Consent guidance will strengthen doctor-patient relationship
The publication of new GMC guidance on obtaining consent1 is timely and welcome.
It recognises changing views on the doctor-patient relationship and takes into account significant changes in the law since the last guidance was published.
The patient-centred clinical method (PCCM) is widely promoted as a model for primary care consultations in the 21st century:2 paternalism has been superseded by partnership. The third of the six components of the PCCM, Finding common ground, is most strongly associated with positive health outcomes, decreased use of investigations and fewer referrals.3 It advocates that the patient and doctor, working together, should define the problem, formulate a management plan and agree their respective roles.
The GMC proposes a basic model derived from the PCCM. Once the GP and patient have mutually assessed the patient's condition, it is the responsibility of the GP to use his or her specialist knowledge and skills to determine which investigations or treatments are likely to be beneficial, bearing in mind the patient's views and understanding.
GPs must explain the potential benefits and risks of each option clearly, including the option of no treatment; it is the responsibility of the patient to weigh up the options and make a choice. If the patient requests a treatment that the GP does not consider beneficial, the GP should explore the reasons for the request but does not have to accede to it.
GPs should not exaggerate the potential benefits or play down the potential risks of the recommended treatment in order to persuade the patient to make the ‘right' choice;4 we should give information in a balanced way and avoid bias. Information on relative risk is more persuasive than absolute risk data and should not be presented in isolation.5
By working together with patients to understand their problems and develop solutions, we can engender trust and strengthen our relationship with them. Guided discovery is the most effective way of helping our patients to gain insight. Patients are more likely to adhere to treatment if they have reached concordance with the GP through shared decision-making. Empowered patients are more satisfied, less likely to complain and have better health outcomes.2
Respect for patient autonomy can, however, be a double-edged sword.6 Patients have a right to refuse the investigation or treatment that we recommend and have no obligation to provide us with an explanation for their decision. The GMC states that we should explain our concerns clearly and outline the possible consequences of their decision but must not pressurise them to accept our advice. There is a danger, however, that by following this guidance too literally we may appear detached and uncaring, and may fail to communicate our concerns.
Time can be an obstacle to effective collaboration with patients. Patient-centred doctors find their work more stressful if they do not have longer appointments.7 One solution may be the use of other suitably trained members of the healthcare team to support patients in making decisions.
For those patients who lack capacity, the GMC provides guidance consistent with the Mental Capacity Act 2005. GPs should assess whether a patient is able
to understand, retain and weigh up the information needed to make a decision, and take all reasonable steps to enable them to do so. Where doubts remain, GPs should seek advice from carers and specialist colleagues.
Article 10 of the Human Rights Act 1998 states that everyone has the right ‘to hold opinions and to receive and impart information and ideas.' Our patients have the right to share their views about their health with us, and to receive from us the information they want or need in order to make decisions about their healthcare. Both doctor and patient alike can benefit from the development of a mature collaborative relationship.Author
Dr Phillip Bland
BA BM BCh MRCGP DRCOG