New Doctor - Medical Protection Society

More documents

Recommendations

Info

6 MEDICOETHICAL FEATURE NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk Essential learning: consent and capacity Consent is an individualised process based on respect – it is more than a signature on a form, says medicolegal adviser Dr Gordon McDavid Dr U is in his first week as an F2 in ENT. A nurse asks him to consent a patient going to theatre, she cannot locate the consent form in the patient’s notes. She says that the consultant will get very cross if the patient turns up to theatre without the appropriate documentation, especially as the patient’s operation has already been cancelled once, and it would be terrible if it happened again. Dr U appears unsure, so the nurse adds that Dr U would only have to take consent for a tonsillectomy, which “isn’t rocket science”. Dr U is in a dilemma that many foundation doctors will be familiar with. The nurse is asking Dr U to work outside his competence, as he has not taken consent from a patient for a tonsillectomy before. So how should Dr U handle this situation? MPS advice is that Dr U should seek advice from a senior colleague before obtaining consent so that the operation can go ahead as planned. Trust, confidence and good communication are fundamental to a successful doctor–patient partnership and providing healthcare involves decisions, which should be made with your patient. Failure to obtain consent properly can lead to problems including legal or disciplinary action against you, or rarely criminal prosecution for battery (contact with an individual without consent.) The foundation programme curriculum stipulates that you should be familiar with the GMC’s guidance document Consent: <strong>Doctor</strong>s and Patients Making Decisions Together, and be able to obtain consent in line with this guidance. By the end of your FY2, you should be able to describe the principles of valid consent and demonstrate this understanding in your practice. You should also be able to undertake a capacity assessment. What is consent? Consent should be a discussion with your patient that assists them to reach a decision. You should facilitate this process by providing the information they need in an appropriate format. Whilst consent must be obtained prior to providing healthcare, often consent may be implied, eg, when a doctor requests a blood sample, the patient holds out their arm thus implying their consent to the procedure. In an emergency situation where a patient cannot provide consent, (eg, the patient is unconscious) a doctor may provide treatment to safeguard the patient’s life or health, acting in the patient’s best interests. Discuss risks It is important to warn patients of the risks of treatment and document that you have done so. Clear documentation is necessary to provide evidence of this. In the 2004 case of Chester v Afshar (2004), the surgeon failed to document his discussions with the patient regarding the possibility of cauda equina syndrome following discectomy for lower back pain and it could not be proven that Miss Chester had been warned of all the risks. 1 Miss Chester successfully argued that if she had been warned, she would have taken the time to think about it and had surgery on another day, thus avoiding the rare complication. The GMC’s consent guidance recommends that patients should be given information in a balanced and tailored way. 2 Patients should be told of any possible significant adverse outcome and of any less serious side effects or complications if they occur frequently. Document, document, document While many patients wish to be fully informed and involved in their healthcare, some patients may not want to know all the details about treatments and their attendant risks and benefits, making it difficult to secure their valid consent. Consent should be a discussion with your patient that assists them to reach a decision. You should facilitate this process by providing the information they need in an appropriate format If a patient does not want to discuss their condition or the treatment in detail, you should respect their wishes as far as possible, but the GMC says: “You must still give them the information they need in order to give their consent”. Safeguard yourself by recording the fact that the patient had declined this information. Refusing consent If patients are competent, they are entitled to refuse consent, no matter how illogical this may seem. If this happens, it is a good idea to explain to them the possible consequences of their decision. Such discussion is not with the intention of changing their mind or coercing the patient, but to clarify the situation. You should listen to patients and respect their views, even if you do not agree. Check their understanding of MBBIRDY/ISTOCKPHOTO.COM
