|Title:||Consent to Treatment Policy for the Western Australian Health System|
|Document ID:||Operational Directive OD 0005/06|
|Date of issue:||Tuesday, 7 November 2006|
|Status:||NO LONGER APPLICABLE|
The Department of Health has developed a revised Consent to Treatment Policy for the WA Health System ('WA Consent Policy') which outlines the process and requirements for obtaining a patient's consent to treatment for clinicians working in WA hospitals and health services.
This policy updates and replaces the Department of Health's 2000 Guidelines for Health Practitioners: Patient Consent to Treatment and Disclosure of Material Risk (OP 1347/00) and related operational circular on Documenting Patient Consent to Treatment and Disclosure of Material Risks by Health Practitioners (OP 1857/04).
A copy of the full WA Consent Policy is available from the Safety and Quality in Health Care Division website at http://www.health.wa.gov.au/safetyandquality/programs/informed_consent.cfm
|Applicable to:||Doctors, Nurses, Health Service Administrators|
|Period of effect:||from 7 November 2006|
|Authorised by:||Dr Neale Fong, Director General, DEPARTMENT OF HEALTH, 07-Nov-2006|
|Print version:||View print version|
Consent to Treatment Policy for the Western Australian Health System
The Department of Health has developed a revised Consent to Treatment Policy for the WA Health System (‘WA Consent Policy’) which outlines the process and requirements for obtaining a patient’s consent to treatment for clinicians working in WA hospitals and health services. This policy updates and replaces the Department of Health’s 2000 Guidelines for Health Practitioners: Patient Consent to Treatment and Disclosure of Material Risk (OP 1347/00) and related operational circular on Documenting Patient Consent to Treatment and Disclosure of Material Risks by Health Practitioners (OP 1857/04).
A copy of the full WA Consent Policy policy is available from the Office of Safety and Quality in Health Care website at: http://www.health.wa.gov.au/safetyandquality/
WHAT IS MEANT BY CONSENT TO TREATMENT?
Consent is a patient’s agreement for a health practitioner to provide treatment. For the purposes of this policy, the consent process should be thought of as a series of steps:
Whether or not medical treatment is to take place is a decision for the patient, and as a matter of policy, no treatment may be performed without the consent of the patient, if the patient is a competent adult, except in narrowly defined circumstances. Failure to obtain a patient’s consent for a procedure may result in a criminal charge of assault or civil action for battery, whereas failure to disclose material risks to a patient may give rise to civil action for negligence.
WHAT INFORMATION SHOULD BE PROVIDED TO A PATIENT?
Information that should be provided to a patient to assist him/her understand his/her illness and the available treatment options include:
Requests for further information or specific anxieties expressed by the patient should be answered frankly and honestly.
DOES CONSENT HAVE TO BE OBTAINED IN WRITING?
Generally, the law does not require consent to be given in writing. An exception to this rule include consents required under the Mental Health Act 1996 (see Section 4 of this Consent Policy). Section 110 of the Mental Health Act 19969 requires the written approval of the Chief Psychiatrist for the provision of medical treatment to an involuntary patient or a mentally impaired.
It is however, the Department of Health’s policy that written consent, using an approved consent form, must be obtained for:
Model consent to treatment forms for adults, minors and patients incapable of consenting to the procedure/treatment are provided at Appendices 1 to 3 of the Consent Policy
Where the patient’s consent is not obtained in writing, the risks and benefits of the procedure must be explained to the patient. A record of what material risks have been disclosed to the patient must be kept in the patient’s consent recorded.
ARE THERE DIFFERENT ARRANGEMENTS APPLYING TO CONSENT?
The requirements for consent to be obtained prior to the commencement of treatment may vary depending on whether the patient is competent (adult or a mature minor), or incompetent (child or adult requiring parent or legally appointed guardian). The following situations may require varying arrangements:
WHO IS RESPONSIBLE FOR OBTAINING THE PATIENT’S CONSENT?
Where a medical practitioner recommends or advises that a patient undergo treatment, they are responsible for providing sufficient, appropriate information and advice to the patient to enable he/she to make their own informed decision to undergo the treatment. In general, the most senior medical practitioner on the treating team is ultimately responsible for ensuring consent to treatment has been adequately obtained.
A senior medical practitioner may delegate the task of obtaining a patient’s consent to treatment to a Junior medical practitioner. However, the senior medical practitioner must ensure that the delegated practitioner is competent to undertake that task and, in appropriate cases, take reasonable steps to ensure that the patient has been properly informed and that a consent form has been completed. The senior medical practitioner may be held responsible, where the task has not been appropriately carried out.
HOW LONG DOES THE PATIENT’S CONSENT LAST?
In principle, a health practitioner’s duty to disclose material risks and obtain a patient’s consent for treatment is a continuing obligation and should occur both before the decision to proceed with treatment and as close as is reasonably practicable to the commencement of the treatment process and preferably, prior to admission.
Consent is considered valid until the patient withdraws consent or there is a change in patient’s circumstances. It is highly recommended that consent be reviewed if consent has been obtained more than 3 months prior to the treatment being performed. The previously completed form may be revalidated if patient’s circumstances have not altered, otherwise a new consent form should be completed. The consent process must be renewed if the period between the date of consent and the date of the procedure being performed exceeds six months.
If a patient consents to a procedure and then subsequently withdraws his/her consent, the date of withdrawal should be documented in patient’s medical record.
WHAT EVIDENCE SHOULD HEALTH SERVICES EXPECT OF DOCTORS TO INDICATE THAT CONSENT HAS BEEN OBTAINED?
It is the hospital/health service’s responsibility to verify that a health practitioner has completed the consent process for each patient and has satisfied his/her obligations in relation to gaining valid consent. It is the responsibility of the hospital to ensure that the patient’s consent has been obtained by the medical practitioner concerned prior to: the patient’s admission to hospital (where possible), pre-medication being administered; and preparation for transfer to Operating Theatre, Diagnostic Unit or Medical Imaging Department. Hospital/Health Service staff must notify the relevant Clinical Nurse Manager and the Medical Director and relevant Health Service Administrators of all incidences where valid consent has not been completed.
All enquiries about the WA Consent Policy should be directed to the Office of Safety and Quality in Health Care on (08) 9222 4080 or e-mail: firstname.lastname@example.org
d Procedural risk refers to a professionally recognised risk that a given procedure is likely to induce any of the following a) functional impairment b) injury c) morbidity d) death
Dr Neale Fong
This circular last updated: Thursday, 11 January 2007 at 1:09pm