3 Important elements of consent
Always obtain the undivided attention of the patient or their SDM
cannot gain informed consent if your patient or the SDM is distracted because you cannot be sure they heard and understood the proposed treatment
Distracted: I would politely redirect them since it is important that I have their undivided attention
Pt has glasses or heraing aids: I would ask the Pt to wear these during your interaction
3 Important elements of consent
Assume the Pt has the capacity to give informed consent unless the case information indicates…
- disoriented/confused
- has a SDM
- Dx with severe dementia
Not of sound mind: in a coma, severe dementia
may not be of sound mind: mild dementia, mild cognitive impairment
3 Important elements of consent
Educate the Pt or their SDM about the proposed plan
- *Nature of the session: *
to perform an assessment which involves asking questions and performing tests. - Risk of the assessment: s
ome tests may exacerbate their symptoms, but these tests will be explained before they are performed and, if possible, alternate options for examination will be provided. - *Benefit of the assessment: *
to form a clinical impression and determine if PT is recommended and, if so, the plan for treatment. - Consequences of not participating in the assessment:*
without a physiotherapy assessment, a clinical impression cannot be made and therefore a treatment plan cannot be created and implemented. - Provide the patient with the opportunity to ask questions and receive answers about the proposed plan.
Adult with sound mind
- Educate the Pt about the proposed plan
- Ask the Pt if I have their informed consent to proceed with the Ax
If the Pt of sound mind does not give consent & refuses the Ax–>DO NOT assess!!
- Responsibility to repect the Pt’s autonomy and give them the opportunity to consent ro or decline to PT service
- Pt of sound mind–>can make decisions about their own care
- I would educate the Pt on the risks of not receiving services and provide alternative options. If the Pt still refuses services and/or any alternative options present–>respect that decision
- I would document the interaction in the Pt’s records
Adult with sound mind with a spouse who is taking the lead during the session (asking and answering questions fro the Pt during the seesion)
- Ask the Pt if they provide consent for their spouse to be involved in their care
- Educate the Pt on the importance of actively participating in their own care by asking and answering questions (ensure their autonomy in the desicison-making process)
- Interact with both the Pt and their spouse (if consent has been given by the Pt to involve their spouse in care)
- Educate the Pt and their spouse about the proposed plan
- Ask the Pt specifically if you have their informed consent to proceed with the Ax
Adult with sound mind who is not fluent in English
Language barrier can make it difficult for the Pt to under stnad the proposed plan and its risks
Best to worse translation option
- Use a translator (more applicable in hospital setting vs private rehab setting)
- Use a colleague who speak the same language
- Use the Pt’s friends/family memeber to help translating (if they speak English)
- Use Google translate
Addtional: Use non-verbal communication strategies
- Gesture (thumbs up/down, head nod)
- Demonstration
- Pointing to objects/pictures
- Drawing on a drawing board
- Use facial expression
If using Pt’s family for translation
Pay close attention to the Pt to see if they appear uncomfortable/unwilling to praticipate–>if it seems that inaccurate information is being translated by the family member, use other way of interpreter
Educate the Pt about the proposed plan: use a combination of options listed: ensure effective communication with the Pt to gain informed consent
Ask the patient if I have their informed consent to proceed with the Ax
Adult without sound mind with SDM
- Educate the Pt & the SDM about the proposed plan
!!When gaining consent–>always tryto involve the Pt in the conversation even if the final decision regarding consent comes from the SDM
- Ask the SDM if I have their informed consent to proceed with the assessment
- If the SDM provides consent but the Pt is refusing and becoming agitated by the intervention
–>Stop and liaise with the team members/SDM to come up with a solution to ensure the Pt’s wellbeing without causing distress/harm
If a Pt is not of sound mind and a family member/friend is present
!!!!DO NOT assume that person is the SDM
–>I would need to find out if that person is the SDM or not
- If they are the SDM, I would ask them for consent to assess
- If they were not the SDM, I would wait to assess until consent had been give by the SDM
*If a person states they are the SDM you can take their verbal word
Should you explain to the Pt who is not of sound mind?
It is important to try to explain the plan and gain the patient’s consent.
Goal: involve the Pt in their care and decision making as much as possible–>more likely to have patient compliance during treatment
Adult without sound mind with unknown/unavailable SDM
Consent does not have to be provided in person–>SDM can provide consent over the phone as long as they has been informed of the proposed plan and has no questions regarding Pt care.
