eSigning Summer Camp Parental Consent Made Easy

Esign detailed medical consent

hey guys welcome back to the channel if you're new here my name is Ali I'm a final year medical student at Cambridge University and this is part of our medical ethics foot interview series and today we're going to be talking about consent capacity and jehovah's witnesses if you look in the description below you'll see timestamps absolutely everything that's mentioned in this video so you can see what the structure is of the video but first I'm just gonna give you a 30-second summary of what we're going to talk about and then the rest of the video is going to be else discussing cases relating to that summary and kind of expanding a little bit more in depth about what the deal is with consent capacity and jehovah's witnesses so here's the 30-second summary basically we need consent before we operate or do anything on anyone because if we don't then that's assault so consent is really important someone can give valid consent if it's in one voluntary number to informed and number three competent or capacitors we can assess capacity by asking them to number one understand number two retain number three way up and number four repeat back or communicate their decision to us if there are kids are under 18 then they can consent to treatment provided they have these four things at capacity but they can't refuse treatment if they're refused treatment and their parent wants to accept the treatment then we override their refusal and we are allowed to do the treatment to them because the parent has consented on their behalf if a patient doesn't have capacity we look to see if there's an advanced directive or if there's a lasting power of attorney and if not as is the case most of the time that we as doctors operate on a best interest principle and that we do whatever we think is in the best interest of the patient so that's the 30-second summary of this whole kind of capacity consent area but now the rest of the video we're going to be expanding on these points in a bit more detail so ideally you want to be watching those so you can actually understand what what the cases were behind these and what the principles are that we're going to be tackling we're now gonna cut to a video of Charlotte and Molly who you might have seen from last week's video and they're gonna be introducing the case that we're gonna start off with so here are shallow and Molly coming up hi guys and it's Charlotte and Molly again hi everyone it's Charlotte and Molly again and this video we're gonna be talking about consent and we're gonna start by thinking about a real case so this is a case in which there is a lady who comes into the hospital and she's she's pregnant she's she's at term so she her baby's ready to be born and there's some complications that means she needs a caesarean section baby's in distress and we need to get baby out and the medical team approached her and asked for her consent and initially she will give her consent to have this surgical procedure but at the last minute she withdraws her consent because she's terrified of needles and she says no I don't give my consent anymore you can't do it and so in this situation mum has withdrawn her consent and baby is in danger what would you do as a doctor in that scenario if you will part of that medical team what would you what would you go how would you go about dealing with it okay so that's the case we need valid consent to save the life of both the mother and the baby Suzie and B but the mother has withdrawn her consent at the last minute so what do we do if you've got this in your interview how would you respond this is a very classic case and I think it's the kind of thing that they might want to ask you about in interviews just so you can have have a little bit of a discussion about about you know what what the ethical issues are in this case so as we mentioned last in the last video you might be talking about tana me benefits and normal Ephesus and justice but I'm not going to go into those in detail because you could probably just make those off on the spot instead we're going to talk about the specifics behind capacity and consent and what the dealer's are that and that's what this video is going to be about so in answer to this question of what do we do if we don't have consent we first need to understand what the valid consent actually means so now we've got a segment of Charlotte and Molly coming up where they're gonna explain what the three components of valid consent are it is definitely worth knowing about the two new interviews because scenarios involving consent are surprisingly common and if you can mention in your interview that right you know to have valid consent we need these three things are informed voluntary and competent then that looks very very impressive and if you can understand it a little bit more about them you'll be able to kind of draw them in to whatever question involves consent so yeah Charlotte Molly talking about the three components of valid consent here we go okay so um in law consent is only valid if it is voluntary it is informed and it is competent and so we'll talk a bit more about what those three things mean and how we might go about checking if our consent has fulfilled those three criteria so one example that we can talk about here is Ricci and which was a legal case in 1992 and it involved a young woman who was pregnant at the time and actually was involved in a car crash which required her to have a blood transfusion and he was from a family of Jehovah's Witnesses who historically are opposed to transfusion of blood products for religious reasons and this is often a really difficult case for a doctor to deal with because it can sometimes mean that a patient won't consent to treatment such as a blood transfusion and that a doctor feels is actually necessary to help improve their health or even to save their life and so it's really important that we make sure consent is valid by being voluntary but also that not giving consent is valid by being voluntary as well so in this situation tea after spending some time with her mother who was a Jehovah's Witness actually decided not to consent to this blood transfusion which the medics deemed to be really important to save her life and because they felt that actually she had been under pressure from her mother to withdraw her consent that