• Informed Consent

    Thomas Walker

    Ensuring Informed Consent Document
  • It is a fundamental right of society that people are autonomous and able to control their own bodies and what others are permitted to do to their bodies.  Kathy Walker is committed to upholding that right. 

    1. Purpose

    Informed consent is the procedure whereby clients consent to, or refuse, an intervention, based on information provided by a health care professional regarding the nature and potential risks of the proposed intervention.  Failure to obtain informed consent for treatment represents a risk to clients and organizations.

    The aim of this policy is to outline the minimum mandatory requirements for staff in relation to obtaining a client’s consent to treatment.  The policy is designed to:

    • provide guidance for staff about the consent process and explain relevant concepts
    • assist staff to be aware of their obligations in regards to seeking and obtaining consent from clients
    • support a consistent approach concerning the documentation of valid consent.
    1. Scope

    This Informed Consent Policy applies to all people responsible for the provision of services on behalf of Kathy Walker.

    1. Policy

    There are two legal principles relevant to informed consent.  Firstly, consent must be obtained in order to avoid a legal claim for trespass to the person (such as assault, battery, or false imprisonment).  Secondly, clients must be warned of the material risks of the proposed treatment/s, so that they can make informed decisions about associated risks and whether they wish to proceed.  Providing sufficient information to the client will negate a claim in negligence for failure to warn.

    • Clients must be given adequate information, pitched at the appropriate level of comprehension of each client, on which to base their decisions.  This should include: the nature, consequences and risks of the proposed treatment; the likely consequences of not receiving treatment, and any alternative treatments or courses of action available to the client.
    • Consent must relate to the interventions actually being performed on the client.
    • Consent is only valid if the client is competent to understand and authorize the intervention.
    • All clients over 18 years of age are assumed to have the capacity to consent unless otherwise proven.  A client has capacity if he/she is capable of understanding the nature, purpose and consequences of the proposed treatment.  Capacity must always be assessed in the context of the decision that is to be made.  The Mental Health Act (2014) states that a person is deemed to have capacity when they:
      • Understand any information or advice about the decision that is required
      • Understand the matters involved in the decision
      • Understand the effect of the decision
      • Weigh up the above factors for the purpose of making the treatment decision
      • Communicate the decision in some way.
    • In Victoria, there is no statutory law around the specific age at which a child becomes competent to consent.  The principles governing determination of capacity are whether the child has sufficient understanding and intelligence to enable him/her to understand what is being proposed.  Kathy Walker strongly recommends that parental/legal guardian consent be obtained for clients younger than 16 years.
    • Clients between 16 and 18 years of age are normally considered capable of giving valid consent to treatment.
    • If a client is deemed incapable of consent then consent must be obtained from a legally appointed guardian or a validly appointed medical agent under an enduring power of attorney.
    • The decision to consent or not consent to treatment must not be made due to pressure or coercion.
    • The client must be informed of his/her right to withdraw their consent at any time, verbally or in writing.
    • The client must be given a reasonable opportunity to make a decision.  This means they must be given a reasonable period of time to consider the matters involved in the decision and a reasonable opportunity to discuss the decision with the practitioner proposing the treatment.  Reasonable support to make the decision must be given, along with a reasonable opportunity to seek any other advice or assistance in relation to the decision must also be given.
    • Obtain signed, written consent before the initial treatment commences.  Thereafter, consent remains an ongoing, dynamic process that is obtained whenever an intervention varies from the original treatment plan or any updated treatment plan.
    • Except in the case of emergency, where the client is incapable of giving consent and the client’s representative is not available, the practitioner has a duty to warn the client of the risk associated with the proposed treatment.
    • If a person is unable to communicate adequately in English, the services of a professional interpreter should be offered whenever a proposed treatment is being explained.
    1. Procedure

    Procedure for Seeking Consent

    1. The practitioner who will be providing the service is the person responsible for seeking consent.

    • Assess the client’s capacity to give consent. 
    • Provide sufficient information to enable the client to make an informed decision.
    • Verify that the client understands the information provided and that all their queries have been addressed.
    • Seek a decision from the client about the proposed treatment.

    Consent must be reviewed if, after consent was obtained, there is a change in the client’s capacity to give consent or the client’s circumstances (including treatment options and risks).

    1. Roles and Responsibilities

    Every practitioner representing Kathy Walker has a duty of care to ensure that informed client consent (or consent from the client’s parent/legal guardian if under 16 years of age) is obtained at the initial consultation before commencing any form of treatment.

    1. Referenced Documents

    Department for Health and Aging (2014)

    Victorian Healthcare Association (2009)

    Mental Health Act (2014)

    1. Policy version control

    Version 2: July 2023 by Thomas Walker (next review date July 2025)