Seaford Medical Practice

Consent To Treatment Policy

This sets out Seaford Medical Practice’s policy on patient consent to treatment:

Created:  September 2023

Review:  September 2024

INTRODUCTION

This policy outlines the importance of obtaining consent when providing treatment, care and support whilst maintaining patient choice and their right not to consent.

Relevant legislation

  • Children Act 2004
  • Equality Act 2010
  • The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
  • The Human Tissue Act 2004
  • Medical Act 1983
  • Mental Capacity Act 2005
  • Mental Health Act 2007
  • Safeguarding Vulnerable Groups Act 2006
  • Data Protection Act 2018

POLICY

Seaford Medical Practice understands the need to only provide treatment with consent from the Patient. Seaford Medical Practice ensures that when a Patient is asked for their consent, information about the proposed treatment will be provided in a way that they can understand. The information will include details about the risks, complications and any alternatives. Only staff with the necessary knowledge and understanding of the treatment will provide this information so that they can answer any questions about it to help the Patient give valid consent.

Where a Patient lacks mental capacity to make an informed decision, or give consent, staff will act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice. Seaford Medical Practice will respect when Patients, or a person acting lawfully on their behalf, refuses to give consent or withdraws it.

All clinical and non-clinical staff members will be trained in the meaning of consent (this includes implied consent and expressed consent) and who is permitted to give consent for a Patient.

Seaford Medical Practice will ensure that it treats consent as a process that continues throughout the duration of care and treatment, recognising that it may be withheld and/or withdrawn at any time. Staff at Seaford Medical Practice will be trained to understand that capacity can fluctuate and this needs to be considered in the context of giving or refusing consent.

Discussions about consent will be held in a way that meets the Patient’s communication needs. This may include the use of different formats or languages and may involve others such as a translator or independent advocate. The Accessible Information Standard (AIS) Policy and Procedure at Seaford Medical Practice can be referred to for more information.

Seaford Medical Practice will ensure that consent procedures do not pressure Patients into giving consent and, where possible, plans will be made well in advance to allow time to respond to Patient questions and provide adequate information.

Seaford Medical Practice will uphold the Patient’s right to be involved in all decisions about their care and treatment.

Seaford Medical Practice will work with other members of the multidisciplinary team to ensure that best interest decisions are made and recorded for Patients who lack mental capacity to give valid consent.

Seaford Medical Practice will ensure that policies and procedures for obtaining consent to care and treatment will reflect current legislation and guidance and that staff follow them at all times.

Each healthcare professional must be satisfied that consent or other valid authority exists before undertaking any examination, investigation, providing treatment or involving a Patient in teaching or research. Usually this will involve providing information to Patients using methods to ensure they understand what intervention they are being required to give their consent for as well as why and how it could affect them. Obtaining informed consent must follow the guidance in “Decision Making and Consent” [GMC November 2020] which includes advice on children (to be read in conjunction with 0-18 Years Guidance for all Doctors GMC) and Patients who are not able to give consent.

Patients will:

  • Be listened to and have their views about their healthcare respected
  • Be informed what their diagnosis, prognosis, treatment and care involves
  • Have information shared with them as they want or need in order to ensure they can make decisions
  • Receive information in whatever way is necessary to enable them to maximise their opportunity and ability to make decisions and communicate them
  • Have their decisions respected by staff in line with legislation

PROCEDURE

Seaford Medical Practice recognises that consent is fundamental in ensuring person-centred care provision.

Seaford Medical Practice understands the need to allow Patients time to process information without feeling rushed or pressured, providing the opportunity for the individual or their legal representative to consider  and formulate any questions that they have relating to their care provision.

Consent and Mental Capacity

A Patient lacks capacity if their mind is impaired or disturbed in some way, and this means the Patient is unable to make a decision at that time.

  • The staff member responsible for the healthcare assessment will ensure that mental capacity is assessed before the Patient consents to treatment and support
  • Where the mental capacity assessment identifies that the Patient lacks the mental capacity to give valid consent, consent will be sought from the Patient’s legally authorised representative (such as a legal guardian or a person having a power of attorney)
  • The assessor will consider whether the lack of capacity is temporary or permanent and consider if there are occasions when capacity fluctuates
  • The Patient will be supported and encouraged to be involved, as far as they want to and are able, in decisions about their treatment and care
  • Staff must adhere to the Mental Capacity Act (MCA) 2005 Policy and Procedure at Seaford Medical Practice

Before Patients can come to a decision about treatment, they need comprehensible information about their condition, possible treatments/investigations, risks and benefits including the risk/benefits of doing nothing. This must be documented in their healthcare record and appropriate information transferred to the consent form e.g. risks, additional procedures. They must be informed of risks/benefits no matter how small or remote unless they have expressly indicated they do not want all of the information. They need to know whether additional procedures are likely to be necessary as part of the procedure.

The healthcare professional is responsible for ensuring explanations are presented sensitively and in a way that the Patient can understand. Unnecessary medical jargon must be avoided. Written information needs to be provided to support verbal explanations.

