Informed decisions

TRAINEES are at the forefront of investigations and treatment in hospital. You may be undertaking your own investigations on a patient, performing a procedure under supervision or obtaining consent before a theatre list. In all of these instances, and many more besides, it is important to be aware of your professional (and legal) duty to obtain valid, informed consent. The importance of consent is perhaps best illustrated by considering what can happen when it is not obtained.

A failure of this kind can have an immediate impact on the doctor-patient relationship. A hospital stay can be a strange and unsettling experience for most patients and one that will only be made worse if they feel “left out” of the decision-making process involving their care. MDDUS is aware of many complaints made by patients who did not sufficiently understand their treatment, leading to a breakdown in communication and subsequent deterioration of the doctor-patient relationship.

Neglecting to obtain consent can also have more serious consequences. There is no special privilege conferred to the actions of a doctor in a hospital setting compared to the actions of members of the public in the community. Even touching your patient to examine them requires their prior consent. Significantly, an absence of such consent may leave you vulnerable to criminal allegations of assault or battery as well as a possible GMC investigation.

While the number of patient complaints relating to consent is relatively low, and the number of doctors facing criminal charges connected to consent lower still, it is something that should be kept at the forefront of every patient interaction. Bear in mind that for consent to be valid it must be:

• Informed – the patient must have been given sufficient information to make a decision
• Competent – the patient must have the maturity and mental capacity to make a decision
• Voluntary – the decision must be an expression of the patient’s free will.

What type of consent do you need?

Some doctors think of obtaining consent as a long and arduous process, involving paperwork and lengthy discussions with a patient and their relatives. In a busy hospital setting, however, it would be impractical to require written consent every time you wanted to take a simple blood pressure measurement. Equally, it would be inappropriate to rely solely on verbal consent for surgical procedures and other complex treatments. There is a balance you must strike, taking into account the nature of the procedure, the patient and your environment.

Consent can be express or implied. When it comes to simple interventions such as measuring blood pressure, implied consent is almost always sufficient and can usually be assumed when the patient co-operates with your request (i.e. rolling up their sleeve and presenting their arm). As with all forms of consent, the important issue is that the patient is aware of what you are doing, and why, before you start doing it. To avoid any doubt, it is useful to ask a question such as “do you mind if I check your blood pressure?”

Express consent is when a patient positively indicates their agreement through more than implication. It can be verbal or in writing. Determining whether you need to obtain written consent, or whether verbal will suffice, is very much dependent on the individual circumstances of your case. The GMC has provided some guidance to doctors in their booklet entitled Consent: patients and doctors making decisions together. This recommends that you should seek written consent in all but minor or routine investigations.

Who should take it?

Ideally, the person performing an investigation or treatment should obtain consent from the patient. However, trainees are often tasked with obtaining consent from a group of patients, for example before a theatre list or endoscopy clinic. In these circumstances, the doctor performing the actual procedure is delegating their responsibility to you. Before accepting a delegated task, you should ensure that you have the necessary knowledge, skills and expertise to perform it. If you think you are out of your depth, it is perfectly reasonable to say so and either obtain the relevant training or refer it to a suitable colleague. Remember a patient can only give you informed consent if you are able to provide them with all the relevant information and answer any questions they may have.

Who should you seek consent from?

Remember that no one else is able to give consent on behalf of a patient who has capacity. Some patients want to bury their heads in the sand and want you to speak to a friend or relative and have them make all the decisions. However, you should make it clear to these patients that you must give them a minimum amount of information to obtain their valid and informed consent. It is also a good idea to document carefully the nature of your discussion and the patient’s views. When should you take it? This very much depends on the nature of the procedure for which you are taking consent. For complex procedures, patients should be given time to absorb all of the information and have an opportunity to reflect upon it before giving you their decision. However, for procedures such as IV cannulation or arterial puncture, it may be reasonable to obtain consent at the time. As well as considering the nature of the procedure, you should also take into account the state of the patient. In order to be valid, consent must be given from a patient with capacity in the absence of any duress. If a patient is acutely unwell or distressed, and you do not need their consent urgently, it is worthwhile deferring it to a time when they are more settled.

Where should you take it?

You should also think carefully about the environment in which you obtain consent. Ideally, it should be free from interruptions and enable the patient to focus on what you are saying. You may want to see if there is a room available nearby or draw the curtains around the patient’s bed to minimise outside distractions. If possible, ask a colleague to hold your bleep to allow you to focus on your conversation with the patient. In addition to making sure the environment is suitable for you to obtain consent, consider whether the patient could benefit from having another party present. They may want to have a close friend or relative to support them and discuss things with afterwards. It is important to ensure that neither you, nor any third party present, exert undue influence over the patient’s decision. What should you say? The nature of your discussion with a patient will very much depend on the procedure. You should try and engage in an open and frank discussion, which enables the patient to feel involved in their care and to clarify anything that is unclear. Your discussion should include the purpose of the intended procedure, the risks and benefits, and the alternative options. Many hospitals have patient information leaflets for common procedures and you may find it useful to go through this with the patient and leave it with them to consider after you have left. As well as thinking about what you should say, think about the manner in which you say it. Most patients find hospitals an unsettling environment and may be quite anxious when you speak with them. It is therefore helpful to pause regularly and check they have understood everything as you go along.

Dr Naeem Nazem is a medical adviser at MDDUS