e. Communication and consent

Specimen consent forms are available below

Introduction

1. The purpose of this advice note is to provide guidance on communication difficulties that can arise when providing veterinary services. Communication issues have arisen in a number of complaints considered by the RCVS Preliminary Investigation Committee (PIC). While the intention is for the advice note to address the concerns expressed by the Lay Observers that sit with the PIC, the RCVS believes by and large most practices do a satisfactory job, based on the fact that the number of complaints is low in comparison with the number of consultations that take place in veterinary practice every day.

Lay Observers’ Concerns

2. Three Lay Observers sit with the PIC, which considers whether to refer complaints against veterinary surgeons to the RCVS Disciplinary Committee. Each year the Lay Observers provide a report to the RCVS Council and in 2007, they raised the issues of communication and consent suggesting that additional advice to veterinary surgeons might reduce the number of such complaints received by the RCVS. They stated that:

‘Poor Communication continues to be a major area of concern as is informed consent for procedures undertaken as well as the failure to provide estimates before treatment begins and when costs escalate. It would be beneficial to all parties if more focus were given to these critical areas by practices, as it would significantly decrease the dissatisfaction being expressed by members of the public.’

RCVS Guide to Professional Conduct

3. The advice on communication and consent in the RCVS Guide to Professional Conduct is as follows:

1.‘The provision of veterinary services creates a contractual relationship under which veterinary surgeons should …

f. Ensure that a range of reasonable treatment options is offered and explained, including prognoses and possible side effects;

g. Give realistic fee estimates based on treatment options;

h. Keep the client informed of progress, and of any escalation in costs once treatment has started;

i. Obtain the client’s informed consent to treatment unless delay would adversely affect the animal’ welfare (to give informed consent, clients must be aware of risks)…’.

RCVS Guide to Professional Conduct Part 1-D ‘Your responsibilities to your clients’

’19. Good communication skills in professional and support staff are essential to good veterinary practice.

20. Veterinary surgeons must endeavour to ensure that what both they and their clients are saying is heard and understood on both sides, and encourage clients to take a full part in any discussion. Explanations should be given wherever possible in non technical language and if there is any doubt as to whether the client has understood, this should be recorded.

21. Informed consent, which is an essential part of any contract, can only be given by a client who has had the opportunity to consider the options for treatment, and had the significance and risks explained to them. Cost may also be relevant to the client's decision. If it is anticipated that any procedure will be performed by a veterinary student, a listed veterinary nurse or other member of the support staff the client should be made aware of the fact.

22 . If the client's consent is in any way limited or qualified or specifically withheld, veterinary surgeons must accept that their own preference for a certain course of action cannot override the client's specific wishes other than on exceptional welfare grounds.

23. When arrangements have been made to bring an animal under the Animals (Scientific Procedures) Act 1986 for experimental investigation, the client should be made aware of the general provisions of the Act so that informed consent can be given, (see Annex 3B, A(SP)A and VSA interface)

4. Consent can be expressed orally or in writing or by implication. Obtaining consent is a process. The signature of the client on a consent form is the culmination of discussions that should have gone before. Clients should be encouraged to ask questions and given time to consider the information provided during the process of obtaining consent. Obtaining consent is the responsibility of the veterinary surgeon with the animal under his or her care. Obtaining consent may also be delegated to the veterinary nurses or other competent staff at the practice.

5. The importance of communicating effectively with clients throughout a case on continuing treatment options, as well as any escalation of fees, is an essential part of maintaining consent. If a client’s consent is in any way limited or qualified (see Part 1 D of the Guide, paragraph 22 above), contemporaneous notes of this should be made on the clinical records.

The provision of veterinary services – contractual relationship

6. For a contract to be valid and legally enforceable there must be (i) capacity to contract; (ii) intention to contract; (iii) consensus ad idem (agreement as to the same thing); (iv) valuable consideration (eg payment); (v) legality of purpose; (vi) sufficient certainty of terms.

7. In the context of the provision of veterinary services, ‘consent’ can be described as the agreement to carrying out specific actions, based on information of what the actions involve and the likely consequences. Effective communication between veterinary surgeon and client is essential. Clients should have an opportunity to consent to the services offered, and accept the costs of those services as estimated and agreed.

8. The existence or otherwise of a contract is relevant, for example, to recover non-payment of fees. Regardless of whether a fee is charged or not, the professional responsibilities remain the same towards the patient and client. For the purposes of determining to whom a veterinary surgeon’s professional responsibilities are owed, the ‘the client’ is the person who requests professional services for an animal.’ (Part 1 D of the Guide).

