DGD12-044
Policy
Consent and Treatment
Policy Statement
Health Directorate health professionals must obtain a consumer’s valid informed consent
before beginning any clinical activity, treatment or procedure, except when:
 The consumer is unable to provide informed consent and then it is sought from an
appropriate substitute decision maker, or
 Urgent medical treatment is required to save a consumer’s life or prevent serious
harm and the consumer is not able to provide consent to the required treatment at
the time through a lack of capacity, (e.g. because the consumer is unconscious).
An adult consumer is presumed to have the capacity to make decisions about their health
care except where it is shown by a clinical assessment that they do not.
Written and verbal consent, and the information provided to the consumer must be
documented in the clinical record.
The Standard Operating Procedures (SOPs) associated with this policy provide all Health
Directorate staff with the information required to assist in meeting legal obligations when
seeking valid informed consent:
 Consent and Treatment
 Consent and Treatment: Children or Young People
 Consent and Treatment: Capacity and Substitute Decision Makers.
Purpose
Informed decision-making is essential for consumer-centred care. Consumers have the right
to decide whether or not they wish to receive health care.
Good practice in gaining informed consent includes communication of the benefits, risks and
alternatives of treatment, taking into account the consumer’s personal circumstances,
beliefs, and priorities including:
 Temperament, attitude and level of understanding
 Cultural and linguistic diversity
 Influences that are non‐medical but may have an impact, or
 Communication and/or cognitive difficulties.
DGD Number
DGD12-044
Version
2.0
Issued
October 2012
Review Date
October 2015
Area Responsible
QSU
Page
1 of 7
DGD12-044
Failure to obtain a consumer’s consent to health care may result in a criminal charge of
assault or civil action for battery. In addition, failure to inform a consumer about the related
risks may give rise to civil action for negligence.
Scope
This policy and the associated Standard Operating Procedures (SOPs) are the overarching
documents for consent processes that apply to all Divisions, Branches and Units within the
Health Directorate.
Principles:
Valid informed consent
When seeking valid informed consent staff must:
 Satisfy themselves that the consumer has the capacity to consent to treatment and
that the consumer’s decision-making capacity is not impaired by therapeutic or other
drugs, or alcohol, and
Ensure that:
 Consent is specific to the relevant clinical activity, treatment or procedure
 Appropriate and sufficient information on the risks, benefits and alternatives is
provided
 The consumer is able to clearly understand the information as it is provided in verbal
or non-verbal means which they can understand, and
 Consent is voluntarily given and once given is properly recorded.
Length of time consent is valid
Consent is considered valid until the consumer withdraws their consent or there is a change
in their circumstances, which may include:
 Unplanned or unexpected improvement or deterioration in the consumer’s condition
 Identification of new risks or side effects associated with the recommended
treatment
 Development of new treatment options since consent was given, or
 Progression of the disease, which may have changed the therapeutic goal – for
example from ‘cure’ to ‘palliation’.
Wherever there is a delay between the consumer giving consent and the provision of
treatment, staff need to assess whether circumstances have changed and whether a new
consent discussion is required. Changes to consent must be documented in the consumer’s
clinical record when this occurs.
Consent to Collection and Sharing of information
Health Directorate staff are also responsible for ensuring consumers are aware that when
they receive care in, or attend a Health Directorate facility, the information relating to their
care will be kept by the Health Directorate and may be shared with members of their
treating team as necessary, including their nominated General Practitioner (GP).
Consumers have the right to decline to have their information shared at any time.
DGD Number
DGD12-044
Version
2.0
Issued
October 2012
Review Date
October 2015
Area Responsible
QSU
Page
2 of 7
DGD12-044
Refer to Health Directorate policy documents relating to clinical records management and
sharing of personal information for further information
Roles & Responsibilities
Executive Directors of Divisons, Branches and Units are responsible for ensuring there are
strategies in place relating to consent within their areas for:
 Communication
 Training and/or orientation, and
 Evaluation and continuous improvement.
