Informed Consent

Policy

We support patients' right to be fully informed about their health care in accordance with the Code of Health and Disability Services Consumers' Rights 1996.

We help patients understand their health needs, so they can make an informed choice, and give informed consent (Right 7) if they are able to.

To do this we:

• provide clear explanations of the patient's condition, the treatment options, and any other relevant information
• ensure that patients can understand the information we give them
• advise patients of their right to have a support person or family/whānau attend their appointment
• consider the patient's cultural preferences.

Patients whose first language is not English, and patients who are deaf or hearing-impaired, should be offered an interpreter.

The clinician treating the patient is responsible for ensuring the patient is able to make an informed decision.

We acknowledge that patients have the right to refuse treatment and withdraw consent at any time.

For more information refer to MCNZ – Information, choice of treatment and informed consent.

Ensuring health literacy

Health providers are responsible for improving health literacy by considering barriers or potential barriers to understanding, and working to reduce them. Reducing the demand on patients to understand information and services can make healthcare more accessible.

You may need to:

• present information in different ways for different people

  For example:

  • Use plain language and simple terms wherever possible (written and spoken).
  • Avoid clinical terms and jargon (including abbreviations and acronyms). If they must be used, explain their meaning – don't assume that the patient is familiar with them.
  • Highlight or underline important words in written information.
  • Give the patient time to:
    • digest and respond to information during the consultation
    • consider the information and decide at a later date if they need to.
  • Provide additional resources, such as handouts, for the patient to take away and look at in their own time.
  • Don't assume the patient understands just because they agree. It may be better to assume that most individuals will have difficulty understanding complex concepts some of the time.
  • Consider what format might be most accessible – use visual tools such as images, diagrams or charts to add context to information and support understanding.

• use strategies to check a patient's understanding of the options and the treatment they are consenting to.

  For example:

  • Use plain language and simple terms wherever possible (written and spoken).
  • Avoid clinical terms and jargon (including abbreviations and acronyms). If they must be used, explain their meaning – don't assume that the patient is familiar with them.
  • Highlight or underline important words in written information.
  • Give the patient time to:
    • digest and respond to information during the consultation
    • consider the information and decide at a later date if they need to.
  • Provide additional resources, such as handouts, for the patient to take away and look at in their own time.
  • Don't assume the patient understands just because they agree. It may be better to assume that most individuals will have difficulty understanding complex concepts some of the time.
  • Consider what format might be most accessible – use visual tools such as images, diagrams or charts to add context to information and support understanding.

If a patient has complex communication or literacy needs, identified by them or by practice staff, record it in the PMS.

For more information see MOH: A Framework for Health Literacy and Healthify | He Puna Waiora Health Literacy for Healthcare Providers.

low health literacy, limited health literacy

Shared decision making

Shared decision making is patient-centred and may involve:

• asking the patient about their beliefs and preferences
• presenting treatment options and discussing them in the context of those beliefs and preferences
• agreeing a course of action/inaction that aligns with what is important to the patient.

Confirm and record who has been involved in the decision-making process (e.g. family/whānau, clinician, patient).

Obtaining consent

Before proceeding with treatment clinicians should:

1. Give the patient all relevant information.

   Provide the patient with information about:

   • the risks and benefits of proposed treatments
   • whether the treatment will be part of any teaching and/or research, and any risks/uncertainties
   • the results of tests and procedures
   • treatment cost and timeframe.

   The patient may also request, and should be supplied with, information about:

   • why a treatment pathway is being recommended
   • how to obtain a second opinion
   • the qualifications of the health provider treating them
   • any relevant research results.

   A written summary should be provided if the patient requests one.

   If a patient is choosing between evidence-based medicine and innovative treatments for which there is no scientific evidence, their clinician should present a clear and balanced summary of the information available.

2. Check the patient's understanding.

   For example:

   • Use plain language and simple terms wherever possible (written and spoken).
   • Avoid clinical terms and jargon (including abbreviations and acronyms). If they must be used, explain their meaning – don't assume that the patient is familiar with them.
   • Highlight or underline important words in written information.
   • Give the patient time to:
     • digest and respond to information during the consultation
     • consider the information and decide at a later date if they need to.
   • Provide additional resources, such as handouts, for the patient to take away and look at in their own time.
   • Don't assume the patient understands just because they agree. It may be better to assume that most individuals will have difficulty understanding complex concepts some of the time.
   • Consider what format might be most accessible – use visual tools such as images, diagrams or charts to add context to information and support understanding.

3. Consider whether consent is being properly obtained for:
   • children under 16 years

     There is no legal minimum age for consenting to health care. Children under 16 can legally give consent if the clinician is satisfied that they:

     • fully understand the purpose, options, and possible consequences of having/not having the treatment
     • are mature enough to make their own decisions about their care.

     The clinician should form a professional judgement on whether the child is capable of giving consent. If the clinician considers the child is not capable, the consent of a parent/legal guardian is needed.

   • patients with reduced capacity to consent

     Where possible obtain the patient's consent for the parts of the treatment they are able to understand.

     If you are confident that a patient lacks the capacity to make decisions about their treatment, you will need to involve someone who has the legal right to make decisions on their behalf. This could be the patient's family/whānau/caregiver, or someone with power of attorney.

     Document in the patient notes, any feedback you received from those parties that helped you reach a decision.

4. Record whether consent is verbal or written:
   • In situations that require written consent, ask the patient to sign a consent form which is scanned into the patient record.

     Written consent must be obtained in any of the following situations:

     • The patient:
       • is participating in research
       • will be under general anaesthesia
       • may be at significant risk of an adverse effect.
     • The procedure/treatment is experimental.
     • A different situation, such as an offsite vaccination programme (for example in a school or office) applies.

     Source: RNZCGP

   • If the discussion is taking place via a telehealth consultation, record the patient's email, text, or voicemail consent in the patient record.
5. Record all communication: consent given/declined, concerns/requests, and decisions made, in the patient record.

If the patient needs emergency treatment and is unable to give consent, the emergency duty of care overrides the need for consent.