Decision-making and consent: the meaning of meaningful dialogue

In the context of Covid-19 and the rise of virtual consultations being clear on the principles of consent and meaningful dialogue has never been more important.

The General Medical Council (GMC) has released new guidance on shared decision-making and consent for good medical practice. The guidance came into force from 9 November 2020 and updates the 12-year-old 2008 guidance.

The GMC start by noting how shared decision-making and consent are fundamental to good medical practice.

The 95 paragraphs of guidance are easily navigable online and cover:

  • Taking a proportionate approach
  • The dialogue leading to a decision
  • Recording decisions
  • Reviewing decisions
  • Circumstances that affect the decision-making process

The overall focus is on exchange of information and better communication between doctors and patients to allow patients to make best decisions about their care. The guidance provides a framework to reinforce good practice and is based on the fundamental ethical and legal principle of consent, which is as set out in 2015 case of Montgomery v Lanarkshire Health Board.

Seven principles

The new guidance details seven principles of decision-making and consent:

  • the patient’s right to be involved in decisions about their treatment
  • decision-making as an ongoing process of meaningful dialogue
  • the patient’s right to be heard and listened to
  • the doctor’s responsibility to ascertain a patient’s wishes so information can be shared about the benefits or limitations of proposed options
  • the presumption that a patient has capacity
  • for patients lacking capacity, the choice of treatment must be of overall benefit to them
  • the need for patients to be supported and involved in the decision-making process, and to exercise choice if possible.

It makes clear that doctors must consider a range of factors before using their clinical judgement to apply the guidance, including the nature of the patient’s medical conditions, the complexity of the decision, the impact on the patient’s circumstances, the options for treating and managing the patient and the nature of the consultation.

Meaningful dialogue

The main body of the guidance is dedicated to creating a meaningful, informed and supportive dialogue with patients to help them understand their role in the process, give them an opportunity to consider the information and to reach a shared understanding of the available options.

Each patient should be taken in isolation and the clinician should make no assumptions as to the information a patient might want to know or what the patient might consider as significant.  The clinician should be aware of how their own preferences might influence the advice they give and the language they use.

Clinicians are required to actively engage patients in the decision-making process by encouraging the patient to ask questions and seeking to explore the patient’s needs, values and priorities.

Recording decisions

The guidance recognises significant time and resource constraints – it states “Obtaining a patient’s consent needn’t always be a formal, time-consuming process” and suggests that consent can be obtained informally, depending on the circumstances.  Later the guidance states that this will depend on the time and resources available and suggests clinicians consider the role other members of staff might play and what other information is available to the patient such as leaflets. It also highlights the need for clinicians to raise a concern if a patient isn’t given the time and support to fully understand the relevant information.

Circumstances that affect the decision-making process

Finally, the guidance considers the factors that might prevent a patient consenting to treatment and the circumstances that can limit the dialogue between doctor and patient.  The guidance advises what to do if a doctor considers a patient is unable to make a free, unencumbered choice or if they are simply unwilling to engage with the decision-making process.

In particular, there is guidance on the presumption of capacity and the proper assessment of capacity.  The guidance states that doctors “should be alert to signs that patients may lack capacity and must give them all reasonable help and support to make a decision”.

Overall, the updated guidance has been designed to be easier for clinicians to follow and provides practical considerations for clinicians to form more robust relationships with patients to share information and assist with informed consent to medical treatment, no matter the patient’s circumstances. Underpinning the guidance is the promotion of a person-centred approach to care and patient safety.

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