Managers are responsible for:
 Ensuring that staff are able to access, interpret and apply this document and are
provided with education related to this policy and associated SOPs.
All Health Directorate staff who obtain consent should be aware of:
 The principles of valid informed consent
 Consumer rights
 The nature of the clinical activity, treatment or procedure the consumer is being
asked to consent to including the likelihood and degree of possible harm
 Required consent procedures including rules applying to:
o Emergencies and particular procedures
o Decision‐making by substitute decision makers
o Documentation requirements
o Legal and ethical considerations and risks, and
o Relevant legislation, policies and standards.
Evaluation
Outcome Measures
 Consumers provide valid informed consent wherever it is required.
 All forms used to document written consent are endorsed for use by the Health
Directorate and comply with this policy and associated SOPs.
Method
 Documentation of consent audits overseen by the Governance Health Service
Standard Group.
Related Legislation, Policies and Standards
Legislation
Age of Majority Act 1974
Children and Young People Act 2008
Civil Law (Wrongs) Act 2002
Guardianship and Management of Property Act 1991
Health Practitioner Regulation National Law (ACT) Act 2010
Health Records (Privacy and Access) Act 1997
DGD Number
DGD12-044
Version
2.0
Issued
October 2012
Review Date
October 2015
Area Responsible
QSU
Page
3 of 7
DGD12-044
Health Regulation (Maternal Health Information) Act 1998
Medical Treatment (Health Directions) Act 2006
Medicare Australia Act 2005
Mental Health (Treatment and Care) Act 1994
Powers of Attorney Act 2006
Public Advocate Act 2005
Road Transport (Alcohol and Drugs) Act 1977
Transplantation and Anatomy Act 1978 (2.2, 2.3, 2.5)
Policy
Clinical Record Management Policy
Clinical Record Documentation SOP
Release or Sharing of Clinical Records or Personal Health Information SOP
Consent and Treatment SOP
Consent and Treatment: Children or Young People SOP
Consent and Treatment: Capacity and Substitute Decision Makers SOP
Guidelines for Assessment of Decision Making Capacity by ACRS Psychologists SOP
Consumer and Carer Participation Framework
Consumer Feedback Standards: Listening and Learning
Elective Surgery Access Policy
Patient Identification: Correct Patient, Correct Site, Correct Procedure Policy
Patient Identification: Correct Patient, Correct Site, Correct Procedure Standard Operating
Procedure
General Practitioner – Hospital Access and sharing of Clinical Information within CHHS –
policy
General Practitioner – Hospital Access and sharing of Clinical Information within CHHS - SOP
Standards
ACHS EQuIP 5:
1.1 Consumers/patients are provided with high quality care throughout the care delivery
process.
1.1.3 Consumers/patients are informed of the consent process, and they understand and
provide consent for their health care.
1.6 The governing body is committed to consumer participation.
1.6.2 Consumers/patients are informed of their rights and responsibilities.
3.1.5 Documented corporate and clinical policies and procedures assist the organisation to
provide quality, safe health care.
National Safety and Quality Health Service (NSQHS) Standards
Std 1: Governance for Safety and Quality in Health Service Organisations
Std 2: Partnering with Consumers
Std 5: Patient Identification and Procedure Matching
DGD Number
DGD12-044
Version
2.0
Issued
October 2012
Review Date
October 2015
Area Responsible
QSU
Page
4 of 7
DGD12-044
Definition of Terms
Capacity
The term capacity is used in this document to mean a person is capable of:
 Understanding the nature and effect of decisions about consent and communicating
the understanding verbally or non-verbally
 Freely and voluntarily making decisions about consent
 Communicating the decisions verbally or non-verbally, and
 Retaining the information, their decision and their consent.
The type of assessment required to determine someone’s capacity will vary depending on
the type of decision being made.
Chief Psychiatrist
Is appointed by the Minister and has the following functions under the Mental Health
(Treatment and Care) Act 1994, Section 112:
 Provision of treatment, care, rehabilitation and protection for persons who have a
mental illness, and
 Reporting and making recommendations to the Minister with respect to matters
affecting the provision of treatment, care, control, accommodation, maintenance and
protection for persons who have a mental illness.
