SURGERY PRACTICAL SKILLS

Obtaining consent
for an operation
How to support patients in making
informed decisions about their
treatment options

M
ore than 10 million
operations and
procedures are
performed each
year in the UK.1
Weighing up whether to go under
the knife is a major decision, and
doctors need to play a supportive role
in making sure that patients are fully
informed about the risks and benefits
of undergoing a treatment.
Obtaining consent for a procedure
is one of the core competencies
for graduates expected by the
General Medical Council,2 and is
a common scenario in medical
school objective structured clinical Key definitions relating to consent
examinations (OSCEs). In this article Capacityfor patients to consent to a treatment, they
we offer guidance on how to take a need the capacity to understand, retain, and weigh up
patient centred approach to sharing the treatment options presented to them
information about a procedure and Informed consentthis is when the patient agrees to
obtaining consent. a treatment after having been provided with sufficient
information about the benefits, risks, and alternatives
What is consent and why is Material risksrisks related to a procedure that are
of relevance to the patients past medical history and
it important?
individual risk factors
The law states that patients have the
right to determine what happens
to their bodies, which means that with surgeons recommending with the patient (known as the
performing a procedure on a patient their preferred option and patients Bolam test).
who hasnt signed a consent form following in tow. Since the Montgomery ruling,
is a form of battery and can lead to In 2015, a landmark decision however, doctors must not make
criminal charges.3 by the UK Supreme Court in the assumptions about which risks are
In the past, the consent process Montgomery v Lanarkshire Health important to patients and must fully
has sometimes been paternalistic, Board case prompted a change in disclose any risks that may be of
the law. The court ruled that doctors particular importance or relevance
Learning points must now take reasonable care to to that patientfor example, a
Consent should be sought by the doctor or surgeon carrying ensure that the patient is aware of professional singer undergoing a
out the operation or procedure any material risks involved in any throat operation.78
Patients need an explanation of what their procedure recommended treatment, and of The Montgomery case prompted
involves, its risks, benefits, and likely outcome any reasonable alternative or variant the Royal College of Surgeons to
Doctors need to understand patients preferences and treatments.6 publish new guidance on consent
priorities in order to be able to discuss any risks that might Previously, doctors could decide Consent: supported decision-
be particularly relevant or important to them what to tell patients about the risks making9which emphasises the
and benefits of a procedure, and their role of surgeons in assisting patients
Medical students and foundation doctors can help by
trying to understand patients concerns, expectations, and actions would have been judged only to make a decision on whether a
preferences, and by relaying them to the rest of the team against other doctors opinions of procedure is right for themrather
what information should be shared than the traditional paternalistic

