Version: / 2
Author: / Prepared by Eithne Ni Dhomhnaill, Nursing Matters & Associates.
Adapted for local use by:
Issue Date: / January 2014
Review date: / January 2016
Authorised by:
1.0Policy Statement:
It is the policy of The Centre that residents will be fully supported, both at individual and collective level, to exercise their rights and to make informed decisions about their health and social care.
2.0Purpose:
The purpose of this policy is to ensure that residents are empowered to make autonomous choices in accordance with their abilities, rights and entitlements and within the context of legal and ethical principles of informed consent.
3.0Objectives:
3.1.1To ensure that all staff in the Centre are aware of the needs and entitlements of residents to make autonomous decisions about everyday activities as well specific health related activities during the process of care delivery.
3.1.2To ensure that all healthcare staff are aware of the professional and legal requirements for seeking and obtaining informed and valid consent during the course of care delivery.
3.1.3To promote a person-centred approach to safeguarding each resident’s right to make informed and autonomous decisions.
3.1.4To provide access to advocacy support and services in accordance with each resident’s known needs, wishes and preferences.
4.0Scope;
This policy applies to all staff providing direct care to residents including, the proprietor, the person in charge; catering staff as well as all nursing and healthcare staff employed by or providing contract services to the Centre.
5.0Definitions:
5.1Consent:
5.2Consent is the giving of permission or agreement for an intervention, receipt or use of a service or participation in research following a process of communication about the proposed intervention (HSE, 2013).
5.3Valid Consent:
5.4In order for consent to be valid, the following criteria must be met:
■The resident have received sufficient information in a comprehensible manner about the nature, purpose, benefits and risks of an intervention/service or research project.
■The resident must not be acting under duress; and
■The resident must have the capacity to make the particular decision.
(Health Services Executive, 2013).
5.5Sufficient Information:
The amount of information required by a resident will depend on the intervention, risks associated with it and the resident’s needs. According to the National Consent Policy (2013), if a resident has to make a choice about whether to undergo or forego
a medical investigation and treatment or choose whether or not to agree to a major lifestyle change such as admission to residential care, he / she will need adequate information about:
Their diagnosis and prognosis including any uncertainties about the diagnosis or prognosis.
Options for treating or managing the condition, including the option not to treat.
The purpose of any proposed intervention and what it will involve
The potential benefits, risks and the likelihood of success of a proposed intervention, as well as that of any available alternative
Whether a proposed investigation or treatment is experimental or part of a research project
If relevant, that costs will have to be paid and how and where information about these costs may be obtained.
The resident should be asked if they have understood the information they have been given, and whether or not they would like more information before making a decision. Questions should be answered honestly and, as far as practical, as fully as the service users wishes.
However, the nature and effect of some interventions, such as removal of a dressing or provision of assisted personal care are often self‐evident and relatively risk‐free. In these circumstances, it is usually enough for staff to seek consent to proceed after a brief description of the intervention.
5.6Expressed or Implied Consent:
Consent can be demonstrated in a number of ways. Agreement can be indicated verbally, in writing or implied. Refusal can also be made in the same way.
◙Expressed Consent – can be given orally or in writing.
◙Oral consent is usually used to obtain permission for less serious procedures e.g. most bedside procedures. In these situations the clinician (nurse) performing the procedure explains the procedure to the resident – giving the resident the requisite information before commencing the procedure (Midland Health Board, 2004).
◙Written Consent: While there is no statutory or legal document that defines specific procedures / treatments that require consent forms to be completed, it is generally accepted that where any procedure or intervention carries a significant risk, evidence of receiving an informed and valid consent should be documented. Moreover, for all nursing procedures that carry a significant risk, the information given to the resident as well as their consent should be documented in nursing notes (An Bord Altranais, 2003). Nurses should only obtain consent for interventions that they themselves will complete. Medical and / or other healthcare staff are responsible for obtaining consent for any procedures/ interventions that they will perform(An Bord Altranais, 2003).
◙Implied Consent – consent should be regarded as implied only by the specific behaviour of the resident but it does not automatically give a carte blanche to staff to treat the resident. Nursing Staff need to be cautious about implied consent and resident acceptance/agreement should be documented in the resident’s file if there is any ambiguity or concern / complaint about treatment given or procedures performed.
5.7Capacity:
The ability to understand the nature and consequences of a decision in the context of availablechoices at the time the decision is to be made (HSE, 2013).
“There is no legal definition of capacity in Ireland. Current Irish law begins with a presumption of capacity, that is, that every person is presumed to have capacity to consent unless proven otherwise. Under current arrangements, health professionals have to exercise personal judgment in assessing capacity and determining how to proceed if an adult is assessed as lacking the capacity to make a healthcare decision.
