November 2024 - Consent and vulnerable patients

Consent is a legal obligation and fundamental ethical principle in healthcare. Approaches and style must be adapted according to the individual patient. As the GOC highlights in Outcome 1.6 of their Requirements for Approved Qualifications in Optometry or Dispensing Optics, registrants must obtain and verify continuation of valid consent from adults, children, young and vulnerable people and their carers and record as appropriate. Furthermore, as Outcome 4.4 states, registrants must apply the relevant national law and take appropriate actions i) to gain consent and ii) if consent cannot be obtained or is withdrawn.

Consent ensures that patients are empowered to participate actively in their own care. As discussed in our feature last month on Patient Centred Care, trust, communication and treating the patient as an individual are key elements of the clinician-patient relationship. Understanding the unique challenges faced by vulnerable patients—such as those with mental health challenges, development disabilities, the elderly, and others who may face barriers in fully understanding or agreeing to treatment—is crucial. 

One of the major challenges in these situations is ensuring that patients' autonomy and rights are respected while safeguarding their well-being. The Mental Capacity Act (MCA) 2005 and similar laws mandate clear steps to assess a patient's capacity to consent and outline alternative decision-making processes, such as identifying an appropriate surrogate decision-maker, if they lack capacity. 

Assessing capacity

  • Mental Capacity Act: In the UK, the Mental Capacity Act 2005 provides a framework for assessing a patient’s capacity to make decisions. It emphasizes that capacity is decision-specific and can fluctuate over time. The MCA requires you to assume that every adult aged 16 or over has mental capacity to make their own decisions, unless proved otherwise.
  • Capacity Assessments: Conduct thorough assessments to determine if the patient can understand, retain, and weigh the information relevant to the decision. Keep comprehensive records of the consent process, including the information provided, the patient’s responses, and any assessments of capacity.

Awareness of the importance of consent and sensitivities around treating vulnerable patients is built up throughout optometry and ophthalmic dispensing courses. A spiral learning approach ensures that topics that are introduced in year one are covered in a more complex nature in following years as knowledge is built and students and learners develop their skillsets and behaviours over time. A spiral curriculum is essential to build confidence and capability safely, especially in relation to vulnerable patients

Find out below how you can apply the spiral learning approach.

1. Initial phase: Introduction to basic concepts

Basic definitions and principles

  • Introduce the concepts on consent and the importance of respecting patient autonomy.
  • Discuss types of patients that may be vulnerable and why they require special consideration.

Simple role plays

  • Peer role play and Peer Based Learning (PBL) can develop empathy and build communication skills. February 2024's Topic of the Month feature has additional resources on a range of different communication methods.
  • Create scenarios where students practice obtaining consent and interacting with vulnerable patients to help understand different patient needs and responses. (Please also see the case study scenario below which is a useful resource for generating questions and discussion).

2. Intermediate phase: Expanding knowledge and skills

Legal and ethical frameworks

  • Legal - the law and safeguarding is essential precursor theory. All healthcare professionals have a legal obligation to obtain consent from patients before providing treatment, examinations, or care and must understand the rights of vulnerable patients.
  • Revisit the principles of consent with a focus on ethical considerations.

Complex case studies

  • Encourage students to discuss and analyse more complex cases in groups, that require students to apply their knowledge and explore different solutions.

3. Advanced phase: Mastery and application

Simulation 

  • Simulation provides further opportunities for more realistic patient management skills and is useful in helping learners refine their skills and gain confidence in treating vulnerable patients.
  • Explore different ways to communicate with patients, their carers or legal guardians, and other healthcare professionals whilst ensuring that the patient is at the centre of all the decisions being made.
  • Allows students to receive detailed feedback in a controlled environment.

Ethics

  • Challenge students to make decisions with incomplete information, or where ethical boundaries are unclear.

4. Continuous reinforcement

Ongoing assessment

  • Regularly review students’ understanding and application of consent principles.

Reflective Practice

  • Encourage students to keep records, reflecting on their experiences, what they learned and what could have been done differently.

As Rupal-Lovell Patel explains, "to offer meaningful learning opportunities around safeguarding and help learners be confident in how to treat vulnerable patients, you need to provide hands-on or real-world experience. However, providing real clinical experience in this topic brings a complexity that makes it difficult to give all learners an equal opportunity. For learners, this topic can be daunting, but it is a crucial part of our clinical role and therefore we need to pitch the teaching in a way that learners can engage with it, they can see the importance of this topic and feel supported when they start to apply their knowledge in a clinical setting."

This teaching activity can be broken down for discussion in class/seminars to assess knowledge, peer discussion and critical thinking. 

Peter’s consultant at the hospital recommended surgery to remove cataracts that were affecting his vision. Peter is 64 years old and has a mild learning disability. He was able to fully understand the consultant’s explanation of the procedure. After receiving information about the cataract surgery, he recognised the potential benefits, risks and side effects of the treatment.

Question for small group discussion: What are your initial thoughts on this situation and how Peter will progress?

Add further information and then put out for small group discussion again.

Peter chose to decline the surgery; he explained that he was happy with his current quality of life and felt the procedure was unnecessary for him. 

Additional commentary to be given as discussions progress: Although the community nurse believed that the surgery would improve his condition and thought it should go ahead, Peter’s decision was respected. 

When an individual can fully grasp the nature of a treatment and its possible outcomes, their choice must be honoured, even if a healthcare professional disagrees.

When closing discussions: It is also essential to acknowledge that Peter may reconsider his decision at any point. If he chooses later to undergo the surgery, that decision should also be respected. Meanwhile, Peter should continue to receive regular monitoring and support, which should be made available to him.

Many people with a learning disability do have the capacity to consent if time is spent explaining issues in appropriate language, using visual aids and signs as necessary

For consent to be considered valid, it must be given freely by a person who is well-informed and has the capacity to understand the proposed intervention. If a person with a learning disability fully comprehends a treatment or intervention and it aligns with their best interests, they can consent to it. [1]

Gaining consent from vulnerable patients in optometry settings requires a compassionate and patient-centred approach. By simplifying information, assessing capacity carefully, involving family and advocates, and adhering to ethical principles, optometrists can ensure that consent is truly informed and respects the dignity and autonomy of all patients.

Resources featured in this article have been shared by both Rupal Lovell-Patel, Senior Lecturer in Optometry & Ophthalmic Dispensing at University of Central Lancashire and  Paula Perrott, Head of School - Ophthalmic Dispensing Bradford College. Sincere thanks to them both for their contributions. 

Keep updated 

If you would like to be kept up to date with the work of SPOKE, please email spokehub@college-optometrists.org to be added to our Advisory Review Group. Similarly, please email with your views of Topic of the month or any suggested themes you would like to see covered. 

References and bibliography

[1] See Ability, Consent Consent to medical treatment for eye health

[2] See Ability, Consent Consent to medical treatment for eye health

Dellen A v, Green M. Difficulties in consent: applying the Mental Capacity Act BMJ 2013; 347 :f6700 doi:10.1136/bmj.f6700

Adults with Incapacity (Scotland) Act 2000

BMA Consent and refusal by adults with decision-making capacity

GOC Supplementary guidance on consent

Mental capacity Act 2005

NICE Decision-making and mental capacity