LIFE IN VIEW/SCIENCE PHOTO LIBRARY the decisions they have made and document the discussion carefully, taking into account factors such as their religious beliefs or values expressed. Patients can withdraw consent during a procedure – but if stopping the procedure at that point would genuinely put the life of the patient at risk, the practitioner may be entitled to continue until this risk no longer applies. What is capacity? To provide consent a patient must be competent (or have capacity) to do so. So what if a patient is unable to give their consent? They may be unable to understand the information, or they may be unable to retain the information to weigh up the risks/benefits, meaning a decision cannot be made. In England and Wales, the Mental Capacity Act (MCA) (2005) exists and is based around five statutory principles: 1. A person must be assumed to have capacity unless it is established otherwise. 2. A person is not to be treated as unable to make a decision, unless all practicable steps to help him do so have been taken without success. 3. A person is not to be treated as unable to make a decision merely because an unwise decision is made. 4. An act done, or decision made, under this Act or on behalf of a person who lacks capacity must be done, or made, in his best interests 5. Before the act is done, or the decision is made, care must be taken to avoid restricting the person’s rights and freedom of action. In Scotland, the Adults with Incapacity Act (2000) applies; however, this is currently under review. In Northern Ireland there is no specific legislation covering mental capacity, so decisions should be based on common law (based on previous cases) and best practice. How do you assess capacity? The method of formally assessing capacity is described in the MCA and its supporting Code of Practice document. 3 The assessment must be decision-specific and there are two stages to the test: 1. Is there an impairment of or disturbance in the functioning of the patient’s mind or brain? 2. Has it made the person unable to make this particular decision? To have capacity to make a decision a person should be able to: ■ ■ Understand the information ■ ■ Retain that information ■ ■ Use or weigh up that information ■ ■ Communicate their decision The MCA states the following should be considered: ■ ■The past and present wishes of the patient (especially any written statement when the patient had capacity) ■ ■ Religious beliefs or values expressed by the patient when competent ■ ■The views of relevant others (eg, carers, relatives) FOR CONSENT TO BE VALID ■ ■ The patient should be informed ■ ■ The patient should be competent ■ ■ Consent must be given voluntarily ■ ■The patient should be involved in the consent process and encouraged to give their consent to particular aspects for which they do have capacity. A person may temporarily lose capacity in certain situations; such as if they are in extreme pain, shock, under the influence of drugs, secondary to delirium or as a consequence of their condition. Patients who have mental health problems may have difficulty making decisions about their treatment, but this should not be assumed. Assessing capacity can be very difficult where patients suffer from serious communication problems. All practicable steps must be taken to assist the patient in communicating their decision (and thus retaining their capacity) such as using interpreters, large print documents or sign language. In order to assess a patient’s understanding, it is best to try to frame questions in such a way that the patient will need to give a full response eg, “Tell me what you understand by…” rather than “Do you understand?” If you are in doubt regarding a patient’s capacity it is worth seeking further advice from your senior. It is vitally important to ensure thorough documentation of a formal assessment of capacity. Deprivation of Liberty Safeguards (DOLS) On each occasion that treatment is required for a patient who does not have the capacity to consent, a decision should be made in the best interests of the patient. The Mental Capacity Act Deprivation of Liberty Safeguards (MCA DOLS) for England and Wales provide legal protection for those who lack capacity and who may be deprived of their liberty in hospitals or care homes. They 7 MEDICOETHICAL FEATURE NEW DOCTOR | VOLUME 5 | ISSUE 2 | 2012 | UNITED KINGDOM www.mps.org.uk
Page 1 and 2: VOLUME 5 | ISSUE 2 | JULY 2012 UNIT
Page 3 and 4: Inside this issue of New Doctor…
Page 5: Competency, in professional terms,
Page 9 and 10: A day in the life of… an F2 in pu
Page 11 and 12: I was not completely comfortable wi
Page 13 and 14: GUNTARS GREBEZS/ISTOCKPHOTO.COM PAS
Page 15 and 16: and treatment, but also balancing t

New Doctor - Medical Protection Society

Create successful ePaper yourself

Delete template?

Save as template?