Healthcare and Medicine Reference
In-Depth Information
Consent and Documentation
Tim Nutbeam
West Midlands School of Emergency Medicine, Birmingham, UK
more serious consequences such as a chest drain. Assessment of
capacity is complicated and varies vastly across the globe.
In England and Wales the following two questions must be asked:
Does the person have an impairment of, or a disturbance in the
By the end of this chapter you should:
understand the components that make up 'valid consent'
understand the principles by which we treat patients who lack
functioning of, their mind or brain?
Does the impairment or disturbance mean that the person is
understand the principles by which we treat children under the
unable to make a specifi c decision when they need to?
age of 16
understand the importance of thorough documentation.
Or alternatively a patient lacks capacity if:
'the patient is incapable of acting on, making, communicating, under-
standing, or remembering decisions by reason of mental disorder or
inability to communicate due to physical disorder'
Consent: patients and doctors making decisions together.
In the vast majority of cases a patient must give consent in order
for a procedure to be performed. The principles of valid consent
are a cornerstone of all medical practice, and therefore protected by
medical law. Without valid consent (or an alternative recognised by
medical law) any procedure performed upon a patient is considered
an assault and criminal charges may result as consequence of this.
Medical law concerning consent varies vastly from country to
country - although the same principles can be found across the
globe. This chapter deals primarily with the law governing patients
treated in the UK.
In order for consent to be valid the following components must
be present:
GMC, June 2008
Capacity can be seen to have four individual elements, which all
must be complete in order for a patient to consent for a particular
The patient must understand: why the procedure is being done;
what the benefi ts and risks of the particular procedure are; what
the alternatives to the procedure are; and that they have the right to
refuse for the procedure to be performed.
The patient must believe the information given by the healthcare
professional and understand it to be true.
The patient must retain (and be able to recall) the information
given by the healthcare professional; in non-urgent procedures giv-
ing written information may aid this process.
'You must work on the presumption that every adult patient has the
capacity to make decisions about their care, and to decide whether to
agree to, or refuse, an examination, investigation or treatment'.
Consent: patients and doctors making decisions together.
The patient must weigh up the information given by the healthcare
professional and make a decision. This decision is not necessarily one
which the healthcare professional would have made themselves:
'This right of choice is not limited to decisions which others might regard
as sensible. It exists notwithstanding that the reasons for making the
choice are rational, irrational, unknown or even non-existent.'
Lord Donaldson 1992
Without all four elements of 'capacity' present the patient cannot
give valid consent for a procedure to take place.
GMC, June 2008
The principle of capacity is complex and variable. A patient may have
the capacity to consent for a minor procedure such as phlebotomy
but may lack the capacity to consent for a procedure with potentially
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