MPS was contacted recently by an orthopaedic surgeon in Trinidad. The surgeon had been asked by his employer to use a newly-developed consent form template, and approached MPS for advice on a number of matters surrounding the taking of written consent.
Any procedure undertaken by a clinician on his patient requires the patient’s consent. Failure to obtain consent would mean that the clinician is at risk of a claim in negligence, battery or even criminal assault.
In order to obtain that consent it is necessary to provide the patient with the required information to enable the patient to understand what the procedure consists of, why it is necessary and its risks and benefits. In describing the risks, it is important to cover those that are commonly likely to occur and to discuss any serious risks that a patient may wish to know about.
In discussing risks, you should bear in mind what an average patient may need to know, but also what the specific patient in front of you may wish to know
In discussing risks, you should bear in mind what an average patient may need to know, but also what the specific patient in front of you may wish to know. For example, for a procedure that may very rarely render a patient hoarse, even temporarily, this particular risk may have less significance for an office worker than it would for a teacher or even more, for an opera singer.
The amount of information that needs to be imparted may also depend on the degree of risk a particular procedure carries. For example, carrying out a phlebotomy procedure may only require a relatively brief explanation and consent can be implied by the fact that the patient presents their arm for the tourniquet to be tied around it and allows a needle to be inserted into the vein.
In obtaining consent, while all the above should be borne in mind, it is essential to ensure that the information imparted to the patient and any special questions they may have discussed with you is properly recorded. This is to ensure that should there be any dispute in the future as to what was discussed and indeed whether consent was even obtained, this can be clearly identified by reference to the record of the consent. The fuller that record, the less risk of dispute. Where that information is recorded is not absolutely key, although clearly a full reference in the medical records is helpful.
Ensure that the information imparted to the patient and any special questions they may have discussed with you is properly recorded
Consent forms, essentially, are only evidence that the issues of consent have been discussed. However, depending on how detailed they are and how well completed, they may not list all the risks and benefits that may have come up for discussion. Therefore you may need to consider a separate record of the discussions in the medical notes, in addition to signing any consent form.
There is no standard consent form. As stated above, a consent form is merely evidence that consent has been obtained from a patient for a particular procedure. Therefore, a form does constitute a legal document that would show evidence of informed consent. However, how informed a consent it is depends on the information the clinician has imparted to the patient and whether he has ensured that the patient has understood that information and whether the amount of information imparted is sufficiently comprehensive.