Consent in everyday practice: reflections from a GP

In my role as a medical adviser at Avant, I have been working with colleagues in education and research to develop a new campaign about consent. As part of that work, we updated our analysis of nearly 16,000 claims and complaints and found that one in six involved consent as either a main or contributing factor.

As we discussed the findings, the team asked me to reflect on an ordinary day in general practice and consider all the different occasions when I sought or confirmed a patient’s consent.

Consent is something I think about every day. However, I had never stopped to consider just how many consent-related conversations take place over the course of a single day. When I did, I was surprised by how deeply consent was embedded in my routine interactions with patients.

It arose not only when discussing a procedure or asking a patient to sign a form. It was present when a family member joined a consultation, when a medical student observed an appointment, when I recommended a change in medication or when I needed to determine whether a patient had capacity to make a healthcare decision.

Most of these conversations did not feel formal or unusual. They were brief exchanges, questions and explanations that had become a natural part of my everyday practise.

Yet three consultations, in particular stood out.

Consent may need to be revisited

My first patient had booked an extended appointment for a skin check. When she arrived at reception, the receptionist confirmed her contact details and asked whether she agreed to receiving SMS reminders and other practice communications.

I also had a medical student working with me that day. While the patient was still at reception, and away from both me and the student, she was asked whether she would be comfortable having the student present during her consultation. This gave her the opportunity to make the decision privately, without feeling pressure from either of us. She agreed.

During the skin check, I identified several lesions that were suitable for cryotherapy. I explained what I had found, why I was recommending treatment and what the procedure would involve. We discussed the expected outcome and potential risks, including pain, infection, scarring, pigment changes and the possibility that further treatment might be required.

After giving the patient the opportunity to ask questions, I confirmed that she wished to proceed.

Treating the lesions would also provide a valuable learning opportunity for the medical student. However, the patient’s consent to the student being present during the consultation did not extend to the student performing the procedure, so I needed to seek specific consent before involving the student.

I explained that I would directly supervise the student throughout and that I could perform the procedure myself if she preferred. I made it clear that she was under no obligation to agree and that declining would not affect the care she received. The patient said she was comfortable with the student performing the cryotherapy under my supervision.

I documented both decisions: the patient’s consent to the procedure and her agreement for the student to perform it.

Several consent decisions had taken place during a single routine appointment. The patient had agreed to receive practice communications, to have a medical student present, to undergo the procedure and to have the student perform it under supervision. Each decision was specific. One did not automatically extend to the next.

Consent does not always mean agreement

My next patient presented with a breast lump. She had also agreed at reception to the medical student being present during her consultation.

After taking a history, I explained that I recommended a breast examination and why it was clinically important. I described what the examination would involve and checked that she was comfortable to proceed.

Before the examination, I asked the student to step outside so I could speak with the patient privately. I asked whether she would be comfortable having the student present during the examination and explained that she could also have a trained observer present if she wished.

The patient declined both options. She wanted me to perform the examination and preferred that no one else be in the room.

Her response was entirely reasonable. Patients need to be able to place limits on their consent without feeling that they have disappointed their doctor or affected the care they will receive. The nature of the examination as well as the gender of the doctor, student or observer, may influence how comfortable a patient feels and should be taken into account when these discussions occur.

I respected her wishes and performed the examination without the student present. I documented our discussion, her consent to the examination and her preference regarding who would be in the room.

The patient had not withdrawn her consent to the consultation or refused the examination. Rather, she had placed a clear limit on her consent, and it was my responsibility to respect it.

Avant’s factsheet on observers and chaperones provides further practical information about sensitive examinations.

When the patient cannot make the decision

Later that day, I received a call from a residential aged-care facility about a patient with mild dementia who had become unwell. The nursing staff asked if I could provide a review.  

I attended the facility at the end of my afternoon session. After reviewing the patient’s symptoms, signs and observations, I considered that she was most likely experiencing pain. She had a known history of severe arthritis and was grimacing and lashing out when staff attended to her care needs.

I considered it would be appropriate to trial a low-dose buprenorphine patch to provide more consistent pain relief throughout the day.

The patient was more confused than usual and could not understand, retain or weigh the information needed to make a decision about the proposed treatment, even with support. Her impaired decision-making capacity may have been related to her dementia, the pain  or a combination of both. Whatever the cause, I needed to assess whether she could make this particular decision at that point in time.

Once I determined that she could not provide informed consent, I asked the facility whether she had an Advance Care Directive and whether anyone had been appointed to make healthcare decisions on her behalf.

The patient’s documents named her daughter as her substitute decision-maker. It was important to confirm this rather than assume that the daughter could provide consent simply because she was a close family member.

I contacted the daughter and explained her mother’s condition, why I was recommending the buprenorphine patch, the expected benefits, the material risks and the potential consequences of declining treatment.. After having an opportunity to ask questions, she consented to the treatment on her mother’s behalf.

I documented my clinical findings, my assessment of the patient’s capacity, the relevant Advance Care Directive, the daughter’s authority to make the decision and our consent discussion. I further discussed the changes with nursing staff and confirmed they were aware I had updated the clinical record.

In South Australia, an Advance Care Directive can appoint one or more substitute decision-makers to make healthcare decisions if a person later loses decision-making capacity. Avant’s South Australian substitute decision-maker guidance provides further information. Avant’s substitute decision-maker overview explains the general principles and links to specific guidance for each state and territory., .

The common thread

These three consultations were very different, but each relied on clear communication and an understanding that consent is specific, voluntary and ongoing.

These consultations also reflect the range of consent issues seen in Avant’s claims data. Among claims where consent was a contributing factor, 56% involved procedural or surgical care. Practitioner behaviour and medication-related issues each accounted for a further 14%.

Across all consent-related claims, the provision of information was the predominant issue. 91% involved concerns about the information provided to patients. Common gaps related to the risks of treatment, the proposed procedure, treatment or test itself, the available alternatives and clinical fees. Failure to obtain consent was another significant concern.

Not every consent discussion requires a form or a lengthy conversation. However, patients need sufficient information to make the particular decision in front of them. Clinicians also need to remain alert to changing circumstances and recognise when consent should be revisited.

Looking back on these consultations, I realised that I rarely asked one broad question: “Do you consent?” Instead, I asked a series of smaller questions. Are you comfortable with the student being here? Do you want to proceed with this treatment? Would you be comfortable with the student performing it? Who would you like present during the examination?

These conversations had become second nature. Reflecting on them reminded me that they are not minor formalities or administrative tasks. They are how we respect our patients’ autonomy, support informed decision-making and involve patients in decisions about their care.

For further guidance, see Consent: the essentials.