Consent and Shared Decisions

Consent is required for examinations, tests, medicines and procedures. It is not permission collected for the clinician's convenience. The person needs relevant information, suitable support and freedom from pressure before agreeing or refusing.

Consent is permission based on a real decision Consent means agreeing to a healthcare examination, test, treatment or procedure. Valid consent must be voluntary, informed and given by someone with capacity for that decision. Consent can be spoken, written or shown clearly through actions during straightforward care. Silence, lack of resistance or a signed form without understanding does not establish valid consent. This lesson focuses mainly on adults. Rules for children, young people and situations governed by specific laws need separate professional assessment. Shared decision making is a conversation Shared decision making brings together clinical evidence and the person's preferences, values and circumstances. The healthcare professional explains reasonable options and may recommend one with clear reasons. The person explains what outcomes, burdens and uncertainties matter most to them. They can ask questions, request more time or involve someone they trust. Shared decision making does not require a clinician to offer treatment that is not clinically appropriate. It also does not remove the person's right to refuse an offered option. The aim is a shared understanding of the choices, not pressure to reach the clinician's preferred answer. The information must match the decision A person usually needs to understand the condition or clinical question, including important uncertainty. They need to know what each option involves and what outcome it aims to achieve. The discussion should cover likely benefits, limitations, burdens and recovery. It should also cover reasonable alternatives, including no treatment or no change when that is an available option. The likely consequences of delaying or declining should be explained without threats. A time sensitive decision should include what delay could change. The healthcare professional should be honest when evidence is uncertain or an individual probability cannot be estimated precisely. Material risks are individual A material risk is one that could reasonably matter to the person making the decision. This depends on the possible harm and the person's circumstances, priorities and concerns. The discussion does not need an exhausting list of every theoretical complication. It should include recognised risks most people would want to know, serious risks even when uncommon and outcomes important to that person. Common expected effects should also be discussed, including what to do if they occur. Individual health conditions can make a benefit or harm more or less likely. Risk is not defined only by frequency. A rare outcome may be material when its consequences would strongly affect the person's life or decision. Numbers should clarify rather than persuade When useful numbers are available, absolute numbers and natural frequencies can make risk easier to understand. For example, saying 3 people in 100 gives a clearer denominator than saying the risk triples. Benefits and harms should use the same timeframe and denominator where possible. Visual aids can help when they are accurate and balanced. No estimate can guarantee what will happen to one person. Population figures must be interpreted with the person's individual clinical circumstances. People should receive support to decide Information should be offered in clear language and a format the person can use. Reasonable adjustment may include extra time, accessible text, pictures, hearing support or another communication method. A professional interpreter should be used when language creates a barrier. Family members, friends, carers or advocates can join when the person wants their support. The clinician should check understanding rather than simply ask whether everything is clear. Asking the person to explain the options in their own words can reveal gaps without turning the conversation into a test. Support should help the person make their own decision. It should not replace their voice or create pressure. Voluntary means free from pressure A voluntary decision is made without coercion or undue pressure from healthcare staff, relatives or other people. Advice and recommendation are allowed, but intimidation or manipulation is not. If pressure is suspected, the clinician may speak with the person privately and arrange further support. Fear of disappointing others should not be mistaken for free agreement. A person can choose to rely heavily on a clinician's recommendation. The clinician should still check that this is the person's preference and that they understand the available options. Capacity is decision specific and time specific Capacity means the ability to make a particular decision at the time it needs to be made. Adults should be presumed to have capacity unless there is a reason for assessment. A person should receive all practicable support before being judged unable to decide. Pain, delirium, medication effects, communication barriers or severe distress may affect decision making temporarily. A person generally needs to understand the relevant information, retain it long enough, use or weigh it and communicate a decision. Communication can use speech, writing, signs, technology or another reliable method. A diagnosis, disability, age or unusual choice does not by itself prove lack of capacity. A person can make a decision others consider unwise and still have capacity. Mental capacity law differs across UK nations. The core professional principles remain presumption, support, decision specific assessment and involvement wherever possible. When an adult lacks capacity A person who lacks capacity cannot give valid consent for that decision, even if they cooperate physically. The team must use the relevant legal framework rather than treating cooperation as permission. The team checks for a valid advance decision, a legally authorised representative or another applicable instruction. Family members do not automatically gain authority to consent simply because they are relatives. When no authorised decision already applies, the team considers the person's best interests or overall benefit under the relevant law. They examine benefits, harms, known wishes, values and the least restrictive option. People close to the person and relevant professionals should usually be consulted about what the person would have wanted. The final decision must focus on the person rather than convenience for others. The scope of consent must be clear Scope of consent means exactly which examination, procedure or treatment the person has agreed to. It can include foreseeable choices that may arise after anaesthesia or sedation reduces decision making ability. For surgery, the discussion may include possible conversion to another approach, blood transfusion or another specified intervention. The person can agree to some parts and decline others when this is clinically workable. The team must not exceed the agreed scope merely because another procedure becomes convenient. An additional intervention without prior consent needs an immediate clinical reason that makes waiting unsafe. Consent is ongoing A consent form is a useful record and prompt, but it is not a binding contract. Important discussions, decisions and agreed limits should also be recorded in the clinical record. The decision should be reviewed before treatment when time has passed, circumstances have changed or new information has emerged. The person should have another opportunity to ask questions. A person with capacity can withdraw consent before a procedure begins. If they are awake during an ongoing procedure, they can ask the team to pause or stop, subject to what can be done safely at that moment. When a person is unconscious, the agreed scope and any prior wishes guide the team. Foreseeable additional procedures should therefore be discussed before anaesthesia whenever practical. Emergencies narrow time but not the principles A conscious adult in an emergency should still be presumed to have capacity and asked for consent when possible. Urgency does not automatically remove the right to decide. If a person is unconscious or lacks capacity and their wishes cannot be established, immediately necessary treatment may be given. It should aim to save life or prevent serious deterioration and restrict future choices as little as possible. The reasons and treatment should be explained once the person can understand. Emergency authority is not permission for unrelated or non urgent treatment. What to do when consent feels incomplete If you do not understand the proposed care, ask the team to explain it differently before proceeding. You can ask about alternatives, likely outcomes, important risks, recovery and what happens without treatment. If you feel pressured, no longer agree or believe the planned scope has changed, tell the team immediately. Ask for the procedure to pause before it starts while your concerns are addressed. This lesson explains general UK clinical principles rather than personal legal advice. The exact law and process depend on the UK nation, the person's age and the clinical circumstances.

Valid consent is an ongoing, voluntary and informed decision made with capacity for a specific choice. It requires individual information, suitable support and a clear agreed scope rather than a signature alone.