· Summary
· Voluntary
· Competent
· Informed
· Gillick competence
· Specific to the intervention
· Must be voluntary
· Must be competent
· Must be informed
· Must be documented
· No coercion
· Ok to say no
· Ok to change one’s mind
· Ok to withdraw consent (e.g. multiple attempts at regional blockade)
· Should have appropriate support if desired (spouse, relative, friend)
· Should be at an appropriate time
· Should be in an appropriate place
(i.e. alone + anaesthetic room + right before induction is a dreadful combination)
· General criteria:
o Every individual presumed confident unless good evidence to the contrary
o Not too young*
o Not mentally incapacitated
o Not unconscious
o Not sedated
· If incompetent and has a parent or guardian
o Must act in the best interests of the patient
· If incompetent and no parent or guardian and in a hurry
o Must attempt to ascertain patient’s views
o Must do what is in the patient’s best interests
o Must do what we believe the patient would want
o Should take into account the views of those close to the patient
o Should obtain legal advice. Statutory body may provide consent or authorize somebody to do so.
· If in a tearing hurry
o Must provide information and allow discussion ASAP
· Hierarchy of surrogate decision makers:
o MPOA
o Partner or spouse
o Adult child
· Principles:
o Person performing the intervention is ultimately responsible
o Person explaining must understand the intervention, pros, cons
o Must provide a qualified interpreter if needed
o Must provide information a reasonable patient would wish to know
o Must provide information in a form the patient is likely to understand
o Must allow for Q&A
o N.B. cookie cutter documents are not sufficient
· Content of information:
o Basic information about the intervention (even if “I don’t want to know”)
o Pros and cons of this treatment
o Pros and cons of alternative treatments
o Pros and cons of no treatment
o Costs (if private)
· Which risks to mention?
o Common (e.g. sore throat, PONV)
o Rare but disastrous (e.g. AMI, anaphylaxis, awareness, nerve damage, dental damage)
o Blood products
o Patient would want to know about it
o Patient would likely consider it significant
o Patient might change his/her mind on that basis
N.B. the above are all subjective! Dependent upon condition + intervention + attitude + understanding + questions
· Principles of Gillick competence
· Varies depending upon the intervention
· Varies depending upon the local law. If in doubt, ask.
· Must be able to understand the nature of the intervention
· Must be able to understand the purpose of the intervention
· Must be able to understand the possible consequences of the intervention
With thanks to former lawyer Dr. Perdita Gregory
|
1.Specificity |
· Pertains to a specific procedure |
|
2.Voluntary |
· Absence of coercion |
|
3.Competence |
· Assumption of capacity in adults |
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4.Knowledge |
· i.e. ‘informed’ · See Rogers v Whitaker 1992 · tl;dr Must warn of risks to which a patient would attach significance |
|
Unconscious patient |
Issue: fails all four limbs · Option 2: surrogate decision maker · Option 3: act in a patient’s best interests / defence of necessity |
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Medicated patient |
Issue: competence, knowledge · If emergency: options 2&3 as above · If elective: defer |
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Non-English speaker |
Issue: knowledge · If emergency: phone interpreter · If elective: interpreter in person |
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Mature minor |
Issue: capacity · See Gillick v West Norfolk 1985 · tl;dr Minors can consent to some medical treatments |
|
Documentation |
· Signature alone is insufficient · Must document the discussion process in detail · Do not use standardised forms |
|
Assistance |
· Involve senior staff if unsure · Hospital legal advisors and MDOs are always contactable |
Feedback welcome at ketaminenightmares@gmail.com