was deemed invalid consent in that situation so there's an example of of consent and not consenting having to be given voluntarily and not forced by anyone else so so we've established that consent has to be voluntary not given under undue pressure the second thing that consent has to be is informed so if you think about every time you open a box of paracetamol there's a big leaflet that says side effects risks and there's a whole host of things written down there and that's a that's a kind of legal coverage for the for the pharmaceutical company they have to tell you what the risks are of whatever you're taking and it's the same in medicine we have to we have to be be sure that we're giving our patients all the information they need to make a reasoned decision so that includes all the benefits that could result and all the complications and risks that are involved so that includes things like infection after an operation or side effects of particular medications and obviously the benefits are that the disease will be cured that they will have a better quality of life and so we have to cover all that with our patients and historically we've used something called the Boland test to decide how much information we should give a patient and this idea is that if you stood up in court and you said I gave the patient this particular set of information and there were another group of doctors another group of reasonable professionals of your profession who would stand up in court and say yeah we would have done the same thing then legally that that meant you are in the clear so if what you did kind of lined up with what another body of doctors would do even if they're not a majority then you were legally okay previously we've used this Bolam test so we'd asked what would the reasonable doctor tell a patient so that was that was historically what we've done but then in 1999 we had this case with a lady called Nadine Montgomery and the Dean Montgomery was pregnant and she gave birth to her son Sam and she gave birth naturally she had a vaginal delivery now during this there were some complications and and what happened some son basically got stuck and that meant that he was deprived of oxygen for a period of time it was over ten minutes and because of that he subsequently developed cerebral palsy which means that his brain had been deprived of oxygen and the brain tissue itself had been damaged and so that's a permanent disability so so this happened and Nadine Montgomery then took lots of legal advice about should should she have been warned about the possibility that this complication that we called shoulder dystocia should should I have been warned about that and and she brought this case to court saying that she should have been advised that there was a risk of this happening she she was saying that regardless of what the outcome would be this risk was big enough that any reasonable patient would have wanted to know and so we we have moved away from the what would a reasonable doctor tell a patient - what would a reasonable patient want to know and and this this one it took many many years to be resolved in the courts and and so now as a doctor we have to ask ourselves what would a reasonable patient expect to know and that that will differ in in varying circumstances so imagine for example you're conducting an operation on someone's eyes if if the patient you are operating on already has no sight in one eye then understanding the risks of visual loss in the other eye is going to be far more significant to them than someone who has perfect sight in both eyes because that's the difference between that person becoming completely blind or still having one eye remaining to see you with so we have to make a judgment on a case-by-case basis about what a reasonable patient in that position would want to know because it's impractical to say we'll give you all the risks and complications because some things will happen one in a million times and we can't list all of those patience it's just not practical so this is our this is our threshold this is our standard which we we judge by what what we should tell our patients honor on a day-to-day basis so that's what defines informed consent that we have given them information about the pros and cons the benefits and risks and to a to a level that would be expected from the reasonable patient okay so we've talked about the fact that consent must be given voluntarily and what that means and we've talked about the fact that consent has to be informed and so lastly consent has to be capacitive or competent and what that means is that we have to make a judgement that this patient is able to make this decision in order to give their consent or to withdraw their consent so we have a framework that we use as medics to navigate this issue and that is called the Mental Capacity Act it was written in 2005 and that Act basically tells us how to go about assessing someone's capacity to make a decision so in that act we must as doctors in order to say that someone has consent they must fulfill certain criteria so in order to make sure that consent is competent we have to check that patients are able to do certain things so first of all they must be able to understand a decision that they have to make they have to be able to retain the information we give them so when we're informing them of all of those risks and benefits they have to be able to retain that information they have to be able to weigh up that information in order to come to a decision so they need to look at the risks and benefits and we need to see that that's what they've done and then they need to be able to communicate that decision to us as doctors saying either that they've decided to consent or that they haven't consented and if all of those principles are fulfilled then we're able to say that this patient has capacity and they are competent it's worth noting that all adults are assumed to be competent unless proven otherwise but we'll check in certain situations where a patient might seem to be making a strange decision and we have to assess their capacity further to make sure that it's a capacities competent decision so we know that to have valid consent it needs to be informed it needs to be voluntary and it needs to be competent but what about with kids you might have heard the phrase phrase a guideline or Gillett competence we're gonna explain