Consent Stations
Legal Framework
Montgomery v Lanarkshire (2015)
- Material risk standard: disclose risks a reasonable person in the patient's position would consider significant
- Doctor must also disclose risks this particular patient would find significant (based on individual circumstances)
- Includes alternatives to the proposed treatment
- Replaces Bolam test for consent
Structured Consent Discussion
- Indication: why the procedure is recommended
- Description: what the procedure involves (in lay terms)
- Benefits: expected outcomes and improvements
- Risks: common AND serious risks (use numbers/percentages where possible)
- Alternatives: other treatment options including doing nothing
- Questions: invite questions, check understanding
- Decision: confirm patient's decision, document, sign consent form
Common Consent Scenarios
Caesarean Section
Risks to discuss:
- Haemorrhage (may need transfusion)
- Infection (wound, endometritis — 5-10%)
- Thromboembolism (VTE prophylaxis given)
- Injury to bladder, bowel, ureter (<1%)
- Need for further surgery
- Fetal laceration (~2%)
- Longer recovery than vaginal delivery
- Future pregnancy implications: scar on uterus, VBAC vs repeat CS, increased risk of placenta praevia and accreta with each subsequent CS
- Anaesthetic risks (spinal headache, nerve damage, GA risks if conversion needed)
Total Abdominal Hysterectomy
Risks:
- Haemorrhage / transfusion
- Infection (wound, pelvic, UTI)
- VTE
- Ureteric injury (~1%)
- Bladder injury
- Bowel injury
- Vaginal vault prolapse (long-term)
- Loss of fertility (permanent)
- Psychological impact
- If BSO included: surgical menopause, need for HRT discussion
- Conversion from laparoscopic to open if applicable
Diagnostic Laparoscopy
Risks:
- Port-site complications (bruising, infection, hernia)
- Visceral injury: bowel, bladder, vascular injury (1-2 per 1000)
- Gas embolism (very rare)
- Shoulder-tip pain (diaphragmatic irritation from CO2)
- Conversion to laparotomy
- Failed entry / inability to complete procedure
- Subcutaneous emphysema
Hysteroscopy
Risks:
- Uterine perforation (1-2%)
- Cervical trauma
- Fluid overload (glycine in monopolar systems — hyponatraemia)
- Infection
- Bleeding
- Failure to complete / false passage
- Gas embolism (if gas distension medium)
Assessing Capacity (MCA 2005)
The patient must be able to:
- Understand the information relevant to the decision
- Retain that information long enough to make a decision
- Weigh (use and balance) the information to make a decision
- Communicate their decision (by any means)
Key principles:
- Assume capacity unless proven otherwise
- An unwise decision does NOT mean lack of capacity
- Support the patient to make their own decision before concluding they lack capacity
- If patient lacks capacity: act in their best interests (consider past wishes, beliefs, values)
Gillick Competence and Fraser Guidelines
- Gillick competence: child under 16 can consent if they have sufficient understanding and intelligence
- Fraser guidelines: specifically for contraception — the young person understands advice, cannot be persuaded to tell parents, is likely to have sex regardless, their health would suffer without treatment, treatment is in their best interests
- 16-17 year olds: can consent to treatment (Family Law Reform Act 1969)
Key Points Examiners Mark
- Clear explanation of the procedure in lay terms
- Discusses indication (why it's needed)
- Lists common and serious risks with approximate frequencies
- Mentions alternatives including conservative management
- Assesses understanding ("What do you understand about what we've discussed?")
- Allows questions
- Does not coerce — respects autonomy
- Documents the discussion
- Arranges time for patient to consider before signing (if not urgent)
Common Pitfalls
- Listing risks without explaining what they mean in practice
- Failing to mention alternatives (including doing nothing)
- Not checking understanding — assuming patient has understood
- Using medical terminology without explanation
- Rushing through the discussion (examiners want to see genuine dialogue)
- Forgetting future pregnancy implications for caesarean consent
- Not mentioning Montgomery v Lanarkshire when discussing material risks
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