The fundamentals of consent
The GMC guidance, Decision making and consent, came into force last year and includes a set of seven fundamental principles that underpin consent. It is important to be familiar with the seven principles.
While the principles hold true for every interaction, the GMC expect doctors to take a proportionate approach. What this means in practice is that seeking consent need not be a complicated or time-consuming process when you are asking about a simple procedure or interaction.
For example, it is not necessary to go into a detailed consent discussion when asking a patient if you can take their history or take their blood pressure – as long as the patient knows the fundamentals such as who you are and why you are asking, and that they are not under pressure to agree. Consent discussions before more complex interactions, such as intimate examinations or surgical procedures, will necessarily be much more detailed.
Signing a consent form
Using this fictional example, we’ll look at the importance of dialogue when consenting patients.
A trainee surgeon had undertaken several excisions of lipomas, with and without supervision, and was confident seeking consent for the procedure. A male patient attended with a lipoma on his upper chest wall. The doctor warned the patient about potential complications such as wound infection and scarring, the patient signed a consent form and the procedure went ahead.
A few weeks later the patient complained that he had not been told how big the scar would be or that there was a possibility of keloid scarring. He said that the large keloid scar was worse than the lipoma and was making it impossible to continue his interest in being a body builder and social media influencer.
Dialogue leading to a decision
Although consent forms can be an important part of the consent process, a signature on a form is not enough. In this case the patient had signed a consent form that listed ‘scarring’ as a complication but he said that he had not been warned how extensive that scarring might be.
The GMC guidance is clear that an effective exchange of information between a doctor and patient is central to good decision making. The doctor should not only give the patient relevant information about the proposed treatment and options, but should tailor the conversation to take into account what matters to the patient. This means that the doctor must listen to the patient and encourage questions.
As well as telling the patient the information that he or she might reasonably expect to be told (such as recognised risks of harm), the doctor should also try to find out what matters to the patient and what information about the options for care might influence their choice.
In this scenario, the doctor had not found out about the patient’s interest in posting pictures on social media and had not realised what an impact scarring might have on him. In addition, the doctor had not found out the family history of keloid scarring. If the doctor had discovered this, it might have helped tailor the discussion of risks and find out what risk the patient might have been willing to accept.
The GMC guidance is clear that an effective exchange of information between a doctor and patient is central to good decision making.
On a practical level, it’s important to take time for discussion with patients and make a conscious point of avoiding assumptions about what your patient might want or need to know or what factors or outcomes they might think are significant. Make sure you ask enough questions to help you understand your patient’s priorities and what they personally might need or want to know, over and above the risks and benefits that anyone would want to know about. Keep a thorough record of your discussion, not just the signature on the consent form.
Working within your capabilities
As a junior doctor, remember that you should seek consent for procedures only if you are satisfied that you have the right knowledge and skills. If you do not, you should explain this and seek support and supervision or training before agreeing to go ahead.
If you are confident in your ability to seek consent but just lack enough time for discussions with patients, consider whether other members of the team might play a part or whether there are other sources of information and support that could be useful. But if you are concerned that you are not competent to seek consent, or that lack of time or resources compromises the ability of patients to make informed decisions, you must consider raising a concern.
The circumstances that affect the decision-making process when taking consent
Using this fictional example, we’ll look at some of the situations which can affect how you approach consent with patients.
A junior doctor was caring for an elderly patient on the ward who spoke very little English. The patient had been admitted with severe anaemia and was being investigated for possible lymphoma – the next planned investigation was a trans-thoracic mediastinal biopsy. The patient’s daughter said that her father did not really understand what the test was and why he needed it. She said he wanted to go home now and that he was feeling better after a blood transfusion.
The doctor had an initial discussion with the patient and his daughter. Having established that the patient usually felt clearer in the mornings, the doctor made an arrangement to come back the next morning with the consultant to have a full discussion and also arranged for an interpreter to be present. The daughter asked if that discussion could be recorded and, as the patient seemed keen on this to keep his other family members updated, the doctor agreed.
The doctors prepared for the meeting by finding some relevant pictures and patient information leaflets in the patient’s language to support the discussion. After the discussion, the doctors concluded that the patient had mental capacity and had provided consent for the biopsy. A further discussion was planned, with the interpreter present, for a time when the biopsy results would be available.
This fictional example allows us to consider some of the following circumstances:
- Translation and communication: patients should, as in this scenario, be supported in their decision making. Patients often want to have a supporter with them during discussions but, if the patient requires an interpreter, it is better to use a translation service or formal interpreter rather than relying on a relative. It may be helpful to use pictures or other methods to provide information and to allow a patient to record a discussion if they wish.
- The scope of decisions: in this scenario, the doctors were seeking consent for an investigation that would probably be the first step in a complex pathway of care. It is always important to be clear about the scope of decisions so patients understand what they are consenting to.
- Looking ahead: it is also important to try to plan ahead and, where practical, anticipate circumstances when the patient might find it more difficult to make decisions. Give the patient information about possible future options so they have time and opportunity to think about what they would want.
- Mental capacity: you should not make assumptions about mental capacity but should be alert to signs that the patient might lack the mental capacity to make a decision at a particular time. In this scenario, the doctors concluded that the patient did have the mental capacity to make the decisions he needed to make at that specific time.
If they had been concerned that he might lack capacity, then they would have needed to make a proper capacity assessment and, if he lacked capacity, must do what was required in his overall benefit.
Other circumstances that affect the decision-making
- If you disagree with a patient: if your patient has mental capacity to make a decision then, whether or not you agree with their decision, you must respect their right to decide.
- In an emergency: remember that, even in an emergency, the consent principles apply but if a patient is unconscious or otherwise lacks capacity and you cannot find out their wishes you can provide immediately necessary treatment, choosing the option that is least restrictive of their future choices. As and when the patient has recovered enough to understand, you must tell them what has been done and why and discuss options for future treatment.