As Practice Advisor, I often receive questions from physiotherapists related to consent, many of which are addressed in the College of Physiotherapists of Alberta’s Consent Resource Guide for Alberta Physiotherapists. This article will cover some of the most common questions we receive.
What is informed consent?
In simple terms, an individual can only give consent to something they fully understand. If consent to an assessment, intervention, or treatment plan was obtained without the patient receiving the relevant information to make a decision, the consent is not considered informed and is not valid.
The obvious question then is, how much information is enough to enable informed consent? When it comes to how much information to provide, the expectation is to provide what the average, reasonable person in a similar position would expect to know prior to providing consent.1
Can we ask patients to sign a consent form before they have been assessed?
This is one of the most commonly asked questions; however, for consent to be considered valid, it must be:1
- Given voluntarily
- Given by a patient who has capacity
- Specific to both the intervention and the person administering the intervention
- Given by a patient who is informed
Asking a patient to consent to a yet to be developed assessment or treatment plan prior to any discussion as to what that would entail, why it is required, or what risks might be involved, does not meet the expectations of the last two bullets.
A signed consent form obtained as part of intake paperwork is not valid, informed consent.
So, what should patient intake forms include?
Ensure that the patient intake form is specific to what the patient can be expected to consent to – a clear and transparent privacy statement, use of financial information and billing processes.
Asking the patient to read the clinic’s privacy statement and indicate that they consent to the appropriate collection, use, disclosure, retention, and disposal of their personal health information is not only good practice and is a requirement of some privacy legislation in Alberta.2,3
Similarly, having clear documentation that the patient has been provided with information about billing policies and procedures and has agreed to them may help to avoid conflict in the future.
How can I make sure that I’ve obtained informed consent?
As with any interaction we have with patients, communication is key when asking for and receiving consent. All patients must be provided relevant information related to what will be assessed, what tests will be used, the results of the assessment, the physiotherapy diagnosis and the treatment plan being recommended. It is vital that the patient be given enough information to give informed consent to the plan. The patient must be informed about both the benefits and the risks related to receiving or refusing the interventions proposed. It is also important that the patient clearly understands any other material information when agreeing to a treatment plan including but not limited to costs, timelines, time commitments, and alternative options if appropriate.
A final, and crucial, aspect of gaining informed consent is the physiotherapist’s responsibility to ensure the patient clearly understands the information presented. Patient populations are very diverse, so a variety of strategies should be employed when communicating information. These strategies may include:1
- Using both verbal and visual explanations or aids
- Providing handouts or other written resources
- Using a medical interpreter
- Using the “teach back” method to confirm that the patient understood the information
- Leaving time for questions and providing reasonable and understandable answers
How long is a patient’s signed consent form valid?
Physiotherapists must understand that consent is an ongoing process, not a one-time event.
It depends on what the patient consented to. When this question relates to consent to or for treatment – the answer is simple. One and done is never enough.
Relying on implied, ongoing consent because the patient continues to attend for physiotherapy can lead to challenges if there is disagreement between what the patient and the physiotherapist think the patient consented to. For this reason, it is recommended that providers informally reaffirm, and document continued consent to the treatment plan at each intervention. This discussion between the provider and the patient allows opportunities for the patient to ask questions and/or withdraw consent for a specific intervention and helps to avoid misunderstandings and disagreements.
It is important to remember that patients have the right to withdraw consent at any time and must be given the opportunity to do so. If consent has been refused or withdrawn, it is equally important that the treating physiotherapist accurately documents the refusal as well as the reasons provided.
If there are any changes to the treatment plan due to changes in the patient’s condition, symptoms, or unexpected responses to the interventions or circumstances, a new discussion must be had with the patient, and they must then provide informed consent to the new/modified plan. This includes any changes of treatment providers (students/support workers/a new physiotherapist), interventions, changes to anticipated treatment timelines/discharge dates/fees or the need to refer the patient to another provider or professional for ongoing or more specialized care.
But if I don’t have a signed intake consent form, how do I obtain and document consent?
Whether a physiotherapist accepts written or verbal consent, it is important to document that the consent discussion was held, and when/how the consent was obtained. Signed consent forms provide evidence that consent was obtained but do not provide evidence that the consent was informed. They never replace the need to have a detailed discussion with the patient. If you choose to obtain a signed consent form, have the patient fill it in after you’ve had the informed consent discussion.
