Consent ( Summary from RCOG Clinical Governance Advice)
The key principles for consent to be valid are:
1. The patient must have capacity to make an informed decision:
- considered competent to give consent
- able to understand information provided
- can communicate their decision.
2. Consent must be provided voluntarily:
- In most cases the decision to provide or withhold consent should be by the patient themselves.
- The patient should not be coerced or influenced by carers, family or friends.
3. The patient should be fully informed of the following by carers with enough time allowed to reflect and ask questions:
- benefits and risks of the intended procedure
- alternative management strategies
- implications of not undergoing the proposed treatment.
Who should take consent- taking consent can be appropriately delegated ( GMC) . Ideally to be taken by the person performing the procedure, or by someone competent to perform the procedure.
Some possible scenarios-
1. In patients whose first language is not English,
consideration should be given to the provision of an approved translation service. ( Relatives/friends may be useful in urgent situations but use of a translation service ensures that the patient has received an unbiased interpretation of the doctor’s explanation.)
2. Any person aged 18 or more can give consent ( unless there is an issue with Mental capacity/Competence) .
Although 16- and 17-year-olds and minors under the age of 16 may have the right to consent
to treatment, they do not necessarily have the same right to withhold consent. Refusal of treatment may be overridden by parental consent, or the courts, however each case should be considered individually.
3. VAGINAL EXAMINATION-
Presence of a chaperone is considered essential for every pelvic examination.
Verbal consent should be obtained in the presence of the chaperone who is to be present during the examination and recorded in the notes.
4. If the patient declines the presence of a chaperone- explain that a chaperone is also required to help in many cases and then attempt to arrange for the chaperone to be standing nearby within earshot.
Document - the reasons for declining a chaperone and alternative arrangements offered.
5. Unexpected pathology- it is unwise to proceed with any additional surgical procedures without discussing them with the woman, even if this means a second operation, unless clear boundaries about additional procedures are documented by the carers prior to the procedure.
6. Unexpected ovarian pathology detected at time of hysterectomy -oophorectomy should not normally be performed without previous consent.
7. UNEXPECTED PREGNANCY- All reasonable steps should be taken to exclude pregnancy before surgery.
Unexpected pregnancy at time of hysterectomy ( even if hysterectomy is being done for cancer)- the operation should be rescheduled.
8. An unexpected ectopic pregnancy at time of surgery- should be removed.
9. A potentially viable pregnancy should not be terminated without the woman’s consent and following the processes outlined in the 1967 Abortion Act.
10. Sterilisation- If a procedure that will permanently remove her fertility, and there is any doubt about a woman’s mental capacity to consent- seek legal input from within the healthcare organisation/ seek opinion from court.
11. Ultrasound examination- Written consent for ultrasound screening is not currently considered necessary.
12. Termination of pregnancy in age less than 16- If Gillick competent, can give consent to undergo medical or surgical
termination of pregnancy.
13. Age less than 16 seeking Contraception- Apply Fraser guidelines.
14. Advance decision that has been made in compliance with the Mental Capacity Act, and the decision refuses life-sustaining treatment - Should be respected.
15. Woman unable to give consent- Unless prior formal arrangement has been made for any person to take decision, next of kin cannot take decision.
16. If a woman lacks mental capacity to consent --> appropriate dialogue with family, carers and multidisciplinary team should be done. If there is differenc of opinion about her best interests , and the differences cannot be resolved satisfactorily --> consult experienced colleagues ( where appropriate , seek legal advice/ including applications to the court)
17. If doctors decide to apply to a court- as soon as possible, inform the woman and her
representative of any decisions and of her right to be represented at the hearing.
18. If images ( laparoscopy , ultrasound, X ray) may be used for education or teaching, then written consent must be obtained and the use must not be wider than that to which consent has been given.
If the woman will be recognisable from the image, this must be made clear to her before she gives consent.
19. Presence of Students- Explicit consent of women is required - during gynaecological and obstetric consultations
in operating theatres as observers and assistants
performing clinical pelvic examination.
20. Pelvic examination of anaesthetised women by medical students- written consent must be obtained.
1. Link to the RCOG Clinical Governance Advice
2. Link to a Trust Guideline on Management of Persons Refusing Blood and Blood Products ( e.g Jehovah's witnesses) ( Also has information on Mental Capacity act in reference to Consent) - Click here
3. Take a Quiz on a Consent Scenario - Click Here
Disclaimer
