cerebral Paulsy) involved in any recommended treatment, and of any reasonable alternative (C section) or variant treatments.”

Question 42

Criteria for consent to be valid

Answer 42

For consent to be valid, our decision-making rules apply :
- Voluntary (not co-erced)
- Informed (adequate information)
- The patient must be competent to make it

Question 43

Patient has given consent, but after talk with mum she then refuses treatment. Doctor suspects its due to undue influence. If patient then looses consciousness can doctor assume consent for treatment due to disruption of undue influence.

Answer 43

No
Cant assume there is consent
Must escalate to court

Judge:
The judge ruled that Karina’s refusal applied to a different situation, and she had not been asked about this situation, where the transfusion would be life-saving. He therefore ruled that she should be treated in her best interests as she had lost capacity