Trust is a vital element in the patient – physiotherapist relationship. For trust to exist, patients and physiotherapists must believe that the other party is honest and willing to provide all necessary information that may influence the treatment or advice. ‘Consent’ for health professionals means permitting someone to do something they would not have the right to do without such permission. The patient must indicate that approval for a particular assessment, and/or procedure(s) has been given, or declined.
Informed consent is a culturally sensitive interactive process between a physiotherapist and patient where the patient gains an understanding of his or her condition and receives an explanation of the options available including an assessment of the expected risks, side effects, benefits and costs of each option and thus can make an informed choice and give their informed consent.
Legally valid informed consent consists of three key components. The patient must be competent to consent, appropriately informed, and able to give voluntary consent or not.
New Zealand law
Code of Health and Disability Services Consumers’ Rights (1996) states every patient has the right to make an informed choice and to give informed consent, except in certain circumstances (Right 4 & 5).
The Care of Children Act 2004 (Section 36) states that children over the age of 16 years can give consent as if they are adults. It is not clear whether parental consent is always necessary for (medical) treatment for persons under 16 years. Section 36 does not automatically prohibit persons under 16 years from consenting treatment.
1.1. Physiotherapists must seek patient informed consent before providing any physiotherapy services, ensuring their consent is freely given and appropriately documented. (Aotearoa New Zealand Code of Ethics and Professional Conduct 2017, 2.6).
This includes, but is not limited to:
- the initial assessment and treatment
- the continuation of care and any changes in treatment
- any clinical imaging
- recording of an assessment or treatment
- when a physiotherapy student is involved
- course participation that involves the application of techniques and modalities
- course demonstrations
- education and research in addition to informed consent for assessment and treatment.
1.2. Physiotherapists must seek prior consent for the presence of an additional person(s), who is not directly involved in the patient’s care, attending an assessment and/or (Involvement of an additional person during a consultation, Standard).
This includes but is not limited to:
- A chaperone, supervisor or peer reviewer
- An observer for education, peer review or research purposes
- An interpreter
2. Competence to give consent
2.1. Every patient must be presumed competent to make an informed choice or give informed consent unless there are reasonable grounds for believing that the patient is not competent. The patient’s age can be a relevant factor to take into account when determining competence. Several other factors must also be considered, these include:
- the patient’s level of understanding, including language and maturity
- the seriousness of the assessment and/or treatment
- whether the particular individual, regardless of their age, has the capacity to consent to the particular form of treatment proposed
- where a patient has diminished competence, that patient retains the right to make informed choices and give informed consent to the extent appropriate to his/her level of
2.2. Determining competence
Physiotherapists must act in accordance with the law where the patient has compromised decision-making capacity or is unable to provide consent. (Aotearoa New Zealand Code of Ethics and Professional Conduct 2017, 2.7).
In any communication regarding Informed Consent, the physiotherapist should try to validate a patient’s comprehension. If there is any doubt a second opinion should be sought.
3.1. Physiotherapists must clearly and adequately inform the patient of the purpose and nature of the physiotherapy intervention to enable their informed choice (Aotearoa New Zealand Code of Ethics and Professional Conduct 2017,5).
3.2. Patients have the right to sufficient information to make an informed choice or give informed consent. This includes, but is not limited to:
- an explanation of the patient’s condition
- an explanation of the options available, including an assessment of the expected risks, side effects, benefits, and the costs, and different treatment options including public and private where appropriate
- the advice about treatment frequency, and estimated numbers of treatments
- explanation of any proposed participation in teaching or research, including whether the research requires and has received ethical approval
- any other information required by legal, professional, ethical, and other relevant standards
- the results of tests and
3.3. Patients are entitled to honest and accurate answers to any questions about services, including the identity and qualifications of the provider, the recommendation of the provider, how to obtain a second opinion from another provider, and the results of relevant research. If requested, a written summary of the information must be provided.
4. Effective communication
4.1. Patients are entitled to effective communication in a form, language and manner that enables the patient to understand the information provided, and for this to take place in an environment that enables open, honest, and effective communication. The involvement of whānau, family or other support persons may often help with understanding.
4.2. Where necessary and reasonably practicable, patients have the right to a competent interpreter (see Involvement of an Additional Person during a consultation standard).
5. Shared decision-making
Physiotherapists must involve the patient in planning care, and revisit their goals and plans on a regular basis (Aotearoa New Zealand Code of Ethics and Professional Conduct 2017, 2.4).
6. Voluntary consent
The patient must be able to give consent freely, without being subject to discrimination, coercion, harassment or exploitation. The patient has the right to refuse services and to withdraw consent that has already been given, without prejudice. The patient is also entitled to express a preference as to who will provide services and have that preference met where practicable.
7. Oral and written informed consent
7.1. Oral informed consent is sufficient for routine assessments and treatments where any perceived risk to the patient (or therapist) is minimal.
7.2. Written informed consent is required if:
- there is a significant risk of adverse effects on the patient or if there is any doubt whether an assessment or treatment has an associated risk
- a physiotherapy student is involved. The initial informed consent pertaining to a patient’s assessment and treatment by physiotherapy students must be undertaken and documented by the supervising physiotherