What is consent? How do you ensure that you have provided enough information to your clients so that they can make an informed decision?
Client autonomy is one of the cornerstones of client-centered care. It is the idea that clients have the ultimate power to make decisions about their health and whether to proceed with the recommended treatment or services. Client-centered care means empowering clients to become informed and involved in decision-making about their health. An important part of this is making sure they have a choice. Even though you may have some influence, the choice of a treatment or intervention plan is always up to the client. This is where consent comes into play. There are three different types of consent:
Informed consent: consent given by a client that is based on a clear appreciation and understanding of the facts, implications and future consequences of actions. To give informed consent, the client must have adequate reasoning faculties and know all of the relevant facts at the time consent is given. In some instances, a substitute decision-maker may be involved in giving informed consent.
Express consent: consent that is given explicitly, either verbally or written, by the client or substitute decision-maker for a specific purpose.
Implied consent: consent that is inferred from signs or actions. The standard to determine whether implied consent was obtained is based on whether a reasonable person in the same circumstances would believe that consent is given.
Knowing the differences between types of consent is helpful, but what does informed consent consist of and how is it applied in practice? There are many components that are required to determine if the client understands and appreciates what is being asked, so that they can agree to the proposed assessment, treatment or intervention:
- The client must be fully informed;
- Consent must be given voluntarily;
- The consent being obtained must be related to the reason for the service or treatment;
- Consent cannot be obtained through fraud or misrepresentation; and
- Where appropriate, consent must be documented in a written form signed by the client or otherwise documented in the client record
Appropriate discussion and dialogue
For consent to be informed, a discussion must take place about the side effects and risks of the proposed assessment, examination, treatment or intervention. You must disclose all risks, even if they are serious. It is important that the nature of the treatment or intervention, benefits, consequences of not pursuing the recommendations, and costs are all discussed up front. The client must be provided with the opportunity to ask questions and have them answered before they give consent (either verbally or written).
Consent is an ongoing discussion
Over time and with treatment, a client’s situation changes, or their risks change. This warrants further discussion between you and the client and documentation of that discussion in the client record. The client should receive ongoing information about the efficacy of treatment through periodic reassessment, and discussion about treatment goals. Clients may withdraw their consent to any assessment, examination or treatment at any time and for any reason, even if compelling evidence indicates that treatment is advisable.
Understanding capacity to consent
In Ontario, the
Health Care Consent Act, 1996 explains the parameters around a client’s capacity to consent to or refuse treatment. A person is capable of providing consent if they are able to:
- Understand the information that is relevant to making a decision about the treatment,
- Appreciate the reasonably foreseeable consequences of a decision or lack of decision, and
- Justify their decision.
It is important to remember that capacity is not global and is not permanent. This means that clients can be incapable of making one decision regarding an aspect of their treatment, but they may be able to understand, appreciate and justify their choice regarding another aspect of treatment. They may have “good days” and “bad days”. Clients with diminished capacity should be provided as much autonomy as is reasonable. Capacity is always presumed. If a client refuses to consent to treatment, or if they withdraw their consent, it does not mean they are incapable.
Learn more about assessing capacity.
If you conclude that the client is not capable of consenting to a proposed intervention, you are expected to inform the client of this finding, and include the client in the process as much as possible. You must then (absent an emergency) obtain consent from a substitute decision-maker.
View the hierarchy of substitute decision-makers.
What about children and youth? The Health Care Consent Act does not identify an age for consent in Ontario. It is accepted that the capacity to make decisions varies with the individual and the complexity of the decision. When a child does not have capacity to consent, you are encouraged to seek consent from the appropriate substitute decision-maker.
Learn more about children’s rights to healthcare.
Consent and record keeping
Consent must always be documented and kept in the client record. You are required to obtain informed consent for:
- Assessment (consent recorded and date it was given);
- The involvement of other care providers;
- Treatment/intervention;
- Collection, use and disclosure of information;
- Cost and billing schedule; and
- Subsequent changes to the treatment plan (explanation note if treatment not completed).
This is a
sample consent form developed by a registered kinesiologist. You may adapt it to suit your practice.
Remember that consent is not just one document or signature. It is a continuous process, and as the health care parameters change for the client, you must ensure that you are obtaining consent.
If you have any questions, contact Lara Thacker, Director of Quality Assurance via
email or at (416) 961-7000 ext. 103.