Taking Time to Inform a Patient is Time Well Spent

Accountability for the informed consent process generally lies with the doctor responsible for the treatment.

Although a senior doctor will often delegate the task of obtaining consent to a junior colleague, the senior doctor remains responsible for both the health care and the consent process.

You may be asked to obtain consent for an examination, investigation, procedure or treatment you’re unfamiliar with. Doctors have a legal and professional responsibility to refuse to undertake this task if they feel they don’t have the appropriate skill or experience.² While you may not want to make a fuss, it’s important that you politely say no.

Informed consent isn’t just a signature or an event, it’s a process based on good communication.

Discuss the health care to be delivered
It’s useful to first ask the patient what they already know. You should provide the patient with information that a reasonable person would require to make an informed decision.

Confirm their understanding
Ask the patient to summarise what they have understood from the conversation, e.g. “I want to make sure I explained this clearly. When you go home today, how will you take this medicine?” Pay attention to their responses to identify if they’ve understood and, if not, communicate the information in a different way.

Give further information
As well as providing information verbally, use diagrams or written information where appropriate.

Document
Depending on the situation and nature of the intervention, you may only be required to make a brief note in the medical records, or you may need to provide more detail particularly where elective procedures are involved.³ Some organisations have policies for the minimum information that needs to be documented.²

Check whether the health department and/or hospital where you work has policies on when consent should be obtained in writing.¹ While the law does not require a consent form to be signed by the patient, the patient’s decision should still be documented in their medical records. Documenting this can substantially strengthen a defence to a claim or complaint.

A clear consent discussion makes the patient better informed and more empowered to take responsibility for their decisions and less likely to have a negative reaction towards the doctor if what was warned actually occurs.

More information on consent is available on the Education portal of our Member Online Services. You can also check out the What’s On page at mdanational.com.au to find out about upcoming workshops.

Gemma Brudenell
MDA National Education Services

1. MDA National. Confidentiality and Consent. 2009. Available at:
members.mdanational.com.au/Documents/education/MDAN18243%20260.4%20ML%20CONFIDENTIALITY%20&%20CONSENT%20BOOKLET_FINAL%20HR.PDF

2. Department of Health. Consent to Treatment Policy for the Western Australian Health System. 3rd ed: East Perth: Department of Health, 2011. Available at: health.wa.gov.au/circularsnew/attachments/564.pdf.

3. Barnett R. The Consent Procedure: Some Thoughts From a Reconstructive and Cosmetic Surgeon. Defence Update. Winter 2011:12. Available at: mdanational.com.au/media/144474/mdan14575%20301.27%20defence%20update%20winter%202011_final_web.pdf.