Informed consent for medical treatment

Informed consent means that you understand your condition and any proposed medical treatment. You have a legal right to be told any information that relates to your medical condition and treatment. Without this information, you are not able to make a fully informed choice and give valid consent for treatment.

Your doctor has a duty to explain your medical condition, the recommended treatment (including the other treatment options available) and the benefits, risks and possible complications of the recommended treatment. This is essential so that you can make a decision.

This is known as ‘informed consent’. Once the information is given, the doctor may ask you to sign a consent form. When signed by you, this form gives the doctor legal permission to perform the procedure.

Information you should be told

Before making a decision about medical treatment, make sure you get written information to take home to read so you can think about what you want to do.

The information that must be given to you as a patient includes:

• The diagnosis and likely outcome (prognosis) of your condition
• An explanation of the recommended treatment
• The risks of the procedure and common side effects
• Possible complications
• Specific details of the treatment; for example, where it will be performed and who will perform it
• Any other options for treatment and their probability of success.

Take an active role

Informed consent is a process of finding out information about the recommended treatment, and weighing up the benefits and risks involved. It is not about just signing a form.

Some ways to take an active role in your own treatment include:

• Find out as much as you can about the procedure. The best way to be actively involved in your care is to learn about the procedure, as well as about its risks and possible complications.
• Find out beforehand if something could go wrong. It’s too late once the procedure is done.
• Take responsibility for your health care decisions. You need to decide about your medical treatment, although it is important to consider the advice of your doctor when doing so.

What to ask your doctor or surgeon

Suggestions on what to ask your doctor or surgeon before treatment include:

• Exactly what procedure will be performed on you?
• What is the aim of the procedure? For example, will the procedure offer a diagnosis, cure or pain relief?
• What are the expected benefits of the procedure?
• What will happen during the procedure?
• Will general or local anaesthesia be needed and what are the associated risks of the chosen anaesthesia?
• What is the success rate for the procedure?
• What side effects can you expect? For example, how much pain will you have afterwards?
• Are there any possible risks? For example, could there be accidental damage to other areas of the body during the operation?
• What are the possible complications of the procedure? For example, is infection of the surgical wound likely?
• Do you have individual risk factors? For example, factors such as age, general health and other chronic medical problems may increase your risk of complications in some cases.
• How long will it take to recover? When can you resume normal everyday activities, work and exercise?
• Are there other treatment options that may offer good alternatives; for example, a different type of medical procedure, prescription medications or lifestyle changes (such as regular exercise or dietary modifications)?
• What will happen if you have no treatment?

If you have doubts

Sometimes it is difficult to decide whether or not to undergo a particular medical procedure. Suggestions include:

• Make a further appointment with your doctor or surgeon to discuss your doubts and fears more fully.
• Ask them to explain the information to you again in simpler terms. If you don’t fully understand the information the doctor or surgeon gives you, then say so.
• Ask for a referral to another specialist to get a second opinion.
• Ask your doctor or surgeon for information in another language or for an interpreter if you, or a family member, can’t understand materials written in English.

Before and after care instructions are important

The doctor should talk to you about any special things you need to do before treatment and during recovery time. The success of your treatment may depend on following these instructions. Make sure that you understand the advice and are prepared and able to follow it.

General consent form information

Before a planned surgical procedure, the surgeon will ask you (or your legal guardian) to sign a consent form. The doctor, not the nurse, must obtain the patient’s consent.

The form will have information specifically about the procedure. Generally speaking, a typical consent form includes:

• Your surname, given names, date of birth, sex and referring doctor
• Whether or not an interpreter is required
• An explanation of your condition, in plain language
• An explanation of the procedure, in plain language
• General risks of anaesthesia, which may be included in a separate form
• General risks of surgery
• Specific risks of this particular procedure, listed by the doctor
• Whether or not the doctor has explained the risks and possible complications
• Whether or not the doctor has explained the risks of not having the proposed treatment
• Your agreement that information has been provided
• Your agreement that you understand that the procedure may not work or may worsen the condition
• Your dated signature to confirm that you understand all of the above and want to undergo the procedure.

Your understanding is crucial

The signed consent form is considered a legal document. According to the High Court of Australia, however, a patient’s signed consent is legal only if the patient was adequately warned about possible risks and complications, and has understood the warnings.

Generally speaking, ‘informed consent’ depends on whether or not you as the patient would have agreed to the surgery if you had known and understood the possible risks and complications.

Your consent can be withheld or withdrawn

Remember that the final decision is always yours. The patient has the legal right to refuse consent or withdraw consent for any proposed treatment.

Where to get help

• Your GP (doctor)
• Surgeon
• Royal Australasian College of Surgeons Tel. (03) 9249 1200
• Medical Practitioners Board of Australia Tel. 1300 419 495
• Office of the Health Complaints CommissionerTel. (03) 8601 5200 or 1800 136 066