Informed Consent

A Consent to Treatment by Operation or Procedure form must be completed and signed before any patient can leave a ward or department for the Operating Theatre. Signing this form is the final phase of the informed consent process, and the person undertaking the procedure is responsible for this.

Responsibility may be delegated providing the delegated person has sufficient knowledge of the procedure to competently inform the patient and therefore can sign the form as a witness.

If a patient is unable to provide consent, and the procedure is deemed urgent and necessary to save their life or prevent permanent physical or mental injury or prolonged pain and suffering, then the section of the Consent to Treatment form headed Decision to Treat Made by Attending Medical Practitioner must be completed. Responsibility for this lies with the person making the decision to treat but is subject to:

• having made reasonable attempts to obtain consent.
• being able to document justification for proceeding without obtaining consent.
• ensuring that where time permits the specialist with overall responsibility for the patient is aware of the proposed action.
• where appropriate and time permits, seeking a second opinion from another senior staff member not involved in the patient’s care.

In non-urgent situations you must take reasonable steps to determine what the patient’s informed choice might be in the given circumstances. This may mean seeking the opinion of others who have an interest in the patient's welfare. In this regard Right 7(4) of the Code of Health and Disability Services Consumers’ Rights applies.

See also:

• CDHB Policy and Procedure Manual, Volume 11 Clinical - Informed Consent

Topic Code: 10798