Joke: What Do You Call Uninformed Consent? Punchline: No Consent at All!

OK. I know, that was a lame joke. I hope you aren’t coming to this blog for humour.

Let me tell you about something that happened to me a few years ago, before I was Registrar of the College of Physiotherapists of Ontario.

I called a sports rehab clinic where I’d been before, to see a physio for treatment for lower back pain. I was assessed and received treatment three times over a two-week period. It wasn’t until then that the clinic asked for payment. After I paid, I was handed a receipt signed by a PT who wasn’t the person I’d seen. I thought it was an error, so I asked the receptionist about it. She told me not to worry because the guy I’d been seeing was a support person and the PT whose name appeared on the receipt was happy to have the billing go out under her name and registration number.

What’s this got to do with consent? Well, I was not informed that the person treating me was not a PT. It was reasonable for me to assume that he was, since when I called to make the appointment, I asked for a PT. When this fellow talked to me about my treatment plan and when I signed the form, I was consenting to receiving treatment from a physiotherapist, not a support person. So, in fact, he did not have consent to treat me at all. There are other problems with this arrangement, including the fact that it’s inappropriate for support personnel to conduct assessments, but that’s a subject for another day.

Sometimes we regulators can make the idea of consent sound tricky, but I don’t think it really is. As a patient, I can only give my informed consent if you have given me all of the information that I need to make choices about my care. The Health Care Consent Act outlines some of the things that patients need to know, but it’s really common sense. You need to give the patient all of the information that a reasonable person would need to know to make a decision about treatment (that includes things like what the treatment plan will look like, what my options are, whether there is support personnel involved and how many visits I can anticipate will be needed).

Signed consent forms are the icing on the cake—they are a good way for the PT to demonstrate that he or she had the consent conversation with the patient. But what if there is no conversation: what if, instead, the patient fills in a form on a clipboard at the reception before even meeting the PT? Without a detailed conversation with the physiotherapist immediately, that’s probably not consent.

In 2007, a researcher looked at how physios in private practice understood informed consent.[1] She found that the PTs thought of informed consent as part of their routine clinical explanations, rather than a process of providing choices. The PTs were more concerned about ensuring a good outcome than enhancing the patient’s ability to make a choice. On the one hand, that’s great—I speak on behalf of all your patients when I tell you how much we appreciate your focus on our well-being. But on the other hand, it’s my body and what happens to it ought to be my decision.

Perhaps it seems like I am oversimplifying. Maybe you work in a place with a number of other professionals on a team and the administrative requirements are for one consent form to be filled out at the beginning of the treatment. As long as there is a real conversation, that’s OK. One team member can obtain consent on behalf of the other care providers. The test is whether the right information was provided and understood by the patient.

Think about this like any other task you might assign to someone else. You may assign obtaining consent, but only if the person who is having the conversation with the patient is appropriately trained and knowledgeable.

Did the patient know who was going to be treating her? Did she understand any potential side effects? Did she know what options she had for treatment? Did she understand her treatment plan and, if it involved support personnel, when she would be reassessed by a PT?

If the answer to each of these questions is yes, it sounds like you got consent. And if the treatment changes as the patient progresses, you should get fresh consent and that doesn’t have to be a form—it can be a conversation and a note in the file (please don’t forget to document that you got consent—there are so many ways it can go badly if you don’t). Remember, the conversation is about offering the patient choice: it’s not about telling them what will happen next.

I have another story about consent. My daughter was delivered by emergency C-section. There I am, with six hours of labour behind me, being rushed to an emergency room. Around me, a battalion of nurses and residents running along beside me. “Do you consent to a C-section because your baby is not getting enough oxygen?” frantically asks a stranger in a mask. And my nod is recorded on my chart. No way was that informed consent. But my fantastic 13-year-old daughter is a good reminder to this regulator that in emergencies sometimes even the most sensible rules need to bend.

Your turn. Have you had consent conundrums? What are your challenges?

___________________________
[1] Clare M. Delany, “In private practice, informed consent is interpreted as providing explanations rather than offering choices: a qualitative study,” Australian Journal of Physiotherapy 2007, Vol. 53: 171-177.

Related resources:
Briefing Note: Health Care Consent Act
E-Learning Module: Consent

3 thoughts on “Joke: What Do You Call Uninformed Consent? Punchline: No Consent at All!

  1. I think that physiotherapists (and probably many other health care professionals) do not sufficiently appreciate the importance of ongoing consent. I am thinking of situations where treatment is painful or when new clinical information leads to different treatment. Obtaining consent is one step, maintaining consent is a continuous process in the course of assessment and treatment.

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  2. Dear Shenda:

    Thanks for this. We have two initial consent forms. The first one is provided to the client before s/he see’s the therapist. This consent form asks the clients consent to give approval for the physiotherapist named on the page to perform the assessment. If this is not signed then the therapist can not assess the client.

    The second consent form is completed after the assessment. There is dialogue between the client and the therapist. The therapist informs the client of a specific diagnosis that s/he has made from the assessment, the goals of this treatment plan and the risks of any modalities that are to be used in this treatment plan. If any of the treatment plan is going to include rostered activities ( ex manipulation or Acupuncture) than individual consent forms are provided to the client to be signed. Giving the client choice on reaching their goals usually is the best way to get improvement.

    DFreer

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  3. Dear Shenda, I am begining to enjoy your blog. It shows the human face of the college.
    Obtaining informed consent before begining any physiotherapy treatment, is not only necessary, but it gives therapist a chance to build a trusting therapist-patient relationship. In LTC setting, however obtaining consent from PGT takes some time, and causes delays in treatment planning.

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