As a GP registrar you are probably keen to undertake some minor surgical procedures if you are not doing so already. You may have been on a training course in surgical techniques, but as well as being skilled in performing surgery, you also need to be aware of what you need to do to obtain patient consent and have a record that it was done. Put simply, it is vital that you are as sure of your skills and responsibilities in obtaining consent as you are of your technique with a scalpel.
Here are some of the common questions about consent raised by GP registrars embarking on their first minor surgical procedure with advice that could help to avoid an unhappy patient.
What information should I give to the patient when obtaining consent?
The GMC's guidance, 'Seeking Patients' Consent: the ethical considerations (1998)', stresses that patients have a right to information about their condition and the treatment options available. The amount of information you give each patient will vary, the GMC suggests, according to factors such as the nature of the condition, the complexity of the treatment, the risks associated with the procedure and the patient's own wishes (paragraph 4).
The GMC says this might include details of the diagnosis and prognosis.
Take the scenario of a middle-aged bus driver with a nasty ingrowing toenail.
Having just completed a minor surgery course, you feel able to offer the patient a lateral nailbed phenolisation under ring block.
As well as explaining to the patient any alternatives to treatment, including the possibility of referral, you will probably need to tell the patient that he is likely to experience some pain from the procedure, for which analgesics may be needed.
Also, that there may be other recognised adverse effects, such as bleeding and infection, and what to do if these occur.
The patient would reasonably need to know that he may have difficulty walking or driving after the procedure, and be told whether it is safe to wear a shoe afterwards, or whether his ability to work will be affected.
Should I warn patients of very rare risks?
You are not obliged to tell a patient about every possible tiny risk involved, but the case law on consent suggests that you should mention significant risks. You should also answer any specific questions the patient raises.
The GMC provides the following guidance (paragraph 6): '... You should not make assumptions about patients' views, but discuss these matters with them, and ask them whether they have any concerns about the treatment or the risks it may involve. You should provide patients with appropriate information, which should include an explanation of any risks to which they may attach particular significance ...'
If I have never performed a procedure before, should I tell the patient?
The GMC's consent guidance says you should give information including 'advice about whether the proposed treatment is experimental' and 'whether doctors in training will be involved' (paragraph 5). The GMC also says doctors must 'respond honestly to any questions the patient raises and, as far as possible, answer as fully as the patient wishes' (paragraph 9).
Most doctors new to minor surgery or to a procedure would probably want to volunteer this fact and should state, if asked by a patient, how often they have performed it before.
What about consent forms?
Signing a consent form is not equivalent to providing consent. GPs have a contractual duty to ensure that the record of minor surgery treatment includes the consent of the patient (NHS (GMS) Regulations 2004, schedule 2, paragraph 8).
The MDU advises that for all procedures, a note should also be made in the records that the procedure has been explained.
Can the practice nurse obtain the patient's consent?
If you are the GP providing treatment, the GMC makes it clear that it is your responsibility to give information and obtain consent (paragraph 14).
If this is not practicable you may delegate the tasks provided that you ensure that the person to whom you delegate is suitably qualified and trained, has sufficient knowledge of the proposed treatment and understands the risks involved.
Dr Lee is a clinical risk manager at the MDU
The best way to obtain consent
- Explain what the procedure will involve, why you think it is appropriate and what the likely risks are of the treatment and of not having it.
- Check the patient has understood you.
- Give patient the opportunity to ask questions, and answer them to the best of your ability.
- Be open about any lack of experience or failure rates, particularly if you are asked a direct question.
- Document your discussion, including the risks and implications for the patient's work and lifestyle, in the records. This will be crucial to justify your actions if the patient alleges they were not properly consented.