On the ward: Everyday consent dilemmas
Dr James Thorpe, Medicolegal Adviser at Medical Protection, reflects on a common issue where junior doctors are asked to perform roles outside their competence, in particular taking informed consent for surgical procedures and other invasive investigations
Read this article to:
- Learn how to handle a request to perform tasks outside your competence
- Understand what is required of you during the process of taking informed consent for a surgical procedure
- Learn from a case study based on real life practice
At Medical Protection we are fully aware of the many challenges facing junior doctors in the modern NHS. On our medicolegal advice line, we are occasionally contacted by doctors who have been asked to perform roles or tasks beyond their level of competence. Such requests often come from consultants or other senior members of staff, and it can be difficult to say no, despite your reservations.
In Good Medical Practice, the GMC make clear that “you must work within the limits of your competence”. This guidance applies to all aspects of your clinical work: you should seek senior support if you feel you are not competent to perform a particular procedure or manage a difficult situation.
One area that can cause an issue for junior doctors is taking informed consent for surgical procedures and other invasive investigations. Consent is an ongoing process and not simply the signing of a form. The GMC make it clear in their guidance that you must give patients information they want or need about the options available to them and about the potential benefits, risks and burdens of any intervention proposed.The recent Supreme Court case of Montgomery v Lanarkshire Health Board has emphasised that this is a legal as well as an ethical duty.
Of particular relevance to junior doctors, the guidance states:
If you are the doctor undertaking an investigation or providing treatment, it is your responsibility to discuss it with the patient. If this is not practical, you can delegate the responsibility to someone else, provided you make sure that the person you delegate to:
- is suitably trained and qualified
- has sufficient knowledge of the proposed investigation or treatment, and understands the risks involved
- understands, and agrees to act in accordance with, the guidance in this booklet.”
In practice, this means that in order to take patient consent, you must be familiar enough with the procedure to be able to explain all of the risks that the individual patient would consider important. As a junior doctor, it is likely you will be able to take verbal consent for a particular blood test, but not for a thoraco-abdominal aortic aneurysm repair!
If you are unhappy to consent a patient for a particular procedure, you should discuss your concerns with a senior colleague, your educational supervisor or your foundation tutor. Our team of medicolegal advisers are also available to discuss any concerns you have.
Dr A is an FY2 working on the vascular surgery ward. He receives a phone call from the consultant interventional radiologist asking him to consent a patient who is due to have a “simple iliac angioplasty” later that morning. Dr A has a general idea of what is involved in an angioplasty but does not feel able to fully discuss the risks, benefits and possible alternatives to the treatment. He explains his reservation to the consultant, who becomes angry, stating that the patient will be cancelled if the consent form is not filled in on the ward. What should Dr A do?
You should not consent a patient for a procedure unless you are entirely happy that you can satisfy the GMC consent guidance. In this situation, Dr A spoke with the vascular surgery consultant who had previously discussed the options for treatment with the patient in the outpatient clinic. The consultant surgeon consented the patient for the procedure as part of the ongoing shared decision-making process.