- Determine the SDM and contact that person and wait to assess until informed consent has been given by the SDM
*Only execption: emergency–>In a situation where consent cannot be explicitly granted, PT may provide health care without consent if the care is urgent and necessary to
- preserve Pt’s life
- prevent servious physical/mental harm
- alleviate severe pain
#Care provided: within SOP & beneficial to Pt
Unless emergency situation–>wait to gain consent from the SDM
e.g. Seizure–>positioning on the side to prevent choking
Choking & can’t breathe
Sign of heat stroke & become delirious
Pt loses consciousness during a Rx session
Uncertain if adult Pt can provide informed consent
Scenario where you are uncertain if the Pt can provide informed consent, e.g.
- mild dementia
- mild cognitive dfecits
- Educate Pt on the proposed plan and determine if they have the capacity to provide consent. Consider the following when deciding if someone has the capacity to provide informed consent…
- Are they paying attention to me when I am explaining the proposed plan and the risks/benefits?
- Are they asking appropriate quesions
- Do they understand what I am telling them
2.1 If the Pt can provide informed consent–>I would get their informed consent to assess
2.2 If the Pt cannot provide informed consent–>I would wait and get informed consent to assess from their SDM
*PT is accountable for determining the Pt’s coapactiy to provide informed consent
–>Fluctuate even within hours of day (ICU Pt sedated in the morning but become alert and able to provide consent in the afternoon)
**Constantly reassess the Pt’s capacity to provide consent–>seek out the SDM if unable
Mature minor/minor
A minor can consent to/refuse PT services on their own if they understand the details of the proposed plan including risk/benefits
Points to consdier:
- Are they paying attention to me when I am explaining the proposed plan and the risks/benefits?
- Are they asking appropriate question?
- Do they understand what I am telling them?
- Is the MOI a cause of concern? (injure themselves/jumping off a root)
If you deem the Pt
a mature minor–>get their informed consent to assess
not a mautre minor–>ge informed consent from their legal guardian to assess
It is possible to revoke the status of a mature minor if you feel it is necessary
If a mature minor refuse to provide informed consent
Need Clinical Reasoning
Points to consider:
- Is the Rx critical to their health?
- Do they just want to take a quick break in therapy vs completely stop Rx?
Can revoke the status of a mature minor if you feel it is necessary
Communication Strategy: Global aphasia
Pt not able to understand & communicate verbally
- communicate with: demonstrations, gestures, images and body language
- Help of family members
–>Ask them if the Pt has any routine body language/facial expressions they use to communicate
Communication Strategy: Aphasia
- Dec. background noises
- Ensure you have the Pt’s attention
- Keep communication simple: 1 step commands
- Allow more time for Pt to respond
- Eye contact & at eye level
Communication Strategy: Expressive aphasia
Pt can understand words but cannot communicate verbally
Encourage pt to…
- Use gestures (thumb up/down, nodding)
- Demonstration
- Point to object
- Facial expression
PT side:
- Use general aphasia strategies above
- Speak slowly
Communication Strategy: Receptive Aphasia
Pt can communicate verbally but the verbal skills are often poor which may not make sense. Pt cannot understand verbally.
Encourage the Pt to
- Speak slowly
- Use PT adaptation
From PT side
- Use gesture (thumb up/down, nodding)
- Demonstration
- Point to objects or pictures
- Use facial expression
Communication Strategy: Delirium, Dementia or Alzheimer’s
Disease knowledge:
- Avoid making assumptions about the Pt’s cognitive abilities
- Symptoms can fluctuate, severtiy of delirium/dementia can vary
- Ask the Pt their perferred way to communicate (verbal, visual, written/actions)
- Build rapport and gaintheir trust
- Avoid aiming for perfection
Set up good environment
- Move slowly & eye level
- Be patient and give the Pt time to speak
- limit distraction and find a quiet space for the session
Communication skills:
If necessary:
- use clear single-step instrucitons
- use gestrues, demonstrations, visual cues vs lots of talking
- yes/no questions
Participation in Ax/Rx:
- Ask them what they like to do–>gain their interest in participating
- Use hand over hand to assist with movement (if needed)
- Make the task functional (if applicable)
- Allow the Pt to choose between 2 activities–>more willing to participate
Communication Strategy: Patients with a history of trauma
- Offer a private room
- Take time to hear the Pt’s story (why they are seeking your help)
- Build rapport with my Pt
- Coninually explain what I will/am doing and gain informed consent each step of the way
- Demonstrate respect for the Pt’s boundaries
- Encourgae the Pt to be an active participant in their own health care
- Acknowledge that I understand recovery from abuse is not linear and I will check in with them often and adjust as needed
Communication Strategy: Intubated and unable to speak
Encouraged Pt to:
-Use gesture (thumbs up/down, nodding)
-Demonstration
-Pointing to objects/pictures
-Draw on a drawing board
PT should
-Speak slowly and clearly
-Allow enough time for the Pt to response
This is an extremely vulnerable time for a Pt. Take extra time to communicate