For ‘informed consent’, Patients are given all the information they need to make an informed decision. Whatever the context in which medical decisions are made, the healthcare professional carrying out the procedure must work in partnership with Patients to ensure they receive high-quality care which involves:

  • Listening to Patients and respecting their views about their health
  • Discussion with Patients about their diagnosis, prognosis, treatment options, risks of each option to help the Patient understand the significance (magnitude of individual effects) of the information clearly and know what they can expect if they give their consent
  • Sharing with Patients the information they want or need, including the results of any tests, in a way that they are able to understand in order that they can make fully informed decisions
  • Maximising the Patient’s opportunities and their ability to make decisions for themselves
  • Respecting Patient’s decisions
  • Ensuring that Patients can be confident that their human rights are respected and taken into account

Consent is checked with the Patient throughout all stages of an intervention or treatment pathway, not only at the outset, and this along with contemporaneous documentation of key points in the discussion is recorded in the Patient’s clinical record and confirmed as informed consent.

Consent must also be checked and recorded when carrying out consultations online or via video.

Communication must be sufficient to ensure that Patients with communication difficulties are enabled to provide informed consent (for example, human – British Sign Language (BSL) interpreter/friend/pen and paper, or technological – hearing loop support for Patients with hearing difficulties).

Due to the time pressures that often exist in healthcare, it is not always possible to give Patients the level of information and support they may need to enable them to give their informed consent. To assist the healthcare professional, other members of the team may be able to spend time with the Patient and provide them with sources of information and support that will help them to make their decision about an intervention and give consent which is sufficiently informed. The resources available might comprise patient information leaflets, advocacy services, a local Expert Patient Programme or support groups/charities for people with specific conditions.

The Patient is given time to agree to treatment based on the information they have received and is not pressurised in any way.

The Patient may enquire of members of the Practice Team concerning treatment at any stage and they will receive a response to their question(s) from a healthcare professional e.g. doctor.

A Patient can refuse consent at any point. If this happens, the decision is to be respected. However, information may be provided to the refusing Patient to help them understand in full what their refusal may mean in terms of risk. Advance refusals of treatment may need to be recorded, signed and witnessed for the clinical record.

If a Patient expresses the wish to have another person, such as a relative, partner, friend, carer or advocate, to be involved in discussions or to help them make decisions, this wish should be accommodated as far as is reasonably possible, taking into account all factors informing the need for the consent in the first place, for example, the urgency or seriousness of the condition etc.

Written consent is obtained for procedures that have to be carried out in situations where consent cannot be checked, such as when the Patient is not conscious for any reason. Consent is recorded in the clinical record for every intervention.

If any healthcare professional believes that operational issues beyond their control are restricting their ability to give Patients the time or information they need to make an informed decision and are seriously compromising the Patient’s ability to make an informed decision, concerns should be formally raised with Dr Ian Cockburn and documented.

Patients can give consent verbally or in writing, or they may imply consent by complying with the proposed examination or treatment, e.g. by rolling up their sleeve to have their blood pressure   taken. Where an intervention is deemed necessary (for example, a blood pressure check) to which the Patient refuses consent, this refusal must be recorded in the Patient’s clinical record.

In the case of minor or routine investigations or treatments, if the healthcare professional is satisfied that the Patient understands what is proposed, and why, it is usually enough to have verbal or implied consent.

In cases that involve higher risk, it is important that the healthcare professional obtains the Patient’s written consent. This is so that everyone involved understands and can confirm what was explained and agreed.

By law, there must be written consent in place for certain treatments, such as fertility treatment and organ donation. Seaford Medical Practice must follow the laws and codes of practice that govern these situations if being requested to obtain consent on behalf of another healthcare provider.

The healthcare professional must also get written consent from a Patient if:

  • The investigation or treatment is complex or involves significant risks
  • There may be significant consequences for the Patient’s employment, social or personal life
  • Providing clinical care is not the primary purpose of the investigation or treatment
  • The treatment is part of a research programme or is an innovative treatment designed specifically for their benefit

If it is not possible to get written consent, for example, in an emergency, or if the Patient needs the treatment to relieve serious pain or distress in the primary care setting, the healthcare professional can   rely on verbal consent. However, the healthcare professional must still give the Patient the information they require or request to make the decision that led to the need for consent for the intervention. The   healthcare professional must record the fact that the Patient has given consent in the Patient’s clinical record.

Written consent must not be altered once it has been signed by the Patient. This signed consent must be scanned into the Patient’s clinical record.

Physical restraint is not used within Seaford Medical Practice, except where life may be in danger. In the presence of physical peril, police support must be requested as a matter of urgency.

Consent to Share Information

Seaford Medical Practice will ensure that the Patient gives permission for information to be shared with other professionals or providers. If a Patient lacks capacity to make this decision, Seaford Medical Practice, in consultation with any representatives, will need to make a best interests decision about sharing information. Examples of when information might be shared are:

  • Transferring care between providers
  • Discussing mobility goals with a physiotherapist involved in the Patient’s care
  • Seaford Medical Practice will also ensure that staff comply with the UK GDPR and Data Protection Act 2018 and that consent is sought from the Patient before sharing any information with inspectors or regulators.
  • Seaford Medical Practice will be aware of the need to maintain confidentiality and that a Patient’s right to confidentiality continues even when they are deceased.
  • Patients must understand what information is recorded about them and how Seaford Medical Practice uses that information, stores it and whether the information is shared. The Patient will be asked to provide consent for any information about their health, care, treatment or personal identifiable information to be shared. Seaford Medical Practice will consider this within the context of the UK GDPR.
  • capacity to make their own decisions about their care and treatment. It applies to people aged 16 and over

 

Date published: 8th November, 2023
Date last updated: 8th November, 2023