Clinical Activity
Clinical activities improve, maintain or assess the health of a person in a clinical situation and
may include invasive and non-invasive procedures (including those performed in settings
other than the operating room). Some examples are:


Invasive
- taking a specimen of blood
- giving medication via an intravenous, intramuscular or subcutaneous route
- inserting intravenous access, or
- performing a surgical procedure, including a procedure performed in
medical imaging.
Non-invasive - interventions such as evaluating, advising, planning
(E.g. dietary education, physiotherapy assessment, crisis intervention,
bereavement counselling, a procedure in medical imaging) and giving
medication.
Consumer
In this document the term ‘consumer’ refers to patients, consumers and clients under the
care of the Health Directorate.
Health Professional
There are two Acts which define ‘health professionals’: the Medical Treatment (Health
Directions) Act 2006 (ACT) and the Health Practitioner Regulation National Law (ACT) Act
2010. For the purpose of this document a ‘health professional’ includes all doctors, dentists,
nurses and allied health professionals engaged the Health Directorate to care for consumers.
DGD Number
DGD12-044
Version
2.0
Issued
October 2012
Review Date
October 2015
Area Responsible
QSU
Page
5 of 7
DGD12-044
Informed consent
A person gives consent based upon an appreciation and understanding of the facts and
implications of an action. The person must be given the relevant information and have the
capacity to understand it.
Valid consent is based on the fundamental legal principle that the law protects the integrity
and autonomy of the person. Consent for a procedure or treatment is valid if:
 The consumer has the capacity to give consent
 Full information on risks, benefits and alternatives has been provided and
understood, with understanding demonstrated
 The consent is given freely, and
 The consent is specific to the procedure.
Substitute Decision Maker
Where it has been identified that an adult consumer does not have the decision-making
capacity to provide consent to treatment or procedures themselves the following substitute
decision makers can provide consent:
 Health Attorney
 The Attorney, under an Enduring Power of Attorney
 Guardian, if approved
 Public Advocate of the ACT if appointed guardian, and the
 Chief Psychiatrist or Community Care Coordinator (where there are issues relating to
mental health or mental dysfunction and the consumer is under a Mental Health
Order).
Treatment
Medical or surgical management of a consumer (including any medical or surgical procedure,
operation, examination and any prophylactic, palliative or rehabilitative care) normally
carried out by, or under the supervision of a Health Professional.
Treating Team
The treating team includes all service providers (located within, or external to the ACT) who
provide a service for the ACT Government Health Directorate involved in diagnosis, care or
treatment for the purpose of improving or maintaining the consumer’s health for a
particular episode of care (Health Records (Privacy and Access) Act 1997).
References
Guidelines for Health Care Professionals Including Medical Practitioners and Dentists. (1999)
Office of the Public Advocate of the ACT Australian Capital Territory Government
Informed Consent for Health Care Treatment. (1999). Office of the Public Advocate of the
ACT. Australian Capital Territory Government
Guide to Informed Decision-making in Healthcare. (2011) Queensland Health. Queensland
Government
DGD Number
DGD12-044
Version
2.0
Issued
October 2012
Review Date
October 2015
Area Responsible
QSU
Page
6 of 7
DGD12-044
Guidelines for Medical Practitioners on Providing Information to Patients. (2004) National
Health and Medical Research Council (NHMRC) (www. nhmrc.gov.au)
Attachments
N/A
Associated SOPs
Consent and Treatment SOP
Consent and Treatment: Children or Young People SOP
Consent and Treatment: Capacity and Substitute Decision Makers SOP
Disclaimer: This document has been developed by Health Directorate, specifically for its own use. Use of this
document and any reliance on the information contained therein by any third party is at his or her own risk and
Health Directorate assumes no responsibility whatsoever.
DGD Number
DGD12-044
Version
2.0
Issued
October 2012
Review Date
October 2015
Area Responsible
QSU
Page
7 of 7