Consent: patients and doctors making decisions together

Introduction

Consent is a crucial theme in modern day practice. Put simply, for a patient to consent to treatment they must give permission before they receive any type of medical treatment, test or examination [1]. Guidance for consent has been informed by high profile legal cases. One prominent example is the case at Bellshill Maternity Hospital, where a diabetic lady who was not aware of all the potential risks of a natural birth, had a complication in pregnancy that led to her baby being deprived of oxygen for a short duration, causing brain damage [2].

There are three key ideas that underpin the notion of consent. The patient’s consent must be voluntary, meaning the decision to give or not to give consent is made by the patient. The patient must be informed, where they are presented with relevant information to make the decision. Finally, the patient must have capacity- the ability to understand the information given to them and use it to make a decision.

For a patient’s consent to be voluntary, the doctor must not make the decision for them. So, even if the doctor does not agree with the patient’s wishes, as long as the patient is informed and has capacity, the doctor must respect the wishes of the patient even if they feel it’s unwise. This idea is relevant in circumstances such as when a Jehovah’s Witness refuses a blood transfusion.

It is the responsibility of the doctor to ensure the patient is informed with what they want to and need to know about their treatment. This usually entails telling the patient about the treatment options open to them, the nature of the risks associated with each treatment and what might happen if they do not accept any treatment. In order to do this to the appropriate standard, the doctor must give information in a balance way, avoiding bias. It is also important for the doctor to convey information in a way that the patient finds it easy to understand. For example, when communicating concepts such as risk associated to a treatment, some patients may want a risk in percentage to help them make a decision.

It’s worth noting that everyone is presumed to have capacity to make decisions unless it can be proved that they do not. When assessing the capacity of a patient, the doctor must determine if they have an impairment affecting the function of their mind. If they do, the physician must consider if the impairment if sufficient enough for the patient to lack capacity [3]. In other words, have they understood the information, can they retain it, weigh up the pros and cons and then communicate their decision. The patient must be able to do all of these.

The format of consent will vary depending on the patient and the treatment. Signed, written consent from patient is necessary if a treatment involves a significant risk. A prime example of this would be an operation [4]. In other situations (such as administering an injection) verbal sufficient is suitable. However, a signed consent form will never be proof that you have given the patient all the information they need to make an informed decision. It is therefore necessary to record discussions of treatments.

Involving patients in discussions about their care should always be done as much as possible, even when the patient is a child/young adult and not an adult. A young person’s ability to make decisions will depend on their ability to understand and weigh up treatment options rather than their exact age. As such, a fourteen year old may have capacity to make a decision. At sixteen, a person is presumed to have capacity to make decisions about their treatment [5].

Adhering to guidelines on consent is a cornerstone of good practice as a doctor. Treatments and the demands of patients may change, but putting the patient at the heart of the decision making process and ensuring they have the information needed to do this will not.

Links

1. http://www.nhs.uk/Conditions/Consent-to-treatment/Pages/Introduction.aspx
2. https://www.supremecourt.uk/decided-cases/docs/UKSC_2013_0136_PressSummary.pdf
3. https://www.bma.org.uk/advice/employment/ethics/consent/consent-tool-kit/5-assessment-of-competence
4. http://www.gmc-uk.org/guidance/29457.asp
5. https://www.bma.org.uk/advice/employment/ethics/children-and-young-people/children-and-young-peoples-ethics-tool-kit/4-consent-and-refusal