what those mean Charlotte Molly coming up right now okay so we've talked about how consent in adults must be given voluntarily it must be informed and it must be competent but what about in kids what happens with children and consent so there's two things we need to think about soon sixteen and seventeen year olds and then below sixteen year olds so the law distinguishes sixteen or seventeen year olds is something slightly different so this this is under a piece of legislation called the Family Law Reform Act 1969 and basically the judge said that if someone is 16 or 17 and can do all the things we expect an adult to do so can understand retain way and communicate decision if if 16 or 17 year olds can do all of that then their consent shall be valid as if they were 18 so that's 16 and 17 years the differences with them is that they can't refuse treatment if a parent or guardian gives consent so if a 16 year old says no I don't want that operation but their parent says I give consent the operation can be carried out even if they refuse treatment so the difference with a 16 or 17 year old from an adult is that they can consent but they cannot refuse so then below 16 years years of age children might be deemed to be competent to have the capacity to make a decision and this is known as Gillick competence and the case surrounding this was a woman called Victoria Gillick who wanted to ensure that her children her female daughters the female of the mentio the Victoria Gillick who wanted to make sure that her daughters who were under 16 couldn't receive contraception or contraceptive advice from their doctor without her knowing without her being informed and the Health Authority went to court with her and they came up with this idea of Frazer guidelines and Gillett competence so basically if a child who's below 16 can do all of those things understand retain weighing communicate and we are satisfied that they are able to do that then they can give consent as if they were an adult what they can't do is refuse again similarly to 16 and 17 year olds they can't refuse and it's unlikely that if you're below 13 years old that you're going to be deemed to to be competent to make a decision and of course we have to remember that decisions can vary massively on a scale so giving consent for a blood test is not the same as giving consent to receive an organ transplant and so 14 year old may well be competent have capacity to understand the risks and benefits of having a blood test or receiving an immunization and that would be absolutely fine but in terms of if I was going to offer them a lung transplant could they understand all of the risks and benefits and weigh that and that's a far more complex decision and so they might be capacities to make a decision about having an injection or a blood test but they might not be capacitors to make a bigger decision about an organ transplant and and it's important to remember that this capacity is function specific and it can vary so if someone is very unwell within a nasty infection they might they might lose their capacity because there can but two days later when they've had a course of antibiotics they're absolutely fine again and I've got capacity to make decisions so capacity is its function specific and it is variable and so that means we have to continually reassess we can't just have a blanket decision that lasts forever so that's what happens with kids basically as long as someone under the age of 18 can do those four things that we need to assess capacity ie understand retain weigh up and communicate the decision then they are treated as having consent and they are able to consent to things being done to them like procedures blood tests whatever however if they're under 18 and they refuse treatment even if they have all these things of capacity then the the person with parental responsibility can consent on their behalf so you can override their refusal of treatment okay so that's all well and good now let's talk about what happens if a patient does not have capacity but needs some kind of treatment and we can imagine the scenario where a patient comes in unconscious to the hospital they need some kind of life-saving procedure but you you know they're unconscious so you can't assess their capacity you can't get their consent what do we do in those cases firstly money is gonna introduce the idea of advanced directives and LPAs lasting powers of attorney this is definitely beyond the scope of what you need to know for your interviews but we've included it here just for completeness and it's it's pretty straightforward so I think if you can understand it then it just makes the whole consent thing a lot more a lot more manageable so here's Molly talking about 80s and LPS okay so we've had a look at what makes consent valid and and in particular we've looked at the fact that you have to assess patients capacity and so thinking a bit more about that and thinking about what do we do when the patient doesn't have capacity and we've assessed that they are unable to do all of those things that we said they had to be able to do in order to give consent so there's a few things that a doctor can do and a few sort of pieces of legal information that we can look to if we think a patient isn't a status and so first the a patient might have something called an advanced directive so this is written by the patient themselves and it's saying what they would and wouldn't consent to in the future so a patient who has a disease which they expect to in the end stop them from having capacity in the future at the time when they did have capacity in the past they can write down this advanced directive and specifically state what situations they would they would have consented and in which situations they wouldn't have consented and what's really important here is if the decision is about anything to do with life saving or life preserving treatments then it's really important that the patient has signed it dated it that it's been co-signed by a witness and that they have specifically stated that they would not be happy to receive treatment that would be life-saving and so there's a few more sort of loopholes that you have to go through if you're talking about life-saving treatment but advanced directives can be about any sort of treatment and another thing that we might look at if there isn't an advanced directive or if this was created since an advanced directive we can go towards a lasting power of attorney so a lasting power of attorney or an LPA has two forms it can either be a sort of health and well-being LPA or it could be a financial LPA so it's worth bearing in mind if someone has a financially LPA it's not going to make any difference to medical decisions so we're looking at the health and well-being side of things if someone has a health and well-being LPA that means that they have nominated someone else to act in their best interest so again this person has previously known that their capacity may at some point go and so they have made a decision to nominate someone else as their LPA as their representative to make those decisions for them in the future and we have to make sure that we think that this LPA is acting in the best interest of that person and if we have any doubts about that and we can actually refer to someone else called a IMC a an independent mental capacity advocate and these MCAS can actually make a decision they're someone who's not known to the patient it's their job to represent the patient's best interest and they can actually make a decision on the patient's behalf okay so if our adult patient does not have the capacity to consent to something then we check to see if there's an advanced directive or a lost in power of attorney in place and we consult those if appropriate but what if as it's quite common they don't have either of those things in place what if I were to be rushed into a knee like you know intoxicated or completely unconscious and obviously I don't have an advanced directive or a lasting power of attorney and they needed an operation to save my life what are the doctors going to do that if we've done all of that if we've assessed our patient and we're not happy that they've they've got the capacity they haven't got a lasting power of attorney they haven't got an advanced directive and we're in a situation where we've got to make a clinical decision ultimately we have to decide what we think is in the patient's best interest it has to be a best interest decision so that means as doctors that we we take into account what the patient may have wanted and that means we have a duty to talk to friends and family about what their religious cultural beliefs were if that would influence their decision we have to we have to understand the interventions that could have could be put in place and what the quality of life the patient would have afterwards and we have to decide as a health care team what is going to be in their best interests and so that doesn't fall to one doctor on their own it's really important to remember that you're never working on your own as a doctor and so it will be a whole team decision with the junior doctors the senior doctors the consultant the nurses physios occupational therapists the whole multidisciplinary team will make that decision together and and sometimes that's really hard because sometimes the decision will be it's not going to be in the patient's best interests send them to intensive care and to integrate them and ventilate them mechanically and that decision is really hard because of course patients families won't want them to stay alive and and as a doctor that's one of the really big challenges that is faced we have to make these these decisions in the best interest of the patient even though sometimes that's going to be really distressing and really difficult for families we have to act in the patient's best interest okay so we've talked a bit more about consent and what it means to give valid consent and we've also spoken a bit about the fact that doctors in the end have to make decisions in a patient's best interest and take into account what they believe the patient would have wanted and it's worth noting that this best interest argument is was one of the key points in the Charlie guard case that you might have seen which played out a great ormond street this year there'll be some more information in the description below and we may end up doing a video in the future discussing particular things about Charlie guard and how that case came about but essentially it was a best interest decision from the doctors involved and there we have it everything you need to know about consent and capacity and Jehovah's Witnesses which can sometimes come up in interviews basically we need to give valid consent before we do anything otherwise it's assault to get valid consent he needs to be informed it needs to be voluntary and it needs to be competent in order for it to be competent the patient needs to be able to understand retain weigh up and communicate their decision and if a patient doesn't have capacity for any reason then we look to see if there's an advanced directive or a lasting power of attorney in place and if not then we operate on a best interests principle we've talked a little bit about the cases that form the basis of some of the laws around capacity in consent and I think it's it's important to know a little bit about them I think it's it's obviously not required knowledge like you don't need to be stating like names and dates and you know whatever but I think if you do get off the question about about Jehovah's Witnesses and you can reference the example of the pregnant lady who was in a car crash but then her mum you know was exerting undue influence even if you just know vague details about the case it looked really really impressive and it looks as if you've really made an effort to try and understand this whole medical ethics and law thing here in preparation for her interview which shows commitment to medicine and all of that which they're definitely looking for so yeah that's it capacity and jehovah's witnesses in hopefully a short and sweet nutshell thank you very much for watching our our next video which will hopefully be coming out next week a week after you see this is going to be about euthanasia assisted suicide do not resuscitate all that heavy stuff but as this tradition with this miniseries I'm going to leave you with Charlotte Molly will be saying a few final words summing up and saying goodbye so thanks and I'll see you next time so thank you again for watching and we hope you found it useful and let us know if there's anything else you'd like us to cover in the future and and we'll see you again for some more fun ethical discussions bye [Laughter]