With regard to informed consent, this means that healthcare professionals will need to make a judgement about the resident’s ability to:
To understand the information relevant to the decision (see protocol for consent).
To retain the information relevant to the decision.
To use or weigh the information.
To communicate the decision (by any means).
(Law Reform Commission, 2006).
5.8 Intervention
The provision of treatment or investigation, whether physical or psychological, or personal or social care for a service user or the involvement of a service user in teaching and research.
5.9Significant/ Material Risk
A risk may be seen as significant/ material if a reasonable person in the patient's position would attach significance to it (HSE, 2013).
5.10Advocacy.
Advocacy is: ‘a means of empowering people by supporting them to assert their views and claim their entitlements and where necessary representing and negotiating on their behalf’ (Comhairle, 2005)
5.11Empowerment.
The process by which residents are given the support and resources they need to become involved in their care. It may involve providing the information and physical resources or may simply involve building confidence to participate (Reed, J. 2004).
6.0Principles Underpinning This Policy.
The following principles underpin the Centre’s policy on consent. Registered nurses and other healthcare staff involved in providing health and social care to residents must adhere to these principles.
6.1It is a basic rule at common law that consent must be obtained for medical examination, treatment, service or investigation. This is well established in Irish case law and ethical standards. The requirement for consent is also recognised in international and European human rights law and under the Irish Constitution.
6.2The requirement of consent to treatment is a fundamental human right and aspect of a person’s right to bodily integrity under article 40, s. 3 of the constitution. If medical treatment is given without consent, it may trespass against the person in civil law, a battery in criminal law and a breach of the individual’s constitutional rights.
6.3All staff have a duty to respect each resident’sright to autonomy, that is their right to control their own life and to decidewhat happens to their own body.
6.4Althoughthose providing health and social care to a resident, might claim greater expertise in decisions regardinga resident’s well-being and health, the competent resident’s right to refuse an interventionapplies even when their decision seems unwise to the health and social care professional.
6.5Decision making about care must recognise and acknowledge the resident’s goals, values and preferences as well as the specialist knowledge, experience and clinical judgment of health and social care professionals.
6.6It must not be assumed that a service user lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including intellectual disability, mental illness, dementia or scores on tests of cognitive function), their beliefs, their apparent inability to communicate, or the fact that they make a decision that seems unwise to the health and social care professional.
6.7Capacity should not be confused with a health and social care professional’s assessment of the reasonableness of the service user’s decision. The person who has capacity can make their own choices, however foolish, irrational or idiosyncratic others may consider those choices.
6.8Similarly, the fact that a service user has been found to lack capacity to make a decision on a particular occasion does not mean that they lack capacity to make any decisions at all, or that they will not be able to make similar or other decisions in the future.
6.9No other person such as a family member, friend or carer and no organisation can give or refuse consent to a health or social care serviceon behalf of an adult service user who lacks capacity to consent unless they have specific legal authority to do so.
6.10Where a resident needs to make a decision about care and / or treatment, nursing staff and other healthcare professionals have a duty to support the resident in making the decision by identifying approaches that would maximise the resident’s decision making capacity. This, for example may include identifying the best time to approach a resident where their decision making capacity can fluctuate because of their condition; identifying the best methods of communication/information giving for residents with specific communication needs and / or recognising that some residents may be able to make simple decisions, but may have difficulty where a decision is complex or involves a number of options.
7.0Responsibilities
Action / Responsible Person (s)Residents / representatives will be provided with all relevant information regarding the facilities and services of the home prior to admission. This will include information on rights and entitlements and the organisational advocacy framework. / Person in Charge / Assistant Director of Nursing.
Residents will have an assessment of needs to identify any specific problems or needs related to understanding and communicating. / Admitting / named nurse
This policy will be disseminated to and read by all healthcare staff, including allied healthcare professionals providing care and treatment to residents in the centre.
A record of those who have read and signed the policy acknowledgement forms will be kept.
This version of the policy will be filed away when a new version is developed. / Person in Charge / Assistant Director of Nursing.
All staff will be given an explanation of this policy on induction and updated where there is a change to the policy. / Person in Charge / Assistant Director of Nursing.
Residents’ permission will be sought prior to any care intervention being carried out. / All staff providing care to residents.
Residents’ care plans will include their ability for making decisions; any supports required for decision making (eg communication needs etc) and any known wishes and preferences for care. / Registered Nurses.
A record of discussions and their outcomes related to complex care decisions will be recorded in the appropriate section of the resident’s healthcare record (eg. Medical notes or nursing care plan). / All healthcare professionals obtaining consent for complex treatments and / or procedures.
Residents will be given all relevant information prior to any interventions or treatments carried out. / Healthcare professional / workers carrying out care interventions/treatment.
