Consent

Dr Lisa Joels MD FRCOGRoyal Devon &Exeter NHS Trust

November 2011

© Royal College of Obstetricians and Gynaecologists

Consent

• Fully informed consent

• The Mental Capacity Act

• Consent relating to family planning issues

Consent – legal issues

• English civil law – deliberately touching another person without their consent is battery

• Civil action for negligence for not receiving enough information about a procedure – especially related to risk

Types of consent

• Tacit – e.g. You tell a patient you want to take a blood test

and she holds out her arm and stays still

• Verbal– E.g. You ask if you can do a vaginal examination

and she says yes

• Written– For all invasive procedures, those involving risk

and those needing anaethesia

Principles of consent

• That it is fully informed• That it is taken at an appropriate time• That respect is paid to the patient’s dignity &

beliefs • That it is freely given without coercion• That the person has capacity to consent

Fully informed consent• You must ensure that she understands:– The nature of the condition for which the

procedure is proposed– The nature of the intervention or procedure– The intended benefits and likely outcome– The risks of the procedure– Alternative treatments– The risk of not having the procedure

• Document any procedures she would not agree to have

Good medical practice

• Courtesy, respect for dignity and beliefs• An appropriate time– “cooling off” period

• Appropriate language– Clear, simple language– Avoid medical jargon– Use examples

Expressing frequency

• Very common 1/1 to 1/100 A person in family

• Common 1/10 to 1/100 A person in street

• Uncommon 1/100 to 1/1000 A person in village

• Rare 1/1000 to 1/10,000 A person in small town

• Very rare Less than 1/10 000 A person in large town

Consent freely given

• Try to ensure that patient is free to express her own free will– Avoid using family members as interpreters– Try to see woman on her own to explore her true

feelings

Specific issues• Screening• Sterilisation• Fertility treatment– HFE Act 1990 & Code of Practice

• Consent in labour if distressed, in pain or had opiate analgesics

• Students• Human Tissue Act– Retention and disposal of human/fetal tissue

• Multimedia

Capacity to consent

• The patient must be able to:– Understand information– Retain information long enough to make decision– Weigh up available information– Communicate their decision

• Must provide information in a way the patient can understand– Braille, sign language, interpreters, simple

language

Mental Capacity Act 2005

• 5 key principles – Presumption of capacity– Every effort must be made to support the patient

making their own decisions– Right to make own (even unwise) decisions– Best interests– Least restrictive of human rights

Mental Capacity Act 2005

• Lasting Powers of Attorney– The patient makes a legal declaration while they

have capacity nominating the person who will make decisions on their behalf when they lack capacity

• Independent Mental Capacity Advocate– Appointed by courts to act in the patient’s best

interests

Girls under 16 years old

• Fraser competency– Girls aged 12 -16 years may be able to consent

without parental knowledge, e.g. for contraceptive or termination services, providing they have capacity

– Able to understand the options and implications of their decision

– Able to weigh up the information and make a decision

Four consent forms• Form 1– Consent by the patient – general or local anaesthetic

• Form 2– Consent by parent for child under 16

• Form 3– Consent by patient/parent where no anaesthetic

needed (optional)

• Form 4– Consent for adult without capacity to consent

The exam

• Consent may come up written or OSCE exam– Counselling a patient– Awareness of need to see patient on her own– Specific items to discuss in consent for sterilisation– Consent in girls under 16 requesting contraceptive

or termination services

Further reading

• www.rcog.org.uk– Consent series: specific guidance about key

obstetric and gynaecological procedures

• Clinical Governance Advice 6 – Obtaining valid consent (Dec 2008)

• Mental Capacity Act 2005• General Medical Council• British Medical Association