Consent forms

9. Consent forms may be used to record agreement to carry out specific procedures. They form part of the clinical records. A copy of the form should be provided to the person signing the form unless the circumstances render this impractical.* If any amendments are made subsequently, these should be made in ink, initialled and dated and a note of subsequent conversations recorded on the clinical records.

10. Provision should be made for uncertain or unexpected outcomes. Clients should be asked to provide contact telephone numbers to ensure discussions can take place at short notice. Provision for the veterinary surgeon to act without the client’s consent if necessary in the interests of the animal should be considered.

11. For routine procedures, information leaflets can be useful to explain to clients what is involved with a specific procedure, anaesthesia, expected outcome, after care etc. Clients should be given an opportunity to consider this information before being asked to provide consent. Use of information sheets should be encouraged but should not be used as a substitute for discussions with individual clients.

12. While responsibility for ensuring a client has provided consent rests with the veterinary surgeon, it should be recognised that veterinary practice staff may be the first to become aware of any misunderstanding concerning the procedure or treatment. Staff should be advised to communicate concerns to senior colleagues. The veterinary practice team should be encouraged to work together to ensure effective communication with clients and with each other.

Who is the client?

13. The client may be the owner of the animal, someone acting with the authority of the owner, or someone with statutory or other appropriate authority. Care should be taken when consent is given by a client who is not the owner of the animal. Practice staff should ensure they are satisfied that the person providing consent has both the authority and capacity to provide consent. For example, if the person providing consent is not the owner and has not confirmed his/her authority of the owner to act, ,only in exceptional circumstances, for example if the request is by the police, should the procedure be carried out.

14. Problems can arise identifying who the client is. Occasionally, more than one owner will come forward and while it is not for the veterinary surgeon to determine ownership, it will be important to identify who the client is so it is clear to whom the professional responsibilities are owed. This should be made clear on the clinical records.

Has the client understood what has been said?

15. Veterinary surgeons should consider their clients’ language and communication needs. Clinical or technical terminology may need to be explained and clients may not wish to admit to a lack of understanding.

16. Misunderstandings can arise when using ambiguous terms and veterinary surgeons should be alert to the possibility of misunderstandings concerning terminology used by the practice.

17. A person’s understanding of the issues may be affected by a number of factors, such as impaired hearing or sight; mental incapacity; learning difficulties; difficulties with reading or language.

18. A person may be competent to sign a consent form, but for reasons of physical disability is unable to provide a signature. An independent witness may be asked to confirm the client has given consent orally. If this is not practicable, then a suitable member of the practice staff could be asked to confirm consent.

19. Persons under the age of 18 are generally considered to lack the capacity to make binding contracts. They should not be made liable for any veterinary or associated fees.

20. Children under the age of 16 should not be asked to sign a consent form. Where they have provided a signature, the parents or guardians should be asked to countersign.

21. Where the person seeking veterinary services is 16 or 17, veterinary surgeons should, depending on the extent of the treatment, the likely costs involved and the welfare implications for the animal, consider whether consent should be sought from parents or guardians before the work is undertaken.

22. Particular care should be taken when the treatment involves issues of health and safety, as for supplying Controlled Drugs (within the meaning of the Misuse of Drugs Act 1971) to anyone under 18.

23. Where the client’s ability to understand is called into question, veterinary surgeons will need to consider whether any practical steps can be taken to assist the client’s understanding. For example, consider whether it would be useful for a family member or friend to be present during the consultation. Additional time may be needed to ensure the client has understood everything and had an opportunity to ask questions.

Mental incapacity

24. The Mental Capacity Act 2005 (England and Wales) states: ‘A person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain. It does not matter whether the impairment or disturbance is permanent or temporary. …’.

See Adults with Incapacity (Scotland) Act 2000

[There is no primary legislation dealing with mental incapacity in Northern Ireland as yet]

25. Where it appears a client lacks the mental capacity to consent, veterinary surgeons should try to determine whether someone is legally entitled to act on that person’s behalf, such as someone who may act under an enduring power of attorney. If not, veterinary surgeons should act in the best interests of the animal and seek to obtain consent from someone close to the client, such as a family member who is willing to provide consent on behalf of the person.

*[The RCVS Practice Standards Scheme Manual provides that for ‘General Practice’ (Tier 2 practices), signed consent forms are required for all procedures including diagnostics, medical treatments, surgery, euthanasia and when a patient is admitted to the care of a veterinary surgeon.]

Specimen consent forms

Specimen Form of Consent for Anaesthesia and Surgical Procedures (WORD 84Kb)

Specimen Form of Request for Euthanasia (WORD 72Kb)