Nurses will maintain their competence regarding consent and advocacy and communicate any knowledge deficits / education needs to the Person in Charge. / All nurses.
All staff providing personal and intimate care to residents will comply with the requirements of this policy in relation to the provision of such care. / All healthcare staff providing personal and intimate care to residents.
A designated staff member will ensure that information regarding activities and events in the home will be provided to all residents in an accessible format. / Person in Charge / Assistant Director of Nursing..
8.0Quick Reference Guide – Consent.
9.0Consent Protocol.
According to the National Consent Policy (2013) The process of communication to facilitate consent begins at the initial contact and continues through to the end of the resident’s involvement in the treatment process, provision of social care or research study. Seeking consent is not merely getting a consent form signed; the consent form is just one means of documenting that a process of communication has occurred. The following protocol outlines the process of facilitating valid consent throughout a resident’s journey in the Centre.
9.19.1 Pre admission.
The decision to move to residential care involves a major lifestyle change. The Centre undertakes the following activities in order to facilitate decision making based on informed consent.
9.1.1A pre admission assessment is carried out with the resident and their representative either at their home or at the referring facility.
9.1.2Prior to obtaining information for the pre admission assessment, the prospective resident must be given an explanation of the purpose of the assessment and how the information will be used.
9.1.3Prospective residents and / or their representatives are offered an opportunity to visit the Centre to be shown around and meet with other residents. .During this visit, the resident / representative is given information about the Centre and any questions they may have are answered.
9.1.4Prospective residents and / or their representatives are given a copy of the Statement of Purpose and Function and Residents’ Guide, which includes information about services and costs and a sample contract of care.
9.2Assessment and Care Planning.
9.2.1On admission, the nurse admitting the resident must again explain the purpose of assessments, how information will be used and who information will be shared with.
9.2.2The admitting nurse must ask the resident if he / she has any preferences regarding the sharing of information and this must be recorded in the resident’s care plan.
9.2.3The admitting nurse must also ask the resident who they would like to have involved in care planning and record same in the resident’s care plan.
9.2.4Throughout the admission/comprehensive assessment, the assessing nurse will identify the resident’s ability to make everyday decisions and to communicate their preferences and wishes related to everyday care. Both the cognitive and communication assessments assist the assessing nurse to identify these abilities.
9.2.5The admission / comprehensive assessment will also provide information about the residents wishes and preferences for care and services.
9.2.6The resident’s care plan should identify the resident’s ability to make everyday decisions and any assistance the resident may need to make decisions. These should be recorded in the cognition care plan.
9.2.7The views and observations of the resident’s family/representative will be sought where the resident does not have the ability to provide information for assessment and care planning.
9.3 The Resident’s Care Plan.
9.3.1 Each nurse who completes a care plan for a resident must involve the resident in the development of the care plan as far as the resident is able. The resident’s representative will be involved where the resident is unable to be involved in the care planning process or where the resident has asked for the involvement of their representative.
9.3.2The resident’s ability and needs to communicate preferences and wishes and consent should be recorded in the communication care plan. These may include non-verbal indicators that the resident is giving or refusing consent /permission to care.
9.3.3The views and observations of family members will be used to provide staff with information about any non-verbal cues or behaviours the resident uses to convey consent or refusal to care or how best to provide information to the resident in a format that he/she will understand.
9.3.4Each nurse completing a care plan must include the resident’s known wishes for care and services and any known likes / dislikes in all domains of the care plan.
9.3.5Where the resident’s care plan is being reviewed, the resident and / or their representative as appropriate must be informed by the nurse undertaking the review and involved in the review process.
9.3.6Where the resident is unable or does not wish to be involved in the development or review of their care plan, this must be recorded in the resident’s care plan.
9.3.7Any alternative arrangements, such as the involvement of a representative in all care planning, must also be recorded in the resident’s care plan.
9.3.8Decision making for complex care decisions must comply with the requirements outlined in 10.2.
10.0Obtaining and Recording Consent for Care and Treatment.
10.1Persons Responsible for Obtaining Consent (National Consent Policy, HSE, 2013).
10.1.1The person who is providing a particular health and social care service or intervention is ultimately responsible for ensuring that the resident is consenting to what is being done.
10.1.2The task of providing information and seeking consent may be delegated to another professional, as long as that professional is suitably trained and qualified. In particular, they must have sufficient knowledge of the proposed intervention and of the benefits and risks in order to be able to provide the information the resident requires.
10.1.3Inappropriate delegation (for example where the seeking of consent is assigned to a junior health and social care professional with inadequate knowledge of the procedure) may mean that the “consent” obtained is not valid.
10.1.4If different aspects of care are to be provided by different professional disciplines, each should usually obtain consent for their particular intervention.