Patient Consent: Elective or Emergency Medical or Surgical Procedure

Rationale

Policy
Emergency situations Adults (majors)
Emergency situations Children (minors)
Obtaining consent for elective procedures on minors
Consent for HIV, Hepatitis B, Hepatitis C testing
Consent for police fingerprinting 

Rationale

Obtaining informed consent for a medical/surgical procedure is an important ethical and legal obligation on the part of all medical practitioners.   The patient’s informed consent should be obtained for all procedures, and documented in writing, using the standard hospital form for all major interventions, including those performed under spinal or general anaesthesia.

Policy

1. Consent must be obtained in advance.  Under no circumstances may a patient undergoing an elective medical or surgical procedure be accepted for any form of systemic anaesthesia if the relevant consent form has not been completed and signed before any premedication has been administered.
2. The patient’s consent must be explicit i.e. it should never be assumed, simply because the patient has placed himself/herself under the doctor’s care.  In Groote Schuur Hospital the consent must be recorded in writing on the prescribed forms.
3. The person giving consent must be assessed as being legally competent, based on acceptable medical techniques of assessing competence, as well as legal standards.  Mentally ill or impaired or intoxicated persons may not be capable of understanding the full implications of a procedure, or of making an informed decision.   However, each patient’s competence should be assessed relative to the complexity of the intended procedure, and the degree of insight required to make an autonomous, informed decision.
4. Consent must be voluntary i.e. the patient must not be coerced into signing.
5. Consent must be informed i.e. the person who gives consent must understand the scope, nature and possible outcome of the procedure, as well as the nature of the anaesthetic and material risks  thereof. (A “material risk” is defined as any frequent complication, or any complication which might have substantial consequences for the patient).
6. Any person who is 18 years of age or older, and mentally competent may give consent for his/her operation/treatment and for any operation/treatment performed on his/her child.
7. A married person under the age of 18 is legally regarded as a major and is competent to grant consent for himself/herself and for his/her child.  This may also apply to a minor who is financially independent.
8. Any person of 14 years of age or older may give consent for any medical (non-surgical) treatment of himself/herself.   (For example : the prescription of oral contraceptives).  Any surgical intervention on a patient under the age of 18 years still requires the consent of a parent or guardian.  Please see Annexure A for “obtaining consent for elective procedures on minors when parental consent is not available.” Please note that the Medical Superintendent is not able to give authority to proceed other than in emergency situations.  The minor’s assent should also always be sought.
9. Consent must be obtained by the registered medical practitioner who will be performing the intervention or his/her delegated registered medical practitioner.  No nurse, intern or student may obtain consent on behalf of the medical practitioner.
10. Any person 16 years of age and older may sign as a witness but this excludes the person taking the consent.  A witness does not sign as to the content of a document,  only to affirm the identity of the person signing it.
11. It is not legally necessary to obtain consent from the patient’s spouse for sterilisation. 
12. Consent is valid as long as the health circumstances of the patient, and nature and circumstances of the procedure remain the same.
    • Consent does not “expire” after a period of time.
    • A new consent form must be completed and signed if circumstances change (e.g. the risks, benefits or details of the procedure change, or the patient is no longer aware of the implications of the consent given).
    • Informed consent must be obtained for each operation i.e. one consent form does not cover multiple separate procedures when the procedures require an anaesthetic.
13. The legal validity of consent is subject to its meeting the requirements in Policy Points 1 to 7 above.
14. Policy for termination of pregnancy is attached as Annexure B.
15. Guidelines for taking consent for HIV blood tests are attached as Annexure C.
16. Please refer to the attached Schedule of Consent which lists who must give consent in various situations.
17. Where consent is refused on religious grounds, please consult the separate hospital notice “Guidelines for Hospital Management of Jehovah’s Witnesses”.  The same guidelines would apply to any patient refusing treatment on any grounds.
18. This policy does not cover consent needed in order to conduct research on patients.  Consent for research purposes is determined by the Research Ethics Committee.

Emergency situations

ADULTS (majors)

In an emergency situation, when the patient is unable to give consent because of a decreased level of consciousness :

•  The doctor should obtain consent from the spouse or partner of the patient or, in the absence of such spouse or partner, a parent, grandparent, an adult child or a brother or sister of the patient, in the specific order as listed.  This consent may be verbal/telephonic but must be recorded on the consent form.
•  Where every effort has been made to contact the next of kin but without success, and an urgent/emergency procedure is required, the doctor should notify the relevant Medical Superintendent to obtain authority to proceed without consent.  (After hours, contact the Medical Superintendent on call).
• Where any delay might result in the patient’s death or irreversible damage to his/her health, the doctor may proceed without consent, without notifying the Medical Superintendent.
•  If any doctor is unsure and needing a second opinion before proceeding at his own discretion, he should contact his senior.
• The doctor who performs the emergency operation must document the procedure in detail and complete the standard consent form, recording the name of the next of kin who has given consent or the name of the Medical Superintendent whom s/he has informed.

