What is informed consent?

As a , you have the right to understand and agree to any treatment or medical procedure before it takes place. This is called informed consent.

Informed consent is the communication between you and your healthcare provider that leads to an agreement or permission for medical care, services, or treatment.

This process ensures your doctor or other healthcare providers give you information about your condition and treatment options before you proceed with care.

The importance of informed consent

As a patient, you are entitled to get details and ask questions before receiving medical treatment or undergoing a procedure. In fact, if you are mentally capable of making your own decisions, medical care cannot be provided unless you give informed consent.

While there are many reasons for informed consent, some of the more critical aspects of this process are to

Establish patient-doctor trust
Prevent misunderstandings
Allow healthcare professionals to provide honest opinions
Avoid legal issues, since consent protects patients against assault and battery in the form of unwanted medical interventions
Improve patient rights, since the informed consent documents are a systems-level check to ensure the consent process has occurred

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Key components of informed consent

The informed consent process often begins with . This results in the patient’s authorization or agreement to go through a specific medical treatment or procedure.

When a healthcare professional seeks a patient’s informed consent, they need to make sure they

Provide an explanation of informed consent: what it is, how it works, and what it involves
Disclose all information about the treatment, such as a description of the procedure, the risks and benefits, and alternative options
Verify that the patient has the capacity to understand and make decisions about their medical care (if not, the patient should appoint someone to make a decision in their place)
Ensure the patient understands the information and voluntarily authorizes the treatment plan

What are the common barriers to informed consent?

Obtaining informed consent is critical to a patient’s care, but getting it isn’t always straightforward. In reality, there are many barriers that can contribute to a lack of understanding about consent, including the following:

Patient-centered barriers: age, education, cultural factors, illness, and others
Process-centered barriers: for example, a lack of information on the consent forms, poor readability, and the discussion timing and duration

Although patients want to take part in making their own medical decisions, they often believe these decisions should be the doctor’s task. In other cases, healthcare professionals might not understand the rationale for the patient’s role in making these types of decisions.

Best practices for getting informed consent

Although there are many ways for healthcare professionals to obtain informed consent, the tactics below are considered best practices.

Develop a practice of involving patients in medical decisions

This technique can be a great way to establish trust and understanding. The healthcare professional should apply it to all patients consistently and ensure it’s sensitive to their preferences for information and .

The practice should be designed to

Address the treatment’s risks, alternatives, and benefits, and what the patient should anticipate before and after the procedure
Allow patients or their representatives to make a voluntary choice that’s free from undue influence
Be easy to understand

Recognize that informed consent serves more than one purpose

Healthcare workers should ensure their informed consent process is flexible enough to fulfill its primary purposes, which are:

Protecting a patient’s rights
Allowing autonomous self-determination and decision-making
Promoting efficiency in the treatments and healthcare provided
Building trust between medical professionals and patients

Document the informed consent process

Medical professionals should document the process using electronic medical records whenever possible to ensure everything is appropriately and permanently stored.

Depending on the jurisdiction and the compliance standards, the techniques involved with this process may include:

Specific procedure consent forms
Having written and electronic patient materials that explain the informed consent process
Providing narrative notes that discuss the informed consent process and the objectives of the treatments and care involved
Offering decision aids for treatments that involve complex decisions