Informed consent

How do I obtain, and document, informed consent?

What is informed consent?

The Code of Professional conduct requires that veterinarians obtain a client’s informed consent before proceeding with a treatment or course of action. In essence, informed consent means that the client has enough information about the treatment to make a rational decision about whether to proceed. The Code makes it clear that this information includes:

• The likely diagnosis (where appropriate) and the reason for the proposed treatment
  • Treatment options, including likely outcomes, risks, side effects, benefits and costs (or range likely range of costs)
• The veterinarian’s experience and skill to undertake the treatment (particularly for more complex or unusual procedures)
• Referral options
• Post treatment requirements and likely costs.

It is important that clients are provided ‘enough relevant information’ meaning sufficient, relevant information being given to be able to make a considered decision on whether to accept or reject the recommended treatment or course of action. 

In general:

• a simple procedure involving minimal risk and using current well-recognised options will require minimal detail
• a complex procedure will require detailed information, especially if less common

For non-urgent procedures, the consent discussion should take place in advance of the treatment/procedure where possible. The client’s consent to treatment should be obtained unless delay would adversely affect the animal’s welfare.

The following matters should also be considered during the discussion with the client to ensure they do understand: 

• Avoid making assumptions, for example, about a client’s financial constraints or a client’s understanding of the possible side effects, complications or the failure to achieve the desired outcome with agreed treatment.
• Provide a range of financial estimates, and an agreement on any financial limits. This should also be documented on the consent form, or on an attached detailed estimate.
• Where appropriate, provide an explanation that the diagnosis is tentative subject to further investigation.
• Check with the client whether they have any questions or concerns regarding the diagnosis, treatment and costs.
• Inform the client (where appropriate) that other treatment is available that may have greater potential benefit than those available at the practice (i.e. Referrals and second opinions).
• Ensure, where possible, that consent can be obtained from the client for any deviations from the treatment plan (including costs), therefore where possible ensuring that the practice has the client’s emergency contact details and that these are up to date.
• Exercise sound professional judgement in determining who is able to consent to treatment. For example the client may be the owner of the animal, someone acting with the authority of the owner, or someone with statutory or other appropriate authority. Consideration should also be given to the age of the person providing the consent or whether the person has limited capacity to provide consent.
• In discussing alternative treatment options veterinarians must not tailor the discussion because of their evaluation of the client’s financial status. Failing to inform clients of reasonable medical alternatives (for example referral) breaches the Code.

Who can obtain a client’s consent?

The veterinarian responsible for the case must ensure that informed consent has been given before proceeding. Delegating some or all of the process to other staff (such as a veterinary nurse or receptionist) may be appropriate when:

• the proposed treatment is a common procedure, especially when requested by the client eg de-sexing operations
• the staff have been appropriately trained and protocols are in place and followed.

The accountability for the process remains with the veterinarian in charge of the case and there must be the opportunity for clients to talk with the veterinarian if they have expressed any concerns or request it.

Recording consent

The Code allows for verbal consent to be given so long as the veterinarian ensures the informed consent process is adequately documented. Other ways to document a client’s consent (in order of increasing reliability) are:

• the veterinarian documents a verbal consent in their clinical records
• a verbal consent is witnessed by a staff member and documented in the records
• a client sends an email or text to the veterinarian/clinic of their consent
• a client signs a consent form electronically and emails it to the clinic
• a client signs consent form at the clinic.

Consent forms are a useful way of robustly documenting the client’s agreement to treatment based on knowledge of what is involved and the likely consequences. Consent forms should be viewed as an aid to consent, in conjunction with a discussion with the client.

Forms may be used to record agreement to carry out specific procedures and they form part of the clinical records. If any amendments are made subsequently, these should be initialled, dated and a note of subsequent conversations recorded on the clinical records.

The clinical record should also include:

• a summary of relevant discussions that took place to arrive at the treatment decision/s
• a client’s decision not to proceed with the veterinarian’s recommendation (for example declining a second opinion or referral).

Regardless of whether verbal consent, an electronic, or a physical form is used, it is important that clients are given information about proposed treatment or course of action in a way that they can understand.  Also a copy of the form should be provided to the person signing the form unless the circumstances render this impractical.

Payment

The agreement to pay for the service (procedure or treatment) should be treated conceptually as a separate process to obtaining informed consent. An agreement to pay costs can be included on the consent form, however.

Some example consent forms

Companion Animal anaesthetic consent form (docx file):

Companion Animal complex procedure anaesthetic consent form (docx file):

Production Animal sedation consent (docx file):