Introduction To Consent

Question 1

What is informed consent?

Answer 1

• A starting point for protecting rights + interests of individuals
• Legitimacy required for certain actions: needed to make actions legally + ethically permissible where lack of consent can turn a seemingly well-intended medical intervention into assault/battery
• Gains significance from autonomy

Question 2

What is autonomy?

Answer 2

“Personal autonomy encompasses at a minimum, self-rule that is free from both controlling interferences by others and from certain limitations such as an inadequate understanding that prevents meaningful choice” although it is a complex & debated philosophical concept

Question 3

Why should we respect patient autonomy?

Answer 3

It is part of respecting the rights and interests of patients

Question 4

When do we need to gain consent in healthcare?

Answer 4

Treatment
Investigation
Examination
Disclosure of information (even for healthcare purposes to an extent)
Research (more stringent than for medical treatment)
Education (e.g. medical student sitting in)

Question 5

How can a doctor avoid a charge of battery?

Answer 5

The doctor must have VALID consent in that the patient understands the broad nature of the procedure and then agrees to it
Note: a written consent form is not proof of valid consent, it is supporting evidence

Question 6

Does a patient need to be harmed by a procedure to claim damages if battery is proved?

Answer 6

No

Question 7

What are the different types of consent?

Answer 7

Explicit; written + verbal

Implicit

Question 8

What 3 elements comprise valid consent?

Answer 8

1. Competence/capacity
2. Information
3. Voluntariness
   (attempts should generally be made to maximise quality of consent via these elements)

Question 9

How should decisions be made as a process for patients with capacity?

Answer 9

Dr + patient assess condition taking into account medical history, views, experience + knowledge -> Dr uses specialist knowledge, experience + clinical judgement along with patients views/understanding of condition to identify which investigations/treatments are likely beneficial -> Dr explains options to patient giving benefits, risks, burdens + side effects including option for no treatment -> Dr may recommend option but not pressurise -> patient weighs up all this information as well as any non-clinical issues with relevance to them -> can chose any option or decline treatment for whatever reason they chose

Question 10

How is capacity assessed?

Answer 10

Assessment must be based on ability to make a specific decision at the time it needs to be made thus, a person is unable to make a decision if they cannot do 1 or more of the following:

• Understand information given to them that is relevant to the decision
• Retain information long enough to make the decision
• Use/weigh up information as part of decision-making
• Communicate decision by any means

Question 11

In terms of capacity, what assumption must doctors work on?

Answer 11

That every adult patient has capacity to make decisions so do not make assumptions because of someones age, disability or communication difficulties (may just need extra support) - capacity can be decision-dependent

Question 12

Why providing a patient with information for informed consent, what must be taken into consideration?

Answer 12

Patients needs + wishes
Their existing knowledge of condition/treatment
Nature of their condition
Complexity of treatment + nature/risks associated with it
- consent needs to be sufficiently informed but information provision should be tailored to specific patients + situations so some routine situations may require very little

Question 13

What is the appropriate information to give to patients based on GMC guidance?

Answer 13

Diagnosis/prognosis
Potential risks/benefits
Alternative treatments (option not to treat)
(will depend on whether patients wants or needs it - more information does not = better quality consent)

Question 14

What case occurred to bring up the issue of the appropriate information provision to give to a patient?

Answer 14

Montgomery V Lanarkshire Health Board in 2015 where a woman was first pregnant with short stature + insulin dependent diabetes
There is a risk of shoulder dystocia in women with diabetes + a small risk of hypoxia leading to cerebral palsy or death
At 36 weeks patient expressed concern about size of baby and vaginal delivery
Reassured by obstetrician but was not told about risks mentioned + complications occurred

Question 15

What is the Montgomery judgement?

Answer 15

If a reasonable person would like to know if that patients position some information or if the particular patient would attach significance to it, it should be told to the patient by the doctor in an understandable way

Question 16

What is voluntariness?

Answer 16

Consent given freely without coercion
Some patients may be under pressure from employers, relatives or insurers and if there is suspicion of this, efforts should be made to speak with patient regarding decision

Question 17

What 4 types of coercion exist?

Answer 17

1. Explicit (outright forced)
2. Implicit (more subtle)
3. Power differentials in patient-doctor relationship (some things said by doctors may be taken as coercion due to power-differentials in relationship)
4. Pressure from family

Question 18

What are the 3 different forms of consent?

Answer 18

1. Implicit via compliance i.e. patient rolls up arm to have BP taken
2. Oral (low risk procedures) - conversation is recorded in notes
3. Written (complex high risk procedures)

Question 19

When should written consent be taken?

Answer 19

• Complex higher-risk interventions
• Significant consequences for patients employment, social or personal life
• If clinical care if not primary aim of investigation/treatment
• If treatment is part of research study
• Some specific treatments e.g. fertility treatment due to large consequences

Question 20

Why does a signed consent form not mean that consent is valid?

Answer 20

Patient could have:
- Lacked capacity
- Not been provided with sufficient understandable information
- Not given consent voluntarily i.e. been coerced
So written consent is simply evidence of consent, not valid informed consent - must document significant aspects of consent conversation to prove valid informed consent

Question 21

Who should take consent?

Answer 21

Either the doctor undertaking an investigation/treatment
OR
Someone else who is suitably trained/qualified, has sufficient knowledge of proposed investigation/treatment understanding the risks + who understands/agrees to act in accordance with GMC guidance

Question 22

Who is responsible for consent in history taking and using patient information?

Answer 22

The person who will take history/use patient information INCLUDING medical students

Question 23

What are potential obstacles to informed consent?

Answer 23

• Poor information/time pressure during information provision
• Being rushed into decision making
• Being pressurised by third parties

Question 24

How can you ensure as a doctor that consent avoids any potential obstacles?

Answer 24

By providing adequate information
Provide alternatives sources of information e.g. other members of healthcare team or information booklets
Give patient time and space to decide where possible
Talk to patient along to establish whether there are any external pressures if concerned + identify potential solutions

Question 25

What would you do in terms of consent in emergency situations?

Answer 25

You can treat without consent if they are unable to consent providing treatment is immediately necessary to save life or prevent serious deterioration

Question 26

What can you do in terms of consent when there is a language barrier?

Answer 26

English-speaking relatives often act as interpreter for non-English speaking patient but there is no certainty that information is translated accurately so should fine independent interpreter if possible if you need to explain complex + important information