Consent

Not getting adequate consent is the fourth most common cause for medical indemnity claims[1].  It also accounts for high proportion of the cases which are taken to the GMC and local Performance Groups.

When consent is not adequately obtained, and a claim arises, 75% of claims are settled without going to court.[2]  This suggests that not getting adequate consent is indefensible.

In general practice, consent usually applies to examination, and can also apply to testing and carrying out procedures.  We generally assume that patients want to be examined, and also that when we ask to perform an examination that the patient will consent.  Most of the time the patient will demonstrate this implied consent by exposing the relevant area to be examined.

During recent performance hearings this assumed implied consent has, however, been highlighted as a risk for the doctor.  For instance; when asking to examine a patient’s chest they may not realize that we want to examine the back of the thorax.  This could lead to the patient feeling that the examiner has not got full consent for examination. 

One complaint which was part of a recent investigation was that “the doctor hit my chest again and again”.  Clearly the doctor was percussing the chest appropriately, but the patient did not understand this.  What this demonstrates is that a proper explanation of procedures, including examination, is essential when gaining consent.  If the doctor had said “I would like to examine the front and back of your chest with my stethoscope, and to tap your chest with my finger, would that be ok?” the patient would have been able to give informed consent to this, verbally and by implication.

When carrying out intimate examinations the need for adequate consent is, of course, more critical.  The GMC has issued specific guidance on intimate examinations, this states;

“Before conducting an intimate examination, you should:

a. explain to the patient why an examination is necessary and give the patient an opportunity to ask questions

b. explain what the examination will involve, in a way the patient can understand, so that the patient has a clear idea of what to expect, including any pain or discomfort

c. get the patient’s permission before the examination and record that the patient has given it

d. offer the patient a chaperone”

We are used to asking for permission to perform examinations, but are not so used to explaining the purpose of the examination, and detailing the exact nature of the examination.

The GMC policy states that we should “offer the patient a chaperone”, and there is further guidance given about chaperoning[3].  The LMC recommends that all practices have a chaperoning policy which reflects this guidance.

Consent for medical procedures is equally important.  The main reason for complaints about medical procedures is that the patient did not have enough information to make an informed choice about whether or not to have the procedure.  For this reason it is recommended that the pros and cons of medical procedures are given to the patient both verbally and in writing in advance of the procedure.  In hospitals this information is usually given on multiple occasions; in clinic, at the pre-op assessment, and prior to surgery.  In general practice we often do not have the luxury to provide this level of information sharing.  However, for commonly carried out procedures, we could, and should, explain the procedure when we initially agree to add the patient to a waiting list.  Ideally the patient should also be given an information leaflet, so that when they return for the procedure they have had time to digest the information and have opportunity to ask questions before giving written consent.

As with all Performance Matters issues, all of the advice is only useful in practice if documented in the patients notes.  Thus, when gaining consent for examinations and procedures, it is vital to record that an explanation was given for the purpose and process, and that the patient consented for the examination or procedure to be carried out.

[1] MPS

[2] Australian MPS

[3] Intimate examinations and chaperones (2013)- GMC