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Written by Riley Botelle
Informed consent means that a patient has agreed to have a procedure or treatment after they have been given all the facts that are necessary for them to make a decision as well as time to consider what they would like to do. This will usually be done in person by a member of the healthcare team and accompanied by resources such as leaflets.
Before a patient can give consent they must have several elements of the treatment explained to them, including:
Only competent patients can give informed consent. Competence refers to a patient’s ability to understand the information provided and make a rational decision on it by themselves. It is a legal judgement. Capacity is essentially the same, only it is a medical rather than legal judgement.
A person lacks capacity if their mind is impaired or disturbed in a way that means they are unable to make the decision at that moment. This may include mental health conditions, dementia, brain damage, severe learning disabilities, intoxication or unconsciousness.
If an adult lacks the capacity to give consent, a decision on whether to go ahead with the treatment will be made by the health professionals treating them – it will be considered whether it is in the patient’s ‘best interests’ or not.
In situations where there’s serious doubt about what’s in an incapacitated patient’s best interests, healthcare professionals can refer the case to the Court of Protection for a ruling.
Some situations must always be referred to the courts. This includes sterilisation for contraceptive purposes, donation of organs or regenerative tissue and withdrawal of nutrition and hydration from a person who’s in a minimally conscious state
Some patients who know their capacity may be reduced in the future choose to draw up a legally binding advance decision, also known as a living will. This sets out the procedures and treatments that a person refuses to undergo. Patients can also assign another person ‘lasting power of attorney’, meaning they have the legal ability to make medical decisions in the future if the patient no longer has capacity.
Patients over the age of 16 are generally assumed to be competent, unless as described above.
Patients below the age of 16 can be deemed competent to give consent provided they are shown to be mature enough to understand the procedure and its consequences. If the child is judged to be competent, the Doctor cannot involve the parents against the will of the child, as this would breach confidentiality. The assessment of a child’s competence is known as the Fraser guidelines.
In England and Wales, whilst under 16s can give consent if competent, they cannot refuse treatment that is deemed in their best interest. In Scotland competent under 16s can refuse treatment.
If all parents/guardians refuse to give consent for a non-competent child for a lifesaving procedure, then Doctors are obligated to act under the best interest of the child. If possible, this may involve a court order to impose the treatment. If due to time restrictions this is impossible, the decision to treat may be justified later in court.
Empathy is the ability to understand and share the feelings of another. Empathy is sometimes confused with sympathy, which involves feelings of sorrow for someone else’s misfortune. Sympathetic responses would include a Doctor feeling sad when their patient starts crying or experiencing righteous anger when their patient experiences injustice.
A Doctor can be empathetic even when they cannot be sympathetic, and empathy is key in building rapport and trust with patients. Empathy involves understanding a patient’s feelings rather than simply feeling sorry for them, and whilst both can be useful, empathy is more important when interacting with patients and is a key skill to highlight and show examples of interviews.
Patient confidentiality means that information regarding a patient cannot be disclosed to other people. Whilst it is possible to talk about cases, all identifying information such as names, ages, locations and specific dates should be left out. Additionally, it is often advised that if you do need or want to talk about a case, you should change small pieces of information. A patient should never be identifiable from talking about their case.
Confidentiality can only be breached under three situations: when implied consent has been given by the patient, when the information is required by a court or judge, and when it is in the public interest (to protect the patient or others).
Implied consent is the idea that it is assumed a patient consents for information sharing between members of the medical team involved in their care. However, if a patient specifically asks you not to share information with a colleague, this must be respected. It may also be implied if a patient brings someone to an appointment with them that they are consenting to the individual hearing anything you have to say, although if you are dealing with a sensitive issue it is still wise to check with the patient first.
If the court or a judge requires information there will be a court order. This may be if the police need records in the course of an investigation.
Reporting in cases of public interest includes notifiable diseases such as meningitis, TB, mumps and measles (not HIV), suspected child (or vulnerable adult) abuse/neglect and informing the DVLA of any conditions that interfere with the ability to drive. Sometimes this also includes identifying a driver who was involved in a vehicle collision, although this is limited to strictly necessary data (e.g. address details and not clinical information). Additionally, gunshot wounds and knife wounds (not self-harm) are reported to the police, although the patient’s identity cannot be disclosed without their permission unless other people are believed to be at risk.
The NHS says that “the disclosure of personal information about a patient without consent may be justified in the public interest if failure to disclose may expose others to a risk of death or serious harm. You should still seek the patient’s consent to disclosure if practicable and consider any reasons given for refusal.”
Evidence-based medicine is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practise of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett 1996)
In practice, this means analysing the best available research evidence combined with your own medical expertise and judgement to determine the best use of medicine for specific patient cases. It means that medicine is a continuous, lifelong learning process where current techniques and treatments must be constantly under review and replaced when the evidence changes. It means staying on top of new evidence and new guidelines, and always looking for better ways to care for patients.
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