Consent&

Confidentiality

Reema Gardner & Emma Spector

Consent

What THREE things are required for valid

consent?

Valid consent

Capacity InformationVoluntariness

(free from coercion)

What FOUR things are required to demonstrate

capacity?

Understand info Retain info Weigh-up Communicat

e decision

Capacity

What FOUR pieces of information are required?

Information

Broad info

Risks, benefits,

alternatives

Defence against BATTERY Defence against NEGLIGENCE

A 52 year old women needs her gallbladder

removed, what would be the first thing to consider?

Assess capacity

Facilitate a capacitous decision if possible

Does patient have a valid advance refusal?

Treat in patient’s “Best Interests”(another topic in itself!)

Does patient have someone with lasting Power of Attorney?

A f

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• Communication aids• Time of day• Remove sedation

• Understand• Retain• Weigh-up information• Communicate decision

• Over 18 years of age• Relevant circumstances• Patient not done anything inconsistent with

directive• For refusal of life-sustaining treatment

• Written• Signed• witnessed

• Can only give or refuse life-sustaining treatment if this was specifically stated

If an adult lacks capacity to consent, who can

consent of their behalf?

Welfare Lasting Power of Attorney which covers healthcare decisions

Appointed by court

Who can give consent for treatment of minors?

16-17 year old with capacity

Gillick competent under 16s

Adults with parental responsibility (only need 1 parent)

Court

May treat without consent in an emergency

Note: children and young people have the right to participate in decisions about their healthcare regardless of their capacity

What are the requirements for Gillick

competence?Understands the problem and implications

Understands the risks and benefits of treatment

Understands the consequences if not treated

Understands the alternative options

Understands the implications on the family

Is able to retain (remember) the information

Is able to weigh the pros and cons 

Is able to make and communicate a reasoned decision about what their wishes are.

What is battery?Any form of procedure (even touching) without

consent

Confidentiality

When can you break confidentiality of an adult

patient without their consent?

Lacks capacity and acting in best interests

Public interest to disclose information

Legally required

When is it legally required to break confidentially?

Notifiable diseases

Suspected cases of abuse

Gunshot wound

DVLA

You must disclose information if ordered to do so by a judge or presiding officer of a court.

What is an ethical justification for breaching

confidentiality?

Consequentialist: best overall consequence – overall benefits outweigh harm (greater good)

Moral duty: non-disclosure would result in serious harm to another individual greater then that of the person whose confidentiality you breached

Scenarios: Break confidentiality, YES or NO?

32-year old man, presents with severe fever, chills, productive cough and

muscle aches. Recent travel history to Philadelphia. You suspect Legionnaire’s

Disease

A notifiable disease. However at this stage it is only a suspicion.

So, no.

20-year old student, known to be sexually active, measures positive for HIV on a routine check. Follow-up investigations

confirm the diagnosis of HIV

No.

HIV is not a notifiable disease.

During a follow-up appointment: Whilst giving the patient information about safe sex, he admits he doesn’t use a condom,

and he hasn’t told his girlfriend he is HIV+

Once the patient is aware of his diagnosis, he is criminally liable for transmission.

In this case, the GMC states you can disclose to the partner without consent

The patient’s girlfriend is at risk of serious infection

After becoming a Doctor (congrats.) you’re working on the stroke ward, you discharge one of your patients and advise her she shouldn’t drive

for a little while. However, she disagrees with you, and when you see her a week later she

informs you she has been driving

Strokes do not require formal notification to the DVLA.

What should you do instead?

Ask them to get a second opinion

What if they keep ignoring you?

Then you should notify the DVLA, after telling the patient what you’re going to do

Strokes/TIA, ACS don’t require formal notification to the DVLA (just advice about a period off driving)

Things that do require notification: epilepsy/seizures, diabetes mellitus, acute psychosis, alcohol/drug abuse

One of your patients, a 14-year old girl, is diagnosed with cancer. You first break this

news to the parents, who inform you that they do not want her to know. What do you do?

You should explain to them that you should assess the capacity of the child and deliver information in a way they can understand. (Children and young people usually want to know about their illnesses.

You shouldn’t withold information unless the patient refuses knowledge of that information

Give me some exceptions:

The information would cause “serious harm”

The child specifically requests that someone else makes the decisions for them

In GP-land: a 15-year-old girl visits you asking for contraception. Do you tell her

parents?

In this case, realistically –no.

Its all about the patients competency.

Think Gillick-Fraser guidelines

These are all about trying to identify abuse btw.

In GP-land: a 15-year-old girl visits you asking for contraception. However, she is visiting with her 35-year-old partner

Do you tell her social services?

In this case, realistically –yes.

The GMC says you should consider sharing information are where: a big difference in age is ringing alarm bells

In GP-land: a 17-year-old girl visits you asking for contraception. However, she is visiting with her 21-year-old partner,

her art teacher Do you tell social services?

In this case, realistically –yes.

The GMC says you should consider sharing information when: The partner is in a position of trust

The full list where the GMC says you should consider sharing information:

The young person is too immature to understand

The child is under 13

A big difference in age is ringing alarm bells

The partner is in a position of trust

There is a force/threat suggesting emotional,psychological or physical pressure

Drugs/Alcohol are involved