Chapter 5: Consent
What is Consent?
Consent is agreement to allow something to happen. From the perspective of the MLT, it is the client’s agreement to provide personal information and allow medical investigations.
There are different types of consent:
- Informed consent means that the person fully understands what he or she is agreeing to.
- Express consent is consent that is very clearly and definitively given. For medical procedures with any significant risk, express consent is typically given in writing.
- Implied consent is not expressed definitively but communicated by word or action. For example, if a person holds out her or his arm to have blood taken, this implies consent to the procedure.
- A substitute decision maker is someone authorized to give consent for an individual who cannot. For example, the substitute decision maker for a small child is a parent.
Express and implied consent, and consent given by a substitute decision maker, should all be informed consent. Taking the time to ensure that the client fully understands why certain information is required, and what is about to happen, not only ensures that consent is informed, it creates a better relationship between the two of you and builds trust. Never assume that a client is familiar with health records or a procedure he or she is consenting to.
Consent and the MLT
In a typical laboratory setting where samples are received for testing and MLTs have no direct patient contact, the issue of consent does not arise, as it will have been dealt with by the health care professional who saw the patient and obtained the sample. There are situations, however, where you must have consent: any time you collect information directly from a patient, or in the case of an animal, from the owner of the animal; and any time you collect samples from a patient. When you find yourself dealing with consent issues, always follow your employer’s policy.
Nonetheless, it is not generally necessary to address the issue of consent in any formal manner. If the client is capable of giving consent, the reason for collecting the information or doing the investigation has been explained, and the client cooperates voluntarily, it is reasonable to assume that you have implied consent. Take care to engage with each patient and get a sense of whether he or she does understand.
SCENARIO:
Marlene works in a veterinary lab, and sometimes collects blood samples directly from animals for lab tests. A vet asks her to collect blood from a dog in one of the examination rooms. The dog is large and appears very nervous, so Marlene decides it might be better to take the dog into another room where she will have more control and can get someone to help her if necessary.
Marlene quickly explains to the owner of the dog that the vet has requested blood tests, and that she will be back soon, before she leads the dog from the room. She notices that the dog’s owner speaks slowly and uses odd words when answering questions; however, she has other things to do and the owner shows no reluctance to hand over the leash, so she assumes that all is well. Later, the dog’s owner makes a complaint against her, saying that he did not give consent for the procedure.
The owner of this dog suffered from aphasia due to a stroke. This means that he had difficulty understanding everything that Marlene said to him, and wasn’t given the time he needed to ask questions. He was fully capable of understanding the situation and giving informed consent, but Marlene didn’t pick up on the clues he gave her: slow responses and trouble finding the right words. Because of this, she failed to obtain informed consent before taking blood from the dog.
After an encounter where informed consent has been obtained, you can normally share the information or sample with another party while still pursuing the original intent, and consent is still assumed.
SCENARIO:
A hospital auxiliary is organizing a major fundraising drive to purchase a new state-of-the-art instrument for blood cultures. Isabel, the chair of the fundraising committee believes that because septicemia is a life threatening condition, people who have had it are likely to give generous donations. She approaches the microbiology lab supervisor and asks for names and contact information for anyone on record who has had a positive blood culture.
The information Isabel is looking for is available from the laboratory information system; however, the supervisor initially says that she would need patient consent in order to release personal information for this purpose. Isabel argues that the patients will never know where she got their information, and that they gave their contact information to the hospital and lab voluntarily. They might not even be alive, she says, if not for diagnosis and treatment made possible by annual fundraising. Who is right? Does the patients’ consent extend to this?
Consent to provide a specimen for lab testing does not imply consent to have personal information shared with those not involved in the client’s care, or consent to be contacted for fundraising purposes. Nor does benefiting from previous fundraising obligate anyone to respond to requests for donations. If you need to share someone’s personal information for a purpose other than that for which you obtained consent, you must ordinarily get the individual’s permission to do so.
In this scenario, it’s likely the hospital has protocols for both fundraising and sharing of personal information that would rule out this sort of sharing. Even if personal information is being shared for medical research purposes, which may be acceptable in some circumstances, a medical ethics committee would have to approve the collaboration.
Some clients are not considered capable of giving consent, and the consent must then come from a substitute decision maker. Those who cannot give consent may include, for example, a child (there is no legal age of consent in Nova Scotia), or an adult who is physically unable or mentally incompetent to give consent. The procedure for identifying who can give consent for someone who is incapable of giving it is laid out in the Personal Health Information Act (Section 21).
Clients Withdrawing Consent
In health care, consent is ongoing, and an individual can withdraw consent for anything, including medical treatment and the use and disclosure of their personal information. Health professionals must respect a client’s decision to withhold or withdraw consent.
SCENARIO:
Rita, an MLT working in a rural hospital, arrives at the bedside of a new mother to collect some blood from the baby. The newborn, however, has just fed and gone to sleep after a fussy few hours and the exhausted mom doesn’t want the baby disturbed. She tells Rita not to take the blood sample.
Rita knows that it will be hard for her to get back later, and she tries to convince the mother that the blood should be taken now. She explains that the doctor ordered the tests and is waiting for the results. She also mentions that if she doesn’t get the blood now, it may have to wait until tomorrow, that discharge may be delayed or the mom might have to make a special trip to bring the baby back for the tests. Her efforts are to no avail—the mom adamantly refuses to have the baby woken up. Rita reluctantly returns to the lab without the blood.
Although a patient may have cooperated with previous procedures, she or he does have the right to refuse at any time, and parents have the right to refuse for children who can’t give their own consent. Regardless of the repercussions, whether serious or merely matters of convenience, we can’t apply unreasonable pressure to obtain consent. Rita was right to leave without the sample; however, she should report the incident following employer policy. If the tests are urgent, the doctor can speak with the mom and try to obtain consent.
If the withdrawal of consent involves personal information, anyone in possession of that information is required to dispose of it. The withdrawal of consent cannot be retroactive: it’s not an offence to have been in possession of personal information for which the client subsequently withdrew consent.
Disclosure of Information Without Consent
Never disclose a client’s personal health information without their consent except inoneofthesituationsdiscussedunder Mandatory Reporting—where you have a duty to make a report—or if you are otherwise legally compelled to do so.
Except for those MLTs who are self-employed, employer protocol will dictate when personal health information is disclosed to other parties without consent, and by whom. Scenarios where this might occur include:
- for research purposes where the disclosure has been approved by an ethics committee
- in crime prevention or criminal investigation
- for healthcare administration purposes
The Personal Health Information Act does allow disclosure “to any person if the custodian believes, on reasonable grounds, that the disclosure will avert or minimize an imminent and significant danger to the health or safety of any person or class of persons” (Section 38 [1d]). Again, in most cases, such a concern can be addressed to a higher authority unless you are self-employed.
Conclusion
Informed consent is vital to the delivery of safe compassionate health care. Because health and health care are not static, informed consent must be ongoing: health care professionals must continually communicate with patients and patients must continue to willingly consent to their care. Without this, there is no informed consent.
Informed consent applies not only to patients and their bodies, but also to their personal and health information. When someone consents to having us store information, it’s expected that we will keep it confidential.
In some circumstances, patients are not capable of giving and/or withholding consent. In these circumstances, we must be careful to ensure that we proceed appropriately.
