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Consent Training
For clinical community healthcare staff.
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Objectives
This programme has been developed to inform all health care professionals
and support staff, on the legal requirements for obtaining valid consent
before starting treatment, physical investigation or providing personal care,
for a patient, in line with Department of Health requirements.
Responsibility
A health care professional (including support staff) who does not respect the
legal and ethical principle for obtaining valid consent may be liable both to
legal action by the patient and action by their professional body.
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Overview
Patients have a fundamental legal and ethical right to
determine what happens to their own bodies. Valid
consent to treatment is therefore absolutely central in all
forms of healthcare, from providing personal care to
undertaking major surgery. Seeking consent is also a
matter of common courtesy between health professionals
and patients. Further guidance can be found on the
Department of Health Website at :http://www.dh.gov.uk/en/Publicationsandstatistics/Publicati
ons/PublicationsPolicyAndGuidance/DH_103643
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Obtaining consent
Obtaining consent is a mutual decision making process which is thorough
and in line with trust policies/procedures and legal consent processes.
Agreement
Context of Consent
“Consent” is a patient’s agreement for a
health professional to provide care. Patients
may indicate consent non-verbally (for
example by presenting their arm for their
pulse to be taken), orally, or in writing. For
the consent to be valid, the patient must:
The context of consent can take many
different forms;
• Active request by a patient of a particular
treatment (which may or may not be
appropriate or available)
• In some cases, the health professional
will suggest a particular form of treatment
or investigation and after discussion the
patient may agree to accept it.
• Passive acceptance of a health
professional’s advice.
• In others, there may be a number of ways
of treating a condition, and the health
professional will help the patient to decide
between them.
•
•
•
Have capacity to take the particular
decision; (refer to The Mental Capacity
Act 2005)
Have received sufficient information to
take it; and
Not be acting under duress.
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Decisions
Decisions must always
demonstrate that the patient’s
“best interest’s” are at the top of
the decision making process!!
Joint Decision Making
Some patients, especially those with chronic
conditions, become very well informed about
their illness and may actively request particular treatments. In many cases, “seeking
consent” is better described as “joint decision-making” the patient and health
professional need to come to an agreement on the best way forward, based on the
patient’s values and preferences and the health professional’s clinical knowledge.
Guidance
Where an adult patient lacks the mental capacity (either temporarily or permanently) to
give or withhold consent for themselves, no-one else can give consent on their behalf,
not even a relative, unless they have a valid lasting Power of Attorney or a Deputy
Appointed by the Court of Protection Guidance with reference to the; Mental Capacity
Act 2005 Deprivation of Liberty will need to be considered.
All staff must follow guidance in Policy MCP1 and MCP2 and associated procedures,
which are in line with the CQC’s regulatory framework and associated guidance and
Risk Management Standards.
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However!
“Treatment may be given if it is in their “best interests” as long as it has not been
refused in advance in a valid and applicable advance decision”
An example of this would be:An individual may need antibiotics for a urinary tract infection which may greatly
improve the quality of the patient’s life.
For further details on advance decisions see the Department of Health’s
Reference guide to consent for examination or treatment 2009 (chapter 1,
paragraph 19). Trust Policy Guidelines CLPG6 which can be accessed from the
Intranet library.
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Case study
 Mary is a 75 year old lady who lives in a local care home and has a diagnosis of
Lewy-Bodies Dementia. She is refusing to accept any pharmacological
interventions for the condition.
 Mary has always felt strongly about this and she has a valid and applicable
advanced decision that she has made in writing, when she had capacity stating
“that she never wanted to be treated with any medication for dementia, specifically
anti-psychotic medication or anxiolytics”.
 Her mother also had been diagnosed with dementia and had experienced “severe
reactions” to these types of medications in the past. Mary had cared for her
mother during the later stages of her condition and found these reactions
extremely distressing to witness; hence her strong wish “never” to be treated with
the same medications specifically in the later stages of her own condition.
 Mary is assessed as lacking capacity to make a decision in relation to accepting
and refusing medication for the treatment of her distressing symptoms. It is felt
that it would be in her “best interest’s” to give her these medications, as they may
alleviate or minimise the delusions and hallucinations she is continually
experiencing.
