Healthcare and Medicine Reference
Box 2.4 Considerations when a patient is unable to consent
Good medical records are essential for delivering good patient care.
They are principally used to improve continuity of care and prevent
medical error. They are also a vital source of information if a negli-
gence claim is made against a healthcare professional.
The General Medical Council of the UK states:
'keep clear, accurate and legible records, reporting the relevant clini-
cal fi ndings, the decisions made, the information given to patients, and
any drugs prescribed or other investigation or treatment; make records
at the same time as the events you are recording or as soon as possible
With particular reference to practical procedures, as a minimum
standard you should document the following.
The time, date, who you are and where you are.
Whether the patient's lack of capacity is temporary or permanent.
Which options for treatment would provide overall clinical benefi t
for the patient.
Which option, including the option not to treat, would be least
restrictive of the patient's future choices.
Any evidence of the patient's previously expressed preferences,
such as an advance statement or decision.
The views of anyone the patient asks you to consult, or who has
legal authority to make a decision on their behalf, or has been
appointed to represent them.
The views of people close to the patient on the patient's
preferences, feelings, beliefs and values, and whether they consider
the proposed treatment to be in the patient's best interests.
What you and the rest of the healthcare team know about the
The name of the procedure proposed.
patient's wishes, feelings, beliefs and values.
Consent: details of the information you discussed, any specifi c
requests by the patient, any written, visual or audio information
given to the patient, and details of any decisions that were made.
Monitoring: document standards of monitoring whilst the pro-
Consent: patients and doctors making decisions together.
GMC, June 2008
cedure was being performed (e.g. ECG, SpO 2 ).
Drugs administered: supplemental oxygen, sedative agents etc.
The treatment or procedure should be what is:
in the patient's best interests (taking into account the patient's
Persons present: the name of anyone assisting or supervising the
procedure (and their grade).
Sterile precautions: include universal precautions (gloves, apron
past wishes and feelings)
the minimum intervention which is required to achieve the
etc.) as well as additional: visor, sterile fi eld etc.
Sterilising agents: what was used to clean the area - chlorhexi-
When it is reasonable and practicable to do so (i.e. in every non-
emergency situation) you must consult with relevant others: family
members, principal carers, etc. Specialised consent forms are used
in this situation and must be signed by two senior doctors (ideally
consultants) who are responsible for the patient's care.
dine, alcohol wipe, normal saline etc.
Local anaesthetic: what was used, in which dose and how it was
The procedure itself: this will be specifi c to the procedure but will
include anatomical location, and a 'step-by-step' documentation
of the procedure.
Complications: document any complications (or lack of them),
Children and consent
including how they were resolved.
Postprocedure management: what needs to be done next (e.g.
The law regarding children's consent is complicated and regularly
The healthcare professional should involve children as much as is
practicably possible in discussions about their care; this is the case
even if the ultimate decision or 'consent' does not lie with the child.
In the UK and most of the developed world a young person is
assessed on an individual basis on their ability to understand and
weigh up options, rather than on their age. This ability to take deci-
sions is known as 'Gillick' competence and originated from a court
case regarding the prescription of oral contraceptives to young
people under the age of 16.
'As a matter of Law the parental right to determine whether or not their
minor child below the age of sixteen will have medical treatment termi-
nates if and when the child achieves suffi cient understanding and intel-
ligence to understand fully what is proposed.'
chest X-ray for central line), period of intensive observation etc.
Medical records should be clear, objective, contemporaneous,
attributable and original.
Department of Health. (2004) Better information, better choices, better health:
putting information at the centre of health .
Department of Health. (2001) Reference guide to consent for examination or
Gillick v West Norfolk and Wisbech AHA  AC 112.
General Medical Council (GMC). (2008) Consent: patients and doctors mak-
ing decisions together .
Mental Capacity Act (2005) Code of Practice.
Medical Protection Society. (2008) Consent and young adults and children
MPS (2008) Guide to consent in the UK .
MPS (2008) Medical Records Booklet .
Royal College of Physicians, Patient Involvement Unit. (2006) Explaining the
risks and benefits of treatment options . www.rcplondon.ac.uk/college/PIU/
Lord Scarman, 1985
If a child is judged as Gillick competent they can consent to a proce-
dure and this decision cannot be overruled by their parents.
If a child is not Gillick competent they can neither give nor with-
hold consent. Those with parental responsibility need to make a
decision on their behalf.
Any further detail is beyond the scope of this text. It is important
to involve senior clinicians with overall responsibility for the child
as early as possible in the decision-making process.