44 September 2017 | studentbmj

 THE PROCESS FOR OBTAINING CONSENT FOR A SURGICAL PROCEDURE
As a medical student, although
you will not be responsible for
obtaining consent, you can
observe senior doctors following
the consent process
1 Explain the diagnosis
Check the patient understands
their diagnosis, the findings
that have led you to this
diagnosis, and their prognosis
if left untreated. Gauge
what the patient already
knows about their condition
in order to clarify any
misunderstandings
2 Explain the supported
decision making process
Reassure the patient that the
consent process is a shared
decision, that you will support
them through it, and that they
can withdraw their consent at
any time.
3 Understand the patients understanding
wishes, needs, views and
expectations
Do not make assumptions
about what is a good any misunderstandings or further
outcome for a patient. Ask
them what matters to them.
Different patients have different
priorities, perspectives about
what constitutes a material risk,
and what risks are acceptable.
Also, in this discussion you
might learn about their fears,
important family relationships,
or previous clinical experiences
that might influence their
decision.
model where a surgeons preference
would often be presented to patients
as the default option. By using
shared decision making, it is hoped
that patients will be more informed
about treatment options, and that
this will reduce the number of errors,
complaints, and misunderstandings.
Ideally, the consent process should
take place over a period of time to
allow patients to understand their
treatment options.
Who can give consent?
For consent to be valid, the patient
must have capacity, give their consent
voluntarily, and must understand the
information given to them about the
proposed treatment.
If a patient does not speak English,
studentbmj | September 2017 45
a trained independent translator
should be used. For children and
4 Discuss the treatment options usually not made in one sitting
Explain the various options or on the spot. Provide the patients who lack capacity, the
and the key risks, benefits, and patient with resources on their process is different. Children under
outcome data of each, including condition and on treatment the age of 16 may be considered
opting for no treatment. Raise any options for them to read in their Gillick competent to make treatment
material risks or complications own time. decisions on their own.10 If a child is
that might be relevant in order unable to give consent, then a parent
to understand the significance 7 Coming to a decision
or guardian will usually do so.
the patient attaches to them.7 The patient should state their
Individual patient risk should choice of treatment and there An adult patient is deemed to lack
also be coveredfor example should be a detailed explanation capacity if, despite support, they
mortality and complication and time for questions about are unable to retain, understand,
riskswhich will be based on the procedure chosen. The and weigh up information about a
several patient factors such as patient should leave a consent procedure. If their impairment is
cardiovascular health, obesity, discussion feeling as supported
temporary, the consent could wait.
and age. as possible.
Discuss trade offs with the If a patient is unable to give
patient in light of their needs, 8 Respect the patients informed consent, decisions must
goals, and expectations. Explain decision be made in their best interests, with
how different options might help Respect the patients decision input from relatives, your colleagues,
them achieve their goals and the and remind them that signing or by an advance directive.
potential impact of the options on a consent form is not a point of
their short and long term quality no returntheir consent can be
What if a patient refuses consent?
of life. withdrawn at any point if they
change their mind. Patients have the right to refuse
5 Check the patients treatment, provided they have
9 Signing the form and capacity. They should be made aware
Assess the patients maintaining a decision of the likely consequences of their
understanding of the discussion making record decision, as well as alternatives.
so far, so that you can address A consent form should be
co-signed by the patient and
doctor, with one copy put in the
Who should obtain consent?
questions. Ask patients to relay
what they have understood using medical notes and another given Consent should be sought by a
a technique such as Teach- to the patient. The discussion doctor or surgeon trained to perform
back, 13 or similar, and check surrounding the procedure the procedure, but the process may
whether there are any further should be documented in the be delegated to another consultant
questions or concerns. notes, with a record shared or registrar.7 As a foundation doctor,
with patients. On the day of
there will be several procedures for
6 Give the patient time to think the procedure its essential to
about their treatment options confirm and countersign that which you will need to obtain verbal
Give patients time to consider the patient remains willing to consent, but it will be uncommon
their treatment options and proceed, and to answer any for you to carry out procedures that
goals. A decision to consent is final questions. require written consent (there are some
exceptions, such as HIV testing).
As a junior member of the team,
Questions relating to obtaining consent
you can spend time with patients
What patients may want to know about a procedure to check their understanding of
or operation
the procedure. Patients experience
When will they be allowed to go home, and when will they
better outcomes when they feel
resume their normal life?
supported.1112
How will their GP be involved in their ongoing care?
What can they do to maximise a successful outcome?
Documenting consent discussions
Can they meet patients who have been through a similar
procedure? Before an operation can go ahead,
a consent form must be completed.
Questions to consider when obtaining consent Having a thorough discussion with
What are the patients priorities and concerns? patients can minimise the risk of later
How have you addressed and/or accommodated their medical negligence claims.
priorities and concerns?
Dafydd Loughran clinical leadership fellow,
Is the patient aware of any material risks?
Aneurin Bevan University Health Board,
Is the patient aware of alternative treatment options, the Newport, UK
risks and benefits, as well as the likely consequences of Aliya Mackenzie core surgical trainee year 1,
refusing treatment? Medway Maritime Hospital, Gillingham, UK
Natalie Farmer fifth year medical student,
What steps have you taken to make sure the information is
Newcastle University, Newcastle, UK
presented in a way the patient understands?
Cite this as: Student BMJ 2017;25:j3821