Consent

 Consent

1. ‘It is a legal and ethical principle that valid consent must be obtained before starting treatment, physical investigation, or providing personal care for a patient. ‘Health professionals who carry out procedures without valid consent are liable to legal action by the patient and investigation by the General Medical Council or equivalent professional bodies.
2. Valid consent implies it is given voluntarily by a competent and informed person, not under duress. To have the capacity for consent, the patient must be able to comprehend and remember the information provided, weigh up the risks and benefits of the proposed procedure, and consider the consequences of not having the procedure in order to make a balanced decision. Consent may be expressed, either written or verbal, or implied, e.g. holding out one’s arm for a blood test.
3.  Adults are presumed to have the capacity to consent unless there is contrary evidence. Doctors must respect patient autonomy and their right to be involved in decisions that affect them. ‘If an adult with capacity makes a voluntary and appropriately informed decision to refuse treatment this decision must be respected. This is the case even when this may result in the death of the patient and/or the death of an unborn child, whatever the stage of the pregnancy.’
4.  Advance decisions: advance refusal of treatment, which may include denial of life-sustaining treatment, written by a competent individual in case of future incapacity is legally binding in many jurisdictions. Lasting powers of attorney may be appointed by a person with the capacity to act on their behalf in health decisions should they lose capacity in the future (England & Wales).
5.  A new independent mental capacity advocacy service (IMCAS) can provide advice for patients without friends or family in England and Wales.
6.  Young adults: competent young adults over the age of 16yr can give consent for any treatment without obtaining separate consent from a parent or guardian.
7.  Children: those under 16yr who demonstrate the ability to fully appreciate the risks and benefits of the intervention planned can be considered competent to give consent.
8. Refusal of treatment: children and young adults who refuse treatment may have their decision overridden by a parent or the court, but the treatment should proceed only if in the child’s ‘best interests’. When a child lacks the capacity for consent, parental consent should be sought. If such a child refuses treatment, judgement needs to be exercised by the parent and the doctor as to the level of restraint that is acceptable, depending on the urgency of the case. Consider postponing the case until adequate premedication can be given.
9.  In an emergency, verbal consent by telephone is adequate, and essential treatment can be started in the absence of parental authorisation if necessary. Where the child or parent refuses essential treatment, a ward of a court order can be obtained, but this should not delay the emergency management. This enables the doctor to proceed with the treatment lawfully.
10. Treatment without consent: in an emergency, consent is not necessary for life-saving procedures. Unconscious patients may be given essential treatment without consent. It is good practice to consult with the next of kin, but they cannot give or refuse consent for adult patients. Patients who are ‘incompetent’ may be given treatment provided it is in their ‘best interests’.
11. Restricted consent: patients may consent to treatment in general but refuse certain aspects of this treatment, e.g. Jehovah’s Witness patients who refuse blood transfusion. This must be discussed in full with the patient so that they are fully aware of the implications of withholding the treatment. The details of the restriction should be carefully documented on the consent form.
12. Research and teaching: the same legal principles apply when seeking consent from patients for research or teaching. All clinical research requires ethics committee approval. As research may not have direct benefits for the patients involved, they must receive the most entire possible information about the proposed study, not be pressured into taking part and be advised they can withdraw at any time without their care being affected. Incompetent patients can be included only in therapeutic research that is considered to be in their best interests or where the therapeutic benefits are genuinely unknown but there are reasons to believe that there may be advantages to the therapy. Competent children may give consent for clinical research associated with minimal risk. Students should obtain a patient’s consent to undertake clinical procedures. 
13. Documentation: after discussion with the patient in an appropriate environment, the agreed anaesthetic and postoperative plan should be documented in the patient’s medical records, including a list of risks explained. Written consent is obtained as part of the overall surgical consent form; separate anaesthetic consent forms are not currently deemed necessary, though they exist in some jurisdictions.