What is the difference between consent and assent?
I will discuss this question by providing a real-life scenario presented to me by a physiotherapist.
I have an elderly patient who has been diagnosed with dementia. The family has provided consent for his participation in physiotherapy exercise classes, but the patient refuses to attend the class when staff approach him and in fact, becomes very angry and aggressive if pressured to attend. The son, who is the patients’ guardian, has told staff to simply take Dad, don’t ask him if he wants to go.
Yes, consent to the treatment plan has been obtained from the individual who has the responsibility and authority to provide it. However, the elderly patient must also assent to the intervention or interaction and has the right to refuse to participate. Assent is defined as an expression of approval or agreement.4 It is given in the moment. If the patient does not assent to treatment, their choice must be respected. Providers do not have the right to force or drag a patient to participate in something they do not want or understand.
Assent is as relevant when dealing with minors as it is with elderly patients. The legal guardian of a young child must provide consent for an assessment or treatment, but the child must also assent to the intervention. If they do not, and cannot be convinced through reasonable dialogue, the treatment session needs to be terminated and tried again at another time.
Any time a guardian is involved in providing consent, if the patient continues to refuse to participate in the treatment intervention, the provider should have further discussions with the guardian. A new treatment plan should be developed, and consent and assent obtained.
Can my 16-year-old patient provide consent, or must I talk to their parent or guardian?
In Alberta, if a child is under the age of 18 they are generally considered a minor by law. Consent must be obtained from the legal guardian and the minor must assent to the intervention as noted above. The only exception is if the minor is declared a “mature minor.” For a minor to be considered a mature minor, they must demonstrate to the provider that they have a clear understanding of the nature and purpose of the intervention as well as the consequences of giving or refusing consent.1
There is no specific set of criteria or “test” available for use by providers to assist in determining if a minor is “mature.” The physiotherapist should engage in a holistic analysis of the capacity of the minor, come to a decision, and document the decision in the patient's health record. The physiotherapist must be able to explain why they concluded the child was a mature minor and how they came to that conclusion.
It is important to keep in mind that, if the patient has been deemed a mature minor, their guardian is no longer allowed to override or veto the minor’s decisions.1
For more information about gaining consent when minors are involved, a discussion of capacity as it relates to minors, and the answers to several FAQs, see the Consent Resource Guide.
It is important for physiotherapists to be aware that most formal complaints submitted to the College of Physiotherapists of Alberta, have a large element of poorly delivered, misunderstood or incomplete communication. If the discussion of the patient’s presenting concerns, the physiotherapy diagnosis and the proposed treatment plan is rushed, the patient may not have understood all the information they were provided and may not be able to provide truly informed consent. Patients may not always divulge pertinent information during their intake, may not ask for clarification of information they have received, or may not realize that they have misunderstood information that they have just heard; therefore, may not ask necessary questions.
Taking the time to initially have a thorough discussion with patients as well as throughout their treatment sessions, and to appropriately document the discussions and decisions made, may help to prevent misunderstandings, issues or complaints related to consent. It is the treating physiotherapist’s responsibility to confirm that both the physiotherapist and the patient have a clear understanding of all the relevant details related to the situation before obtaining consent to a proposed treatment plan.
As a physiotherapist, it is important that you understand informed consent. Reviewing the Consent Standard of Practice and the Consent Resource Guide may answer any questions you have. If you still have questions, contact the College of Physiotherapists of Alberta’s Practice Advisor for help.
- Physiotherapy Alberta College + Association. (2018) Consent Resource Guide for Alberta Physiotherapists. Available at ………………………………….. Accessed Sept 26, 2018.
- Government of Alberta (2014) Personal Information Protection Act. Alberta Queen’s Printer. Available at http://www.qp.alberta/documents/Acts/P06P5.pdf. Access Sept 26, 2018.
- Government of Alberta. (2011). Health Information Act: Guidelines and practices manual. Alberta Queen’s Printer. Available at: http://www.health.alberta.ca/documents/HIA-Guidelines-Practices-Manual.pdf. Accessed Sept 26, 2018
- Merriam-Webster. Definition of assent. Available at https://www.merriam-webster.com/dictionary/assent Accessed Sept 27, 2018.