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AHS Clinical Policy

AHS Clinical Policy. Consent to Treatment/Procedure. Overview. Purpose of Consent Policy Consent to Treatment/Procedures Forms Resources Case Scenarios Questions. Consent Policy Suite. AHS CONSENT POLICY (Broad Principles). Suite of Associated Procedures. Adults with Capacity.

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AHS Clinical Policy

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  1. AHS Clinical Policy Consent to Treatment/Procedure

  2. Overview Purpose of Consent Policy Consent to Treatment/Procedures Forms Resources Case Scenarios Questions

  3. Consent Policy Suite AHS CONSENT POLICY (Broad Principles) Suite of Associated Procedures Adults with Capacity Adults with Impaired / Lack of Capacity Mature Minors & Minors Human Tissue & Organ Donation Mental Health Formal Patients & Community Treatment Orders Consent Form(s) As per national & international requirements Consent Form(s) (limited # of forms: needs-based) RESOURCES e.g. patient guides, clinical algorithm etc.

  4. Introduction Purpose of a new consent policy: Consistency of consent process within AHS Legislative compliance Informed consent

  5. Legislative Compliance Adult Guardianship and Trustee Act Human Tissue and Organ Donation Act Mental Health Act Family Law Act

  6. Informed Consent Reflects good practice Contributes to Patient safety Enhances patient experience

  7. Give Consent Withdraw Consent Refuse Treatment Voluntary Informed Specific Shared Decision-Making & Accountability PRINCIPLES Patients / Partners Practitioners Capacity Substitute Decision-Maker Emergency

  8. Consent Process The consent process, when clinically safe to do so, consists of adhering to the following five steps: Determine capacity: as per continuum Commence dialogue: as per rights & principles Verify understanding: address barriers Decision-making: patient/alternate & provider Document process & outcome: verbal or written as required, or noted in health record.

  9. When Consent is Required Before a procedure or treatment is provided there must be express or implied consent Unless a valid exception applies e.g. in an emergency

  10. Most Responsible Health Practitioner Means the Health Practitioner who has responsibility and accountability for the specific Treatment/Procedure(s) provided to a Patient and who is authorized by Alberta Health Services to perform the duties required to fulfill the delivery of such a Treatment/Procedure(s) within the scope of his/her practice. Only the Most Responsible Health Practitioner may now obtain informed consent from the patient

  11. Informed Consent Duty of Most Responsible Health Practitioner to inform the Patient: Nature of Treatment/Procedure Risks Benefits Alternatives Consequences

  12. Implied Consent Consent inferred from the Patient or Alternate Decision-Maker (if applicable) Presumed by actions and surrounding circumstances Example: Presents voluntarily for an examination Minor or less invasive treatment/procedure

  13. New Criteria for Consent “The Most Responsible Health Practitioner is responsible for ensuring that there is valid and informed consent for any given Treatment/ Procedure(s) …… Informed Consent may be expressed verbally or in writing, or be implied.”

  14. New Criteria for Consent “Express written consent shall be obtained for the transfusion of blood and blood products.” (PRR-01, Section 1.3)

  15. Documenting Consent Outcomes • The MRHP is responsible for ensuring appropriate documentation of the consent process and outcomes on the patient health record. • Specifically, the following outcomes shall be recorded: a. Agreement to treatment/procedures b. Refusal of treatment/procedures c. Withdrawal of consent previously given (PRR-01 7.1)

  16. Adults with Capacity An Adult Patient is presumed to have Capacity and is able to make decisions until the contrary is determined

  17. Adults with Capacity Scenario: The patient arrives at the office of Dr. X and needs a bowel resection. “I generally obtain written consent for surgical procedures from patients in my office • In some cases a blood transfusion is needed and I generally discuss the possibility with the patient • Typically in the past where I work I would witness the patient’s signature. • What do I do now?”

  18. Obtaining the Consent Form • Form Name: • Consent to Specific Treatment/Procedure • Form #09741 • Where do I get the form? • Obtain the form the way previously obtained or on Insite • Access on Insite: http://insite.albertahealthservices.ca/frm-09741.pdf

  19. Consent Policy: Blood • The MRHP is responsible for obtaining the consent for blood and blood products. • Per Consent Policy: “Express written consent shall be obtained for the transfusion of blood and blood products.”

  20. Patient Witness MRHP

  21. Witnessing a Consent • Written Consent should be witnessed: • a) Any person, other than a relative of the Patient, the Most Responsible Health Practitioner or the interpreter for the Patient, may witness the signing of a Consent Form.

  22. Witnessing a Consent • Written Consent should be witnessed: • c) In the event that the Patient expresses doubt about the Consent Process and requests further explanation, the witness shall not sign the Consent Form and the Most Responsible Health Practitioner shall be notified. • PRR-01-01 Section 5.6

  23. Procedure: Adults with Capacity • Scenario: • Dr. X is now proceeding with surgery on a patient and consent was obtained over a year ago on the old consent form. • Do I need to do the consent process again?

