CONSENT TO MEDICAL TREATMENT

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CONSENT TO MEDICAL TREATMENT

• Dr Peter Jefferys
• Northwick Park Hospital, London
• 11 July 2001

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Aims

• Examine consent process
• DoH guidance
• Relevant case law
• Understand medical perspective
• Mental Health Act
• Challenges

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Key references

• DH
• Reference guide to consent Mar 2001
• 12 key points on consent - Apr 2001
• MHAct Code of Practice 1983 (1999)
• GMC
• Seeking patients consent (1998)
• Protecting patients, guiding doctors (2000)

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Definition

• Agreement to an action based on what the action
  involves and its likely consequences (GMC 2000)
• Valid consent
• given voluntarily
• appropriately informed
• capacity to consent to specified treatment

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Seeking consent

• Does patient have capacity?
• Take in information
• Retain
• Consequences
• Believing
• Weighing up
• Specific to treatment proposed

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Alteration of capacity

• Temporary
• confusion
• panic
• shock
• fatigue
• pain
• medication

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Irrational decisions

• Warning - unreasonable or irrational decisions
  may be valid
• unusual value system
• OR
• misperception of reality
• e.g. patient denies foot gangrenous - unable to
  comprehend use relevant information

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Consent given voluntarily?

• Freely
• without pressure or undue influence
• health
• care professionals
• partners
• family members
• others
• Interview alone

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Sufficient information?

• Understand - broad terms
• nature purpose of procedure
• case law Bolam test - post Sidaway
• courts final arbiter of responsible practice
• ensure patient makes balanced judgement
• Court of Appeal advice - inform patient of
  material or significant risks
• which would affect judgement - reasonable pt

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GMC and information

• Find out - individual needs priorities
• Truthfully answer specific questions -procedure
  risks
• Withholding exceptional - justify
• Record when information declined
• Change with time
• Always provide basic information

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Who seeks consent?

• Best for person actually treating patient
• Delegation to another health professional
• only if capable of performing procedure
• or specifically trained to seek consent for that
  procedure
• Clinicians know competence limits

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When and how?

• Seeking giving consent - a process
• Best sought well in advance
• Consent can be written (Trust policy)
• oral
• non-verbal
• New forms planned (DH)

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Consent Process

• Explain yourself
• What do they know?
• Agree clinical story
• Tailor information (leaflets)
• Check understanding
• Anything else?
• Record process

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Explaining

• What is wrong
• what will happen
• outcome
• choices
• variations / alternatives
• complications risks
• right of refusal

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Children young people

• Parental consent for young child
• Assess understanding
• Seek consent if Gillick competent
• Inform parents if under 16
• Parental / court over-ride if refusal 16/17
• Responsible adult issues

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Incapacity?

• Check communication (informant)
• language / culture / hearing / speech
• Observe behaviour / mental state
• lucid moments?
• Previous wishes / intentions
• best interests?
• Be patient - second opinion

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Confidentiality carers

• Carers expect involvement
• get permission first
• explain to carers
• carers cannot consent
• seek support for plan
• keep carers informed
• conflict of interest

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Moving goal posts

• Higher Bolam test
• High Court directives for incapable
• Case law post Human Rights Act
• Advance directives legal
• Statute changes ahead
• Incapacity law
• New Mental Health Act

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Part IV Mental Health Act 1983

• Treatments for mental disorder only
• Detained patients only (ex s57)
• Assumption of competence
• Urgent treatment provision
• Second opinion process
• refusal or incapable
• High concurrence rate

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Section 58 in practice

• Limited use of leaflets
• Scrappy treatment plans
• Consent discussion rarely recorded
• Compliance poorly monitored
• Paternalism rules OK
• Patchy negotiation skills

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Challenges for clinicians

• Consistent procedures
• Core information
• Communication skills
• Capacity assessment
• Consumer / carer demands
• Court expectations
• Clinical resources