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When do Health Professionals need consent?
Who is the right person?
Before examining, treating or caring for a child, you must seek consent.
 Young people aged 16 and 17 are presumed to have competence to give consent for
themselves.
 Younger children who understand fully what is involved in the proposed procedure can
also give consent (although parents will ideally be involved) For Example: - Blood
transfusion or chemotherapy.
 In other cases where a child is not deemed competent, someone with parental
responsibility must give consent on the child’s behalf, unless they cannot be reached in
an emergency. For example: - A child falls in the playground and fractures their arm as
their circulation may be compromised they need urgent medical treatment in this case a
schoolteacher may be needed to intervene.
If a competent child consents to treatment, a parent cannot over-ride that consent an
example of this is an adolescent requesting contraception.
It should be noted however that there are very rare exceptions to this, and further
advice and guidance on this is available within the Consent Policy.
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Covering the Bases
Is Consent Voluntary?
“If a patient is not offered as much
information as they reasonably need
to make their decision, and in a form
they can understand, their consent
may not be valid”
Consent must be given voluntarily;
not under any form of
• Duress
• Undue influence from health
professionals, family or friends.
Refusals of treatment
Competent adult patients are entitled to refuse treatment, even where it would
clearly benefit their health.
Although the above statement is in the main true it should be noted that there are
exceptions to this rule;
• Where the treatment is for a mental disorder and the person is detained under
the Mental Health Act 1983
• A competent pregnant woman may refuse treatment, even if this would be
detrimental to the foetus.
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Advanced Refusal
If an incompetent patient has clearly indicated in the past, while competent, that they
would refuse treatment in certain circumstances (an advanced refusal Advanced
Decisions CLPG 6), and those circumstances arise, you must abide by that refusal.
All answers are based on information within appendix A of CLP 16 For further details,
consult the Reference guide to consent for examination or treatment, available from
the NHS Response Line 0541 555 455 and at www.doh.gov.uk/consen
Further Advice
Specific guidance, incorporating both the law and good practice advice, is available
for health professionals working with children, with people with learning disabilities
and with older people. Copies are available on the Trusts Intranet site (see clinical
governance/clinical effectiveness) and may also be accessed on the Internet at
www.dh.gov.uk/consent.
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Question
Competent adult patients are entitled to refuse
treatment, even where it would clearly benefit their
health.
FALSE
TRUE
Continue
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Documentation
For significant procedures, it is essential for health professionals to document
clearly both a patient’s agreement to the intervention and the discussions which led
up to that agreement. This may be done either through the use of a consent form
(with further detail in the patient’s notes if necessary), or through documenting in
the patient’s notes that they have given oral consent.
Considerations
Consent maybe incorrectly equated with a patient’s signature on a consent form.
A signature on a form is evidence that the patient has given consent, but is not
proof of valid consent.
If a patient is rushed into signing a form, on the basis of too little information, the
consent may not be valid, despite the signature.
Similarly, if a patient has given valid verbal consent, the fact that they are physically
unable to sign the form is no bar to treatment.
Patients may, if they wish, withdraw consent after they have signed a form: the
signature is evidence of the process of consent-giving, not a binding contract.
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Written Consent
It is rarely a legal requirement to seek written consent, (The Mental Health Act 1983
and the Human Fertilisation and Embryology Act 1990 require written consent in
certain circumstances) but it is good practice to do so if any of the following
circumstances apply;
The treatment or procedure is complex, or involves significant risks (the term risk. is
used to refer to any adverse outcome, including those which some health
professionals would describe as side-effects. or complications.)
The procedure involves general/regional anaesthesia or sedation providing clinical
care is not the primary purpose of the procedure
There may be significant consequences for the patient’s employment, social or
personal life
The treatment is part of a project or programme of research approved by this Trust.
Consent will always be sought if examination or treatment of an intimate nature is
required i.e., Smear Test or Enema or Suppositories
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Trust forms
 Completed forms must be kept with the patient’s notes.
 Any changes to a form, made after the form has been signed by the patient,
should be initialled and dated by both patient and health professional.
 Forms can be located in the appendices of CLP16.
