Information Sheet for Candidates

You are the covering resident in a suburban

hospital when the charge nurse of the surgical
ward calls you at 9 pm because the surgical
resident has not consented a 75 year old man,
Mr. Smith, who was admitted earlier that day via
the emergency department for amputation of his
right leg because of gangrene of his diabetic
foot. She asks you to do the appropriate
paperwork.

How do you respond to the patient’s request?

HOPC:
Mr. Smith had been referred by his GP because he had developed a gangrenous right foot
over the last 6 weeks on the back ground of poorly controlled IDDM, PVD and heavy
smoking.
It had been documented that he had extensive moist gangrene of his fore-foot involving
all toes which looked putrid, partially necrotic, with sloughing exudate and it was found
to be rather smelly. He had a long history of PVD on the background of atherosclerosis
and heavy smoking with no peripheral pulses palpable below his femoral pulse.
The vascular surgeon had written in the notes “for admission for amputation of right
lower leg”.

PHx: IDDM for 20 years, PVD with severe claudicatio in his right leg for 5 years,
angina for 10 years, no operations.

Med.: mixtard (30/70) insulin, 40 units mane and 30 units nocte, transiderm (GTN)
patch 10 mg/24 hours daily

FHx: unremarkable
S:Hx.: married, 3 children, retired boiler maker, smokes 30 cig. / day, drinks about 3
stubbies every night, NKA.

CONSENT PROCEDURE:
Informed consent to a treatment, investigation or procedure is required and enforced
under Australian law. It reflects the cultural value of the individual’s rights and autonomy
in our society.
Consent should be given without any coercion (voluntary) or time pressure by a
competent patient with adequate information (specific to the situation!)!
It must cover the specific proposed procedure or treatment, considering the relevance to
the individual patient, e.g. a dislocation of a shoulder could have greater significance for
a cricket player (bowler) than a retired accountant.

It must be in writing, signed by the patient and witnessed by a doctor. Risks (anything, if
known to a reasonable person, s/he would attach significance to), complications,
alternatives and the likely outcome need to be specified for the proposed Rx, Ix or Mx..
You have to prove that the patient understood your advice! If the patient’s first language
is not English, consider the involvement of an interpreter!!!

Informed consent does not apply to emergency situations (implied consent)

If the health professional decides that a patient is not competent to consent to treatment,
either because of limited cognitive capacity or insufficient understanding, or next of kin
are not available or able to give consent, contact the guardianship board of the Victorian
Civil and Administrative Tribunal (VCAT). Next of kin can give consent if there is no
dispute about a treatment or procedure, if there is any disagreement, VCAT needs to be
involved.
Ability to consent has to consider the following capacities of a patient:
 Intellectual
 Mental
 Physical
 Sensory
 Neurological

However, if there is no dispute between the doctor, the relatives or primary carer, it is not
necessary to approach the guardianship board!
If a person, appointed under a medical enduring power of attorney, seems to be not acting
in the best interest of the patient, VCAT should be approached to have the person’s
authority cancelled and to have a guardian appointed.

PROGRESS:
When you approach the patient to discuss the operation with him, he starts to become
very upset and tells you that he does not want to be in hospital and he does not want any
operation, “Nobody can touch my body” and similar statements catch you by surprise.
WHAT DO YOU DO NOW???

COMPETENCE: Decision making capacity referring to the ability of the patient to

comprehend, believe and understand the information provided. The patient has to
have the cognitive capacity (SOUND MIND) to understand the medical condition, the
options for treatment, the risks and what may happen if no treatment is given.
? DOES THIS PATIENT FALL UNDER THE RULES OF THE REFUSAL OF
MEDICAL TREATMENT GUIDELINES / ACT?

PROGRESS:
The charge nurse informs you that a relative has turned up who has a written piece of
paper stating that he has the power of attorney for Mr. Smith. You meet the relative, an
elderly woman who seems to be a bit strange. She listens to your request of obtaining
consent for the operation but she says that Mr. Smith has always hated surgeons and
never wanted to have an operation and she states categorically that she refuses to give the
consent for the operation.
WHAT DO YOU DO NOW?

YOU APPROACH THE GUARDIONSHIP BOARD!

Special considerations:
In Victoria a minor is a person under the age of 18 years. Although a person under the
age of 18 years can be considered to be able to consent if they have the maturity and
intelligence to understand the effects of treatment, it’s complications and alternatives
although the Victorian courts have been reluctant to uphold the right of a person under 18
to refuse medical treatment, even when the person is mature.
“Next of kin”
“Person responsible”
“hierarchy” –spouse, primary carer, next relative
Power of Attorney
Medical enduring attorney – agents - guardian