  24. Duration of Consent • New consent is needed if: • a) The Patient’s condition has materially changed; • b) The medical knowledge about the Patient’s condition or the Treatment available has materially changed; or • c) There has been a refusal to a portion of the Treatment/Procedure(s) originally planned or a refusal regarding the involvement of particular individuals in the Treatment/Procedure(s) (e.g. medical trainees).

  25. Duration of Consent • Dr. X determines that he does not need to obtain a new consent. • Does Dr. X need to complete the new form? No, the old form should be honoured.

  26. Consent Policy • Dr. X requests clarification: “In my facility written consent is required for some procedures yet in other facilities my colleagues tell me that verbal consent is obtained. Does AHS have a list of procedures that require written consent?”

  27. Procedure: Adults with Capacity • Scenario: • The patient was admitted to hospital for treatment of a medical condition but now requires surgery. The resident from the service usually completes the consent form with the patient. • Is this permitted now?

  28. Adults with Capacity • Dr X sees 2 people are waiting for him in his office. He is surprised when the person accompanying the patient requests to see the lab work. • Does this person have the right to see the health record? • The patient identifies this person as a supportive decision maker. • How do I know that this person is the supportive decision maker? • Can he/she sign the consent form?

  29. Supported Decision Maker • Means a trusted person that the capable adult appoints pursuant to the Adult Guardianship and Trusteeship Act to: • Assist him/her with accessing, collecting or obtaining information, making decision(s) and communicating his/her decision(s). • Form obtained from the Office of the Public Guardian website

  30. Adults with Impaired Capacity • Scenario: Dr. X walks into his office and sees 2 people sitting there. The person with the patient says he is the co-decision maker. • Dr X asks: What do I do?

  31. Co-Decision-Maker A Patient who is assessed as having significant capacity impairment, but who is able to make decisions with appropriate guidance, or an interested party, may apply to the court for an order appointing a Co-Decision-Maker to be a partner with the Patient in decision-making for personal matters, including health care.

  32. Co-decision Maker • Decisions are made jointly by the patient and the Co-decision Maker, and both individuals sign the consent form. • What do I do if they disagree on whether to go ahead with the proposed procedure? • The adult patient’s decision takes precedence and he/she can sign without the co-decision maker.

  33. Print names of both Patient and Co-decision Maker Check Co-decision Maker Co-decision Maker Patient Patient and Co-decision Maker both sign

  34. Adults who Lack Capacity Who may give consent for an adult patient who lacks capacity? An Agent named in a Personal Directive A Guardian appointed by the Court A Specific Decision-Maker under the Adult Guardianship and Trusteeship Act

  35. Adults who Lack Capacity • Scenario: • Mrs. B., a 60 year old woman presents to the Emergency department with acute stroke and has had a bleed requiring emergency surgery. • How do we obtain consent for surgery?

  36. Adults who Lack Capacity • Scenario: • Mrs. B goes to ICU post surgery and over the next few days will require a variety of invasive procedures that are typical in the ICU setting • How do we obtain consent now?

  37. Specific Decision Maker Mrs B has no designated agent or guardian Dr X knows that A physician, nurse practitioner, or dentist (for dental care only) may choose the nearest relative* to act as a specific decision maker for a time sensitive health care decision or temporary admission/discharge for a residential facility Dr X meets Mrs. B’s eldest daughter

  38. Specific Decision Maker List Ranked order: spouse or adult interdependent partner adult son or daughter father or mother adult brother or sister Grandfather or grandmother adult grandson or granddaughter adult uncle or aunt; or adult nephew or niece Office of the Public Guardian Contact the Office of the Public Guardian if there is a dispute as to who should be selected or when no person meets the criteria.

  39. Specific Decision Maker is chosen in the ranked order 42

  40. Specific Decision Maker May not: Make health care decisions where a decision respecting the provision of, withdrawal of or withholding of health care would be likely to result in the imminent death of the Adult (PRR-01, Section 8.2)

  41. Adults who Lack Capacity • Scenario: • Mrs. B. recuperates from the surgery and goes to rehab. Despite her physical progression she appears to lack capacity. A formal capacity assessment is planned. • Who can do a formal capacity assessment? • In addition, Mrs. B needs to go to a long term care facility. What happens now?

  42. Minors / Mature Minors Who may give consent Who may not give consent Mature minor assessment Emergency health care

  43. Mature Minor Patient Scenario: A 13 year old teen comes to an STD clinic requesting care. How do we confirm this 13 year old is a mature minor?

  44. Minor Patient Scenario: A 6-year old girl needs surgery but neither of her parents is in town but the mother is available by telephone. How should I complete the consent form?

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