 It will not usually be necessary to document patients consent to routine and
low-risk procedures, such as providing personal care or taking a blood
sample. HOWEVER ASK YOURSELF.......
 If any of these are the case then it would be helpful to do so!
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Procedures
 Procedures to follow when Patients lack capacity to give or withhold consent
 Where an adult patient does not have the capacity to give or withhold consent
to a significant intervention,
 This fact should be documented in form 4 (for adults who are unable to
consent to investigation or treatment CLPG16)
 Along with the assessment of the patient’s capacity, why the health
professional believes the treatment to be in the patient’s best interests,
 Involvement of people close to the patient.
 The standard consent forms should never be used for adult patients unable to
consent for themselves.
 For more minor interventions, this information should be entered in the
patient’s notes.
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Question
Where must completed forms be kept?
In an office
In a safe
With the patients
notes
Placed in the ‘in’
tray
Continue
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Lack of capacity
An apparent lack of capacity to give or withhold consent may in fact be the result
of communication difficulties rather than genuine incapacity.
You should involve appropriate colleagues in making such assessments of
incapacity, such as specialist learning disability teams and speech and language
therapists, unless the urgency of the patient’s situation prevents this.
If at all possible, the patient should be assisted to make and communicate their
own decision, for example by providing information in non-verbal ways where
appropriate.
Information disclosed will vary from each patient, relatives and carer’s, some
require comprehensive information, including rare risks, to some who ask health
professional to make decisions on their behalf. Sound clinical judgment is required
in determining the information given.
However, the presumption must be that all patients will be treated with the upmost
respect and all information will be imparted allowing the patient to make an
informed decision.
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The following sources of patient information are available in this Trust:
 Ward and service leaflets
 Touch screen information kiosks,(the touch screen Information Kiosks in Essex
provide web links to many on-line sources of information)
 In addition, the PALS Service (Patient Advice and Liaison Service) and NHS
Direct can assist patients to access more detailed information.
 Written fact sheets on common mental health conditions and drugs
For example;
All written information can be translated on request, or made available in large print,
braille or recorded onto tape or CD. Departmental managers or the PALS will advise of
all local advocacy services.
A provision for patients where English is not their first language; This Trust is
committed to ensuring that patients whose first language is not English receive the
information they need and are able to communicate appropriately with healthcare staff.
It is not appropriate to use children to interpret for family members who do
not speak English.
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Useful Contacts
For interpreting and translation services please contact:Essex Interpreting Service on 01375 842244
Bedfordshire and Luton: Milton Keynes community Language
Service on 01908 253253 or www.milton-keynes.gov.uk
/community language service
The information contained in the consent policy can also be
produced in other formats on request. Please contact the
Communication Department at Pride House
Further Considerations
The Human Rights Act 1998 Article 2
Protection of right to life Article 3
Prohibition of torture and inhumane or degrading punishment Article 5
Right to liberty and security Article 9
Freedom of thought, conscience and religion
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Responsibility of Health Professionals
It is a health professional’s own responsibility to: To adhere to Trust policies and Procedures at all times.
 Adhere to professional codes of conduct
 To ensure that when they require colleagues to seek consent on their behalf
they are confident that the colleague is competent
 To work within their own competence and not to agree to perform tasks which
exceed that competence.
 If you feel pressurised to seek consent, when you do not feel competent do so.
You must contact your line manager immediately for advice.
 Ensure where possible that professionals adhere to Multidisciplinary Team
working.
 Keep clear, concise and up to date records
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Remember, if you want to find more information / evidence
about this subject or anything else which is relevant to your
work or study, join your local healthcare library.
For staff in Essex contact Basildon Healthcare Library.
www.btuheks.nhs.uk
[email protected]
01268 524900 EX3594
It may be that you work in a different
area,
for example Luton.
Details of all the Health Libraries in
the East of England can be found at
this site…
www.eel.nhs.uk
You are welcome to join any of these.
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Review of Objective(s)
Before completing the test, please ensure you have acquired the
relevant knowledge against the modules objective(s) below:
“To inform all health care professionals and support staff, on the legal
requirements for obtaining valid consent before starting treatment,
physical investigation or providing personal care, for a patient, in line
with Department of Health requirements.”
If not, please take this opportunity to revisit the presentation content.
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