Trust Board Febuary 2010 - Sandwell & West Birmingham Hospitals

SWBTB (2/10) 037 (b)
8. What may happen if you do not have the procedure/treatment?
9. Do you need more information or time to help you to make a decision?
10. Would you like to talk to someone else about the procedure/treatment before you make a
decision?
11. What is your decision?
The Clinician assessing capacity to complete:
It is my clinical judgment that ………………………….........…(write in patient’s name) does not have the
capacity to consent
Has the capacity to give consent to (the procedure or course of treatment)
because………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………
Information regarding the procedure has been given in language appropriate to his/her age and
understanding (please state what aids were used in communication e.g. interpreter)
The following communication aids were used
DOH information booklet given
Verbal discussion
Audio tape
Interpreter
The young person is able to comprehend and retain the relevant information and demonstrate
he/she is able to use this information in the decision making process through:
Reiterating the main points of the procedure to me.
Asking questions about the procedure/treatment to clarify what they have understood
Showing an understanding of the consequence of not consenting
to the procedure /treatment
Completing the question sheet regarding consent.
The patient is able to outline the consequences of having the intervention in question by ..
Listing the benefits of the procedure/treatment.
Listing the potential risks of the procedure/treatment