Consent – it’s not just about risk

In the last blog we spent time understanding the history of consent and the complete switch in the focus of consent since 2015. If you missed it, watch the video on facebook or see the previous post.

Consent is the most important aspect of practice

In my opinion gaining consent is the most important aspect to osteopathic treatment. It doesn’t matter if you are the most amazing osteopath with incredible premises if you practice without gaining valid consent you are both ethically and legally deficient. Good communication is fundamental to gaining consent. We are going to spend some time considering different aspects of consent and communication. Reading these blogs or listening to the videos can count towards your CPD if you document your learning and development.

A Montgomery approach to consent

A Montgomery view should be the foundation for your approach to consent. The patient perspective is the priority at all times.

Many practitioners have become focussed on consent as informing patients of benefits and risks of treatment. That is certainly part of informed consent but it is only a part, there is a lot more to consent.

3 fundamentals for consent

You will have noticed that in the new OPS A4 on Consent has quite a different look. There are three fundamentals to consent that are clearly highlighted in the guidance. Consent must be voluntary, by an appropriately informed person with the capacity to consent to the intervention in question.

A4 states that you must have valid consent for all aspects of examination and treatment. That statement alone makes it clear that consent is not simply informing patient’s of risk.

If any of the three caveats already mentioned – voluntary, appropriately informed, with capacity – are not applicable the consent is considered invalid.

We’re going to consider the first two in detail here but capacity is a large subject that will considered in a further post.

Voluntary consent

You must be sure that your patients have come to the clinic voluntarily. This does not simply mean that they drove to the clinic and walked through the door by themselves. Where there are arrangements with workplaces or family pressures patients may feel obligated to attend treatment. Sometimes asking the question – how did you hear about the clinic? Or what has brought you to the clinic today? can illicit a response that may suggest that the patient has not come voluntarily. You should address and either obtain the patient’s consent to continue or allow them to leave without continuing the consultation. Make sure this is documented in the patient record.

Informed consent

Before you examine or treat a patient you must ensure that they know that they can have a chaperone, they can stop treatment at any time and what they can realistically expect from you.

Patients need to give you permission for what you are doing and why you are doing it – this includes examination and treatment. How do you achieve this? Maybe you spend time beforehand explaining what will happen during a session, yes, including the risks and benefits but also the different options for treatment and what the patient wants to achieve, their personal goals. Perhaps it is a mix of an initial explanation and then an ongoing dialogue – explaining and gaining permission.

Patients should always understand what you are doing – if you are using the patella hammer, why? If you are touching them on their leg and their pain is in their back, why? – everything must be done with the patient’s agreement. It can be difficult for practitioners to remember what ‘normal’ people know and put themselves in the patient’s shoes who mostly have no idea about how the body works or is interconnected.

When you have a working diagnosis or hypothesis this must beexplained to the patient in a way in which they understand. Patient’s must beinvolved in planning treatment. This involves discussing care options and identifying their goals. This may simply be to get out of pain or it may be more specific –to attend an event or return to an activity or achieve a particularresponsibility. Treatment plans and priorities must be based on the individualpatient’s values and preferences.

If your treatment is going to involve an intimate area then you need to make sure you have explicit permission for this. You may need to allow patient’s time to go away and consider having that treatment. You must have written consent for examination or treatment of intimate areas.

Another area you need consent for is information collecting, use and sharing. This should all be done within GDPR parameters. Hopefully you are up to date with GDPR.

One of the most important things you can say to a patient is:

‘Do you have any questions?’ Or more recently I heard a practitioner had tried rephrasing this as ‘Ask me 2 questions’ with much more response than simply inviting questions.

We’ll return to this when we look into communication more.

Recording consent

Finally in this post, we are going to consider how you record consent. There are a couple of areas that we need to return to in further posts – children and young people and capacity and communication.

Your notes should include the information you discuss with your patient, any concerns, expectations or requests for more information and how these were addressed and any decisions made. To me, that is two sections on your patient history form:

  1. The information discussed – proposed treatment plan, diagnostic hypothesis, benefits, risks and alternatives explained to treatment
  2. Concerns, expectations or requests for more information and how you addressed these.

You must obtain written consent for intimate examination.

Develop your own consistent, robust procedures for informing patients and recording your evidence. The evidence of your consent procedures with the individual patient is very important should any problems arise.

My ambition is for all osteopaths to be confident in their consent procedures. The reflective practitioner will always be able identify areas for improvement and individual patients where procedures could have been improved but as long as you fundamentally have good procedures you can continue on your personal development.

In Summary

In summary – consent must be voluntary, informed and with capacity. It is an ongoing process throughout examination and treatment and includes all decisions made about treatment. Patients must understand at all times what you are doing and why, understand their condition and agree the treatment plan including – areas to be treated, methods involved, benefits and risks, self management, expectations of treatment and so on. You may have amazing consent procedures in your first appointments but how are your consent procedures for follow-up treatments or returning patients – do you achieve the same standards?

To me good consent is a conversation. You will notice I haven’t referred to consent forms or signatures. You may choose to use these as part of your patient contract and demonstrating your professionalism and focus of your clinic from the start but a form alone is useless as evidence of consent. It’s making sure your patients are informed and understand what is going. Good consent is fundamental to your patient-practitioner relationship. It will make sure your patients are fully engaged with the treatment process. It is really important that patients are active participants in the treatment process rather than passive recipient in paternalistic care. Patient outcomes and satisfaction are far better for informed, active participation in their care.

What are you going to do now?

Are there any aspects of consent that you need to improve?

Look at any notes you may have made or areas which have particularly struck you and take action today. Make your consent procedures robust and your recording consistent so that you can have confidence in your practice. Have you got any questions or do you need any support? Please feel free to ask in the Mint Practice group.

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