Frequently asked questions
Do I need to obtain consent for all procedures, and does it need to be written consent?
It is Department of Health policy that consent for treatment is obtained in writing, using an approved consent form for all surgical operations, and for all medical anaesthetic, radiology or oncology procedures. Written consent must also be obtained for:
- surgical, medical, radiology, oncology and endoscopy treatments/procedures requiring general, regional or local anaesthesia
- invasive procedures or treatment where there are known significant risks or complications
- sterilisation of a minor
- application of electroconvulsive therapy
- administration of medications with known high risks of complications or new or unusual medications
- drugs administered under the Special Access Scheme
- participation in clinical trials and medical research
Can we still use the old procedure-specific consent forms?
The old procedure-specific consent forms will no longer be supported by the Office of Safety and Quality in Healthcare (OSQH). The OSQH has developed generic consent forms and these should be used for obtaining consent to treatment.
The procedure-specific consent forms remain accessible on the OSQH website. Health professionals can adapt these procedure-specific consent forms into information sheets. However, it is the responsibility of the health professional to ensure that any amended forms are endorsed by Hospital/Area Health Service Executive prior to use, and that the information sheets are kept up to date, accurate, and relevant to patients’ needs.
The generic consent forms do not contain any information about the procedure. How do we inform patients about the nature of the proposed treatment and material risks?
It is the responsibility of health practitioners to provide their patients with information about their condition and the risks and benefits of the procedure. Written materials and/or audiovisual materials can be used to aid this discussion, but they should not be used as a substitute for a face-to-face meeting.
The Department of Health has purchased a suite of procedure-specific information sheets from EIDO Health Care under copyright, and these have been adapted for the Australian context. These procedure-specific information sheets are accessible only to health professionals working in WA public hospitals via the Department of Health intranet site.
Information sheets can also be obtained from other State/Territory Departments of Health or Learned Colleges (i.e. Royal Australasian College of Surgeons, Australian and New Zealand College of Anaesthetists). Use of these materials must be endorsed by the Hospital/Health Service Executive and ensure that they are kept up-to-date and accurate.
Do I need to obtain consent for anaesthesia using a separate consent form?
If general, local or intravenous sedation is going to be used for a planned treatment or procedure, the patient must be given appropriate information and be appropriately informed about the material risks involved. The patient’s consent must be documented in writing in the anaesthetic record, medical record, or on an appropriate consent form.
If an appropriate anaesthetic form is not available, the generic consent form can be used. It should be marked as ‘anaesthetic consent form’ and stored in the patient’s medical record.
The generic consent forms developed by the Department of Health are not suitable for our needs. Can we develop our own forms?
Hospitals/health services are strongly encouraged to use the generic consent forms developed by the Department of Health. If new forms need to be developed for specialty procedures such as experimental treatment or immunisations, these requirements need to be clearly outlined in local operational policies, and endorsed by Hospital/Health Service Executive. The new forms must contain:
- type of consent form (standard or other)
- communication needs identified
- procedure/s for which the consent has been obtained
- the correct site and anatomical location on which the procedure is to be performed
- the name and signature of the patient
- the printed name and signature of the doctor
- the printed name of the responsible doctor and their designation
- the printed name and signature of the interpreter (if applicable)
- acknowledgement of alternative treatment options
- acknowledgement of General Risk disclosure
- the material risks specific to the patient (where appropriate)
- a record of any benefits or outcomes discussed with the patient
- a copy of any information resources provided to the patient
What happens if a patient refuses to consent to treatment?
If a mentally-competent patient refuses to sign a written consent form for non-urgent treatment, the practitioner cannot proceed with the treatment until consent has been documented.
If a patient refuses recommended diagnostic or therapeutic interventions, and this decision could result in potentially life-threatening conditions, the refusal should be clearly documented in the medical record.
What happens if a patient is not capable of providing consent to treatment?
If a patient is not capable of consenting to treatment, consent should be obtained from one of the following (listed in order of priority):
- a guardian of the person who needs the treatment
- the spouse or defacto partner of the person who needs the treatment
- a person who provides domestic services or support for the person needing treatment, but who does not receive remuneration for doing so
- a person who is the nearest relative of the person who needs the treatment, and who maintains a close relationship with the person
- any other person who maintains a close personal relationship with the person who needs the treatment
- a person prescribed in the regulations (see section 119 of the Guardianship and Administration Act 1990).
What happens if I am unsure whether a person is competent to give consent, or whether a person is suitable to give consent on behalf of another person?
Seek Legal advice.
I do not have any more generic consent forms left. Where can I order some more?
Forms can be ordered from:
OfficeMax Australia Ltd
PH: (08) 9238 6977
FAX (08) 9238 6913
www.officemax.com.au
Omax # 3079015 = MR30-1
Omax # 3079023 = MR30-2
Omax # 3079031 = MR30-3
Omax # 3079058 = MR30-4
Omax # 3079066 = MR30-5
Omax # 3079074 = MR30-6