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Consent (Making decisions (Must provide (Unicertainties, Options,…
Consent
Making
decisions
Must
provide
Unicertainties
Options, including no tx
Diagnosis and prognosis
Purpose of proposed
investigations/management
Benefits, risks of treatment
Tx part of research/innovative
Rights of patient to refuse
teaching/research, or get 2nd opinion
CIs (self and trust)
Tx that another organisation can
offer that may be more beneficial
Any bills
Do not
assume...
Info wanted/needed
Factors important to the patient
Patient knowledge/understanding
Sharing
information
Patient knowledge
Nature of condition
Patient needs and wishes
Complexity of treatment
Nature and risks of treatment
Questions
Honest
Fully as needed
When to not
share info
Pt has capacity
Important to understand options
and what treatment will involve
Free to involve family etc to aid
If don't want any info, explain
consequences e.g. non valid consent,
can change mind if needed
Do not withold by family request
unless you think it would cause serious harm
If withold, record reasons,
regularly review and reassess
How to share
In a way patient can understand,
at best time and place for them to understand
Give distressing info in a considerate way
Involve other members of team as needed
Give patient time to reflect before and after decision
Inform patient if there is a time limit to the decision,
and who to contact with any questions
Provide info in a balanced, unbiased way;
give reasons for recommending any treatment
Supporting material (written, visual etc.) must be
accurate and up to date
Check if patient needs any additional support
to understand the information
Involve family if patient wishes to
Obstacles
Limited resources
Patient with additional needs
Time pressure
Responsibility
for consent
Sufficient knowledge of the investigation/
treatment, including risks
Understands and acts per GMC guidance
Suitably trained and qualified
Ensure anyone you delegate to has these qualities
Discussing risks
Always disclose common but minor and rare but serious AEs
Consider patient condition and likelihood
of adverse event occurring
SEs, complications, treatment failure
Establish patients concerns and worries
Give information in a balanced way (risk/benefit)
Simple language and check understanding
Keep up to date with risks
Making decisions
Voluntariness
Pressure from employers, insurers, relatives
Vulnerable patients e.g. care homes, mental health patients,
under police or immigration services, prisoners
Ensure patient has considered information
and made their own decision
Future events
Discuss potential future problems where
patient may not be in a position to decide
Seek their views on how they would like
it to be dealt with
Scope
Treatment in stages
HCPs involved
Number of investigations/treatments
Diagnostic uncertainty
Check if patient agrees with all or part of the plan
Only exceed the scope of authority from
a patient in an emergency
Respecting decisions
Can refuse an investigation or treatment
Respect choice even if it seems irrational
Explain concerns and consequences, but
do not pressurise patient
Expressing consent
Beforehand, consider have they been given all
information and have they understood it
Methods
Implied
Minor/routine investigations/treatments
Oral
Minor/routine investigations/treatment
If written not possible e.g. emergency
Written
Investigations with higher risk
Investigations required by law e.g. fertility treatment
Consequences for employment, social or personal life
Clinical care is not primary purpose of the investigation/treatment
Part of a research programme/innovative treatment
Recording and
reviewing decisions
Recording
Medical records or consent form
Include information discussed, patient requests,
information given, decision made
Reviewing
Check patient still wants to go ahead pre-procedure
Especially if time has passed, changes to condition, changes
to investigation/treatment, new info available
Information to patient at all stages with regular review
Children and
young people
Involve as much as possible in
discussions, even if no capacity
Young person <16y may have capacity depending
on maturaty and ability to understand
Assumed to have capacity at 16 to make decisions
Advance care
planning
Suitable patients
Condition affecting length/quality of life
Condition affecting capacity
Loss of capacity is a forseeable possibility
Discussions
Wishes, beliefs, values, preferences and fears
Treatments they would refuse and únder
what circumstances
What they may want for themselves in
event where they can't make own decision
Relatives/friends they want to be involved
Emergency interventions e.g. CPR
Discuss sensitively, include other HCPs as needed
Record discussion and any decisions made,
available for patient and others involved
Review and update as the situation and
patients views change
Capacity
Presumption of capacity
Presume all adults
have capacity
Regard as not having capacity once
clear that unable to understand, retain, weigh up,
or communicate their decision
Don't assume lack of capacity based on age, disability,
behaviour, medical condition, mental illness, beliefs,
apparent inability to communicate, make a illogical decision
Maximising ability
to make decisions
Fluctuating conditions, type of decision
(may be able to make simple but not complex decisions)
Time and support, maximise ability to make decision
Forsee changes in
patients condition
Provide aids to remember e.g. partner/family
present, written information, audio info
Speak to family and HCPs about best way to
communicate with patient (care with confidentiality)
Discuss options in place/time
when patient best able to understand
Record decisions; advance refusals must be
recorded, signed and witnessed
Legality
Mental Capacity Act 2005
Criteria and procedures to follow
when a patient lacks capacity
Grants legal authority to
certain people to make decisions
Assessing capacity
If unsure, seek advice from HCPs and family
on patients usual ability and communication needs
Consult colleagues about specialist communication
needs e.g. SALT, psychiatry, neurology
Relating to the particular decision
at the particular time
If still unsure, may need legal advice
Making decisions when
patient lacks capacity
Treat as individual and respect dignity
Support patients to be involved in decisions
Care of patient first concern
Treat with respect
Consider if lack of capacity
is temporary or permenant
Options providing overall benefit to patient
Option least restrictive of patient future choices
Evidence of previous prefs from patient,
views of family, or those with legal authority e.g. LPAs
Patient's known wishes, feelings, beliefs, values
Resolving disagreements
Seek to reach consensus
HCPs, family, etc.
Discussion with experienced colleagues,
case conference, mediation services,
legal advice (court/statutory body)
Emergencies
If not possible to get patient's
wishes, you can treat without consent
Treatment must be immediately needed to save life
or prevent serious deterioration
Must be least restrictive of patients future choices
Once regain capacity, inform what
has been done and why
Principles
Pt w/o capacity
Work with those close to the patient
and other medical team
Views and preferences previously
expressed by the patient
Dr-pt partnership
Info on diagnosis, prognosis, treatment
Share wanted/needed info
Listen and respect views
Max ability to decide themselves
Pt with capacity
Assess condition and pt views
Identify investigations and treatment
likely to benefit patient and explain these
Patient weighs up to conclude
If patient requests an unsuitable option, discuss,
but ultimately do not have to provide
Apply to all decisions about investigations
(including screening) and care