CHILDREN (minors)

• Where possible, consent for an emergency procedure on a minor child should be obtained from a parent/curator/guardian.
• In an emergency situation when consent is unobtainable for a minor child (i.e. from the parent/guardian), the Medical Superintendent may consent on the child’s behalf.
  • The operation being authorised telephonically by the Medical Superintendent must be the operation that the clinician intends to do i.e. strictly defined.
  • The doctor who performs the emergency operation must document the procedure in detail and complete the standard consent form, recording the name of the Medical Superintendent who gives telephonic authority.

Consent to treatment and operations for illness other than mental illness

Obtaining consent for elective procedures on minors

( <18 years of age when parental consent is not available)

1. Every reasonable attempt must have been made to contact the parents at the address or telephone number given – telephone, telegraph, police, neighbour or next of kin. The ward social worker should assist and document these attempts.
2. If these attempts have been unsuccessful or if there is no contact address or number, the consent may be given for minor children by one of the persons listed in point 3 below.  They will require the following information which can be faxed :
   1. The child’s name and age.
   2. A report by the social worker or doctor indicating the unsuccessful attempts to contact the parents, or stating that the parents and their whereabouts are unknown.
   3. A report by the doctor indicating the nature of the problem, proposed operation, why the intervention is considered necessary and whether this will take place under general anaesthesia or not and when.
   4. A consent form.
3. PGWC : Social Services Department

            For any medical or surgical procedure :

                        Ms Marie Louw

                        Tel. : (021) 483-4621

                        Fax : (021) 483-4481

            For consent for HIV-testing for children under 12 :

                        Ms Sharon Follentine

                        Fax : (021) 483-4783

Consent for HIV / Hepatitis B / Hepatitis C Testing

1. Consent for HIV testing in Groote Schuur Hospital may be given verbally by the patient to the doctor once adequate pre-test counselling has taken place.
2. This must be documented briefly in the patient’s folder.
3. Children of 12 years and older may consent to their own HIV test.
4. Should the HIV test be positive, a legal obligation would arise for the doctor or other health care worker involved to inform the patient – provided the patient has indicated that he/she wishes to know the result - and to counsel him or her properly.
5. If a health care worker suffers a needle-stick injury or other exposure to blood or body fluids, the source patient needs to be approached to undergo tests for HIV / Hep.B / Hep.C.  The patient must be asked if he/she consents, and must be provided with pre- and post-test counselling.
   • If the source patient refuses permission or is unconscious, the doctor concerned may not draw blood specifically for the HIV test without the patient’s consent.  Instead, consider the following options :
   • Regard the source patient as HIV-positive and treat the healthcare worker accordingly.  An unconscious patient may be prepared to give consent once conscious.
   • Test an existing blood sample taken prior to the exposure incident, and, should the patient regain consciousness at any time, he/she should be informed that an HIV/Hep test was done, and the reason for doing it, and then be allowed to indicate whether or not he/she wishes to be informed of the result.
   • If no existing blood sample exists, but there is a legitimate medical indication  to do another blood test while the patient is unconscious, then this sample may also be used for anonymous testing.
   • Offer to test the source patient, but do not disclose the result (i.e. anonymous testing).  The source patient must agree to this and it must be documented.
   • If the source patient is legally incapable of giving consent (mentally ill or under 12 years of age), the normal guidelines for these patients apply.
   • It is suggested also that when completing the Consent for Medical Procedure form prior to the procedure, the patient should be asked to sign in the middle block that reads, “I agree that a sample of my blood will be taken and tested for …… etc.”  (There is a small gap available on the right, after the word “procedure”).  This will ensure that the patient’s attention is drawn to this statement.

Consent for Police fingerprinting

1. It sometimes happens that the South African Police Service (SAPS) arrives at the hospital and requests to be allowed to fingerprint and/or photograph a suspect who is also a patient at the hospital.
2. If the patient consents to being fingerprinted and/or photographed, this must be recorded in the patient’s file and the police allowed to go ahead.
3. If the patient refuses consent, the police may only go ahead if the patient has been arrested and charged, or is already in custody.
4. If the police obtain the photographs/fingerprints without the Hospital’s and patient’s consent, this must be documented in the patient’s file.
5. If the patient refuses consent, the police should be advised to wait until the patient is discharged or is formally arrested, before attempting to obtain the evidence needed.