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Guidance to health professionals

(to be read in conjunction with The Consent to Treatment or Examination

policy)

When NOT to use this form

What a consent form is for

When a patient is below 18 and does not have the capacity to consent, you should

This form documents the patient’s agreement to go ahead with the investigation or

use consent form 2 (i.e. Parental (or person with parental responsibility) agreement to

treatment you have proposed. It is not a legal waiver - if patients, for example, do not

investigation or treatment for a child or young person). A patient lacks the capacity

receive enough information on which to base their decision, then the consent may not

to consent to the proposed treatment or investigation if they have an impairment of

be valid, even though the form has been signed. Patients are also entitled to change

the mind or brain or disturbance affecting the way their mind or brain works and they

their mind after signing the form, if they retain capacity to do so. The form should

cannot:

act as an aide-memoire to health professionals and patients, by providing a check-list

• understand the information about the decision to be made

of the kind of information patients should be offered, and by enabling the patient

• retain that information

to have a written record of the main points discussed. In no way, however, should the

• use or weigh that information as part of the process of making a decision

written information provided for the patient be regarded as a substitute for face-to-

• communicate their decision (by talking, using sign language or any other means)

face discussions with the patient.

You should always take all reasonable steps (e.g. involving more specialist colleagues)

to support a patient in making their own decision, before concluding that they lack

The law on consent

the capacity to do so.

Relatives cannot be asked to sign a form on behalf of an adult who lacks capacity to

The process of taking consent is underpinned by the common law, the Human Rights

consent for themselves unless they have been given the authority to do so under a

Act 1998 and the Mental Capacity Act 2005. All staff involved in providing care to

Lasting Power of Attorney or as a Court Appointed Deputy.

patients must be familiar with the Consent to Treatment or Examination policy.

Information

More information on consent and the legislation behind it can be found in the

Department of Health’s Reference Guide to Consent for Examination or Treatment at

Information about what the treatment will involve, its beneﬁts and risks (including

or the Ofﬁce of the Public Guardian at

side-effects and complications) and the alternatives to this procedure proposed is

crucial for patients when making up their minds. The courts have stated that patients

should be told about ‘signiﬁcant’ risks which would affect the judgement of a

reasonable patient. ‘Signiﬁcant’ has not been legally deﬁned, but the GMC requires

Who can give consent

doctors to tell patients about signiﬁcant, unavoidable and frequently occurring risks.

In addition if patients make it clear they have particular concerns about certain kinds

Everyone aged 16 or more is presumed to be competent to give consent for

of risk, you should make sure they are informed about these risks, even if they are

themselves, unless the opposite is demonstrated. If a child under the age of 16 has

very small or rare. You should always answer questions honestly. Sometimes, patients

“sufﬁcient understanding and intelligence to enable him or her to understand fully

may make it clear that they do not want to have any information about the options,

what is proposed”, then he or she will be competent to give consent for himself or

but want you to decide on their behalf. In such circumstances, you should do your best

herself. Young people aged 16 and 17, and legally ‘competent’ younger children, may

to ensure that the patient receives at least the very basic information about what is

therefore sign this form for themselves, but may like a parent to counter sign as well.

proposed. Where information is refused, you should document this on this form and

However even where a child is able to give consent for himself or herself, you should

in the patient’s medical records.

always involve those with parental responsibility in the child’s care, unless the child

If consent is sought for the use of tissue/blood products from the patient for one or

speciﬁcally asks you not to do so. If a patient is mentally competent to give consent

more of the purposes identified in the consent form, information should be given to

but physically unable to sign a form, you should complete this form as usual, and ask

the patient about the nature and purpose of what is proposed so that the patient is

an independent witness to conﬁrm that the patient has given consent.

able to make an informed decision. The patient should be told of any ‘significant’ risks

inherent in the way the tissue/blood products will be obtained, how the tissue/blood

products will be used and any risks or possible implications of its use. When taking

consent for the use of tissue/blood products, you should comply with the Human Tissue

Authority Code of Practice on Consent.

Patient Agreement To Investigation Or Treatment - Heart Of England Nhs Foundation Trust Page 2

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