Principles of Surgical ConsentDr Felicity V Connon

Surgical HMO

Dr Felicity V Connon

Surgical HMO

Why Consent?

Manifestation of respect and protection of patient autonomy

Rogers vs Whitaker

Chester vs Ashfar

Process not an event

“Informed consent” is a legal obligationNo consent = assault/clinical negligence

Process of Informed Consent

Does an intervention require consent?Yes

Invasive procedures – done awake, LA, GA

NoMinor procedures eg. IVC, IDC, NGT verbal

Prove/ be satisfied with capacity

Obtain consentProvide appropriate information

Allow them to make the decision coercion is not acceptable

Record consent

Presenting Information

Information that must be provided:The purposes and details of the Ix/procedure

Details/uncertainties of the diagnosis

Options for treatment and the likely prognosis (including the option not to treat)

Explanation of the likely benefits and risks and of probabilities of each

That the patient can change their mind at any time

Answer their questions

Formal Evidence of Consent

Consent Form

Progress notes

Signed consent/written consent is mandatory for legal reasons in hospitals in Australia.

Written evidence of consent = medical indemnity

Capacity

The patient must be able to:Comprehend the given information

Retain the information

Appreciate the nature and purpose of their treatment and the consequence of giving or refusing consent

Consider the information rationally to arrive at a decision

The assumption is normally made that adults have legal capacity

If they do – no other consent needed

Difficult = children, mentally incapable, emergencies

Children

If the child is under age or lack capacity, parents have (joint) legal authority to make treatment decision.Mature minors

Gillick competence

Parental refusal can be overridden by court order if not in child’s best interests (child protection legislation)

Emergencies

May treat without consent if:Injury is life-threatening or poses severe imminent threat to the patient’s health

The patient is not able to give consent and and a substitute is not readily available

Mentally Incapable

Impairment may be temporary or permanentAssessment of capacity is functional - specific to issue in questionNot automatically lacking capacity because of diagnosis (eg. dementia, psychosis, etc. )Refusal of treatment others see as beneficial or necessary does not imply incompetenceTesting:

NeuropsychPsychiatry

Options

Chase the hierarchyEPOA

A person/guardian appointed by the Victorian Civil and Administrative Tribunal (VCAT) to make decisions about the proposed treatment

An enduring guardian with appropriate powers appointed by the patient

The patient’s spouse or domestic partner

The patient’s primary carer

The patient’s nearest relative over the age of 18

No responsible person Section 42K of the Guardianship and Administration Act 1986 to the Office of the Public Advocate (OPA).

Psychiatric issues Section 10 (MHA)

Medical Executive

References

Consent in Surgery, Review, R.Wheeler, Annals of the Royal College of Surgeons England (2006) 88: 261-264

A Review of Surgical Informed Consent: Past, Present and Future, Leclercq et al, World Journal of Surgery, (2010) 34: 1406-1415

RACS Informed Consent Policy, Policies and Procedures Manual, Fellowship and Standards Division