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Gaining consent to treatment from adults

You must respect the rights of patients to be fully involved in decisions about their care.238
If the patient has the capacity to consent, you must obtain their consent before a physical examination, starting treatment or helping them with their eye care, for example putting in drops or contact lenses.239, 240, 241, 242, 243
Patients can give consent orally or in writing, or may imply consent by their behaviour, such as resting their chin on the chin rest after you have explained the procedure. However, acquiescence when the patient does not know what the examination or treatment entails is not consent.
You should use your professional judgement to decide what type of consent is required. As most of the tests conducted during a routine eye examination are safe and non-invasive, implied consent would normally be sufficient for these. However, for more invasive tests, such as drop instillation, contact lens fitting or applanation tonometry you should obtain explicit consent from the patient.
You should get written consent from a patient if:
  1. the investigation or treatment is complex or involves significant risks
  2. there may be significant consequences for the patient’s employment, or social or personal life
  3. providing clinical care is not the primary purpose of the investigation or treatment
  4. the treatment is part of a research programme or is an innovative treatment designed specifically for the patient’s benefit.
You are responsible for ensuring the patient has given valid consent. You may delegate this to another person only if you are sure they:
  1. are suitably trained and qualified
  2. have sufficient knowledge of the proposed examination or treatment
  3. understand the risks involved
  4. are able to provide clear and accurate information in response to the patient's questions.
If you delegate the task of seeking patient consent but carry out the subsequent examination or treatment you must be able to determine:
  1. whether the patient had the capacity to make the decision to proceed244 
  2. what steps to take if the patient lacked capacity to make that decision.
In order for the consent to be valid, the patient must:
  1. have the capacity to consent
  2. be informed about the procedure
  3. understand the nature and purpose of the procedure.
If you misrepresent the elements in paragraphs C32 b or C32 c the patient’s consent will be invalid.
You should provide information to the patient in a balanced way and explain your reasons for any particular course of action that you recommend.
You must ‘take reasonable care’ to make sure that the patient has understood any material risks involved in any treatment or procedure, and of any reasonable alternatives. What constitutes a material risk will depend both on what a reasonable person would consider to be significant, as well as what is significant to your particular patient.245, 246 Failure to do this may mean you have breached your duty of care and make you liable in negligence if the patient suffers harm as a result of the treatment. You should not withhold any information necessary for the patient to make a decision, unless the patient specifically asks not to have the information. You should keep a record of any discussions. 
You should find out what information the patient wants, as well as telling them what you think they need to know. What patients might want to know includes:
  1. the options available: risks and benefits
  2. which option you feel is the most appropriate for them and why
  3. the cost of various options
If a carer or relative asks you to withhold information from the patient, you should not do so, unless you feel that giving the patient the information would cause serious harm. ‘Serious harm’ means more than the patient becoming upset or refusing treatment. If you withhold information from the patient you must record the reason in the patient notes.
You should not put pressure on the patient to accept your recommendation.
You should give patients with additional needs the time and support to make a decision.
The patient may withhold their consent for any part of the consultation.
It may constitute battery if you touch a patient without their consent.
You should always seek legal advice if you have any doubt about the legal validity of the examination or treatment.
Gaining consent from a patient is not a one-off event and is part of the ongoing liaison between you and the patient. You should be alert to unspoken signals which could indicate a patient’s lack of understanding, discomfort, or lack of consent.247 A patient who is capable of giving consent may withdraw it at any time, including during a procedure. If your patient does object during a procedure you should:
  1. stop the procedure, if possible
  2. find out the patient’s concerns
  3. establish if it is an expression of anxiety rather than withdrawal of consent
  4. give reassurance
  5. explain the consequences of not completing the procedure.
An adult patient with the capacity to consent has the right to refuse any treatment, even if you feel that their decision is unwise or it would lead to them (but no one else) suffering serious harm. If you believe that there is a risk of serious harm to the patient or others due to their decision to refuse a treatment or service, such as referral, you must raise this issue with appropriate healthcare colleagues or people involved in the patient’s care.248 However, you must respect the patient’s confidence when you do this.249 This can be done by discussing the case in general without revealing details which may identify the patient. See section on Confidentiality.