Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Understanding Capacity and Consent in Surgery Jada Saunders MBBS MRCS(Edin) MSc PGCert (MedEd) th April 30 , 2024Objectives • Capacity • Definition of Informed Consent • GMC Guidance - 7 Principles of Consent • Who can give consent • Types of Consent • Consent For Common Surgical Procedures • ScenariosCapacity • Capacity means the ability to use and understand information to make a decision, and communicate any decision made. • Capacity is time and situation specific. • A patient has capacity when they can: • understand information relevant to the decision • retain that information • use or weigh it as part of a decision, AND • communicate their decision effectively, by any means • Capacity is assessed by an appropriately trained and experienced healthcare professional who's either: • recommending the treatment or investigation • involved in carrying it outCapacity • A person lacks capacity if their mind is impaired or disturbed in some way, which means they're unable to make a decision at that time. • Examples of how a person's brain or mind may be impaired include: • mental health conditions – such as schizophrenia or bipolar disorder • dementia • severe learning disabilities • brain damage – for example, from a stroke or other brain injury • physical or mental conditions that cause confusion, drowsiness or a loss of consciousness • intoxication caused by drugs or alcohol misuse Mental Capacity Act 2005 • The Mental Capacity Act 2005 (MCA) is the essential framework for making of people aged 16 and over, who mightt lack mental capacity to make their own decisions to consent to, or refuse, interventions that are offered by health or social care professionals. • It balances the right to autonomy with the necessity, where essential, for make decisions on their behalf, in their best interests.The Liberty Protection Safeguards • The Deprivation of Liberty Safeguards (DoLS) is the procedure prescribed in law when it is necessary to deprive of their liberty a resident or patient who lacks capacity to consent to their care and treatment in order to keep them safe from harm. • LPS will protect the rights of people who use health and care services not to be deprived of their liberty without a proper legal process and rights to challenge. • They will provide these important human rights protections to people aged 16 and above who • are or need to be deprived of their liberty to enable care or treatment and • lack the relevant mental capacity to consent to their care and treatment arrangements.What is Consent? • Consent is the agreement by a patient to undergo specific medical treatments or procedures after receiving information about the risks, benefits, alternatives, and implications of the proposed interventions. • Ensures that medical treatments are conducted ethically and legally • It respects patient autonomy and promoting trust in the patient-doctor relationship. • For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision.GMC 7 Principles of Consent • Principle 1: Ensure all patients are involved in decisions about their care and supported to make informed choices. • Principle 2: Treat decision-making as a continuous dialogue, focusing on the exchange of relevant information tailored to each patient. • Principle 3: Guarantee that patients are listened to and provided with the necessary information to make decisions, with adequate time and support for understanding. • Principle 4: Strive to understand what matters to each patient to communicate relevant benefits, risks, and alternatives effectively, including the choice of no action. • Principle 5: Presume that all adult patients have the capacity to make decisions unless assessed otherwise based on specific, time-sensitive evidence. • Principle 6: Ensure that choices made for patients lacking capacity are in their best interests, with decisions made in consultation with their close contacts or legal advocates. • Principle 7: Support patients whose legal rights to consent are affected to participate in decision-making and exercise choice to the extent possible under the law.Informed Consent • You must give patients the information they want or need to make a decision. • This will usually include: • diagnosis and prognosis • uncertainties about the diagnosis or prognosis, including options for further investigation • oaction for treating or managing the condition, including the option to take no • the nature of each option, what would be involved, and the desired outcome • the potential benefits, risks of harm, uncertainties about and likelihood of success for each option, including the option to take no action.Montgomery vs Lanarkshire Health Board (2015)Montgomery vs Bolam • Before Montgomery, a doctor's duty to warn patients of risks was based on whether they had acted in line with a responsible body of medical opinion. This was known as the Bolam test. • Montgomery’s Rule means doctors must provide information any risk to which a reasonablelosing person in the patient's position would attach significance. • The judgment therefore means that doctors must share all such material risks, as well as any it would be reasonable for them to attach significance. patient wouldMaterial Risks • Materiality is whether a reasonable person in the patient's position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it. • Recognised risks of harm that you believe anyone in the patient's position would want to know. • The effect of the patient's individual clinical circumstances on the probability of a benefit or harm occurring. • Risks of harm and potential benefits the patient would consider significant for any reason. • Any risk of serious harm, however unlikely it is to occur. • Expected harms, including common side effects and what to do if they occur.Types of ConsentTypes of Consent • Consent can be given: • verbally – for example, a person saying they're happy to have an X-ray • in writing – for example, signing a consent form for surgery • Someone could also give non-verbal or implied consent, as long as they understand the treatment or examination about to take place – for example, holding out an arm for a blood test.Types of Consent • Consent form 1 is for adults with capacity, undergoing procedures under general anaesthetic • Consent form 2 is for paediatrics patients, given by the parents or legal guardian • Consent form 3 is for procedures done via local anaesthesia or without sedation • Consent form 4 should be used when the patients lack capacity and should be completed by the professional doing the procedure.Gillick v West Norfolk and Wisbech Area Health Authority (1986)Gillick Competence • Children under the age of 16 can consent to their own treatment if they're believed to have enough intelligence, competence and understanding to fully appreciate what's involved in their treatment. • This is known as being Gillick competent. • If a young person refuses treatment, which may lead to their death or a severe permanent injury, their decision can be overruled by the Court of Protection. • This is the legal body that oversees the operation of the Mental Capacity Act.Next of Kin & Lasting Power of Attorney – Are they the same? • A health and welfare LPA gives your attorney the power to make decisions about your daily routine (washing, dressing, eating), medical care, moving into a care home and life-sustaining medical treatment. • This is determined via a legal document, while the person has the capacity to do so. • NOK and LPA are not essentially the same thing • Upon hospital admission, NOK is identified and clearly documented, in the event the patient loses capacity later.Consenting Common Surgical Procedures • Laparoscopic Appendicectomy • Laparoscopic Cholecystectomy • Hernia Repair • Incision and Drainage of Abscess • LaparotomyLaparoscopic Appendicectomy • General surgical, anaesthetic and hospital risks • Conversion to open • Risk of Collections/Drains • Risk of damage to surrounding structures • Risk of bowel resection/stoma formation (Rare)Laparoscopic Cholecystectomy • General surgical, anaesthetic and hospital risks • Risk of subtotal cholecystectomy • Risk of retained stones • Risk of conversion to open (rare) • Risk of damage to surrounding structures • Bile leak • CBD injury • Liver/Bowel injury • Risk of collection/drainsHernia Repair • General Surgical Risks • Use of mesh • Risk of mesh migration • Risk of mesh infection • Hernia recurrence • Damage to surrounding structures • In Inguinal • Risk of damage to cord structures • Risk of orchiectomyLaparotomy • ALWAYS CALCULATE NELA! • General surgical, anaesthetic and hospital risks. • Risk of bowel resection/stoma formation • Risk of anastamotic leak • Risk of damage to surrounding structures • Risk of collections/drains • Risk of ileus • Risk of post-op ITU requirements • Needing tubes/lines etc • Impact on post-op nutrition • Impact on post-op quality of life • Especially in elderlyIncision and Drainage • General surgical, anaesthetic and hospital risks • Delayed wound healing • Need for packing • Risk of recurrence or need for redrainage • If perianal • Need for EUA • Damage to Anal Sphincter – incontinence (rare)Concentric TemplateConcentric Template • 2020 https://www.gmc-uk.org/-/media/documents/gmc- guidance-for-doctors---decision-making-and-consent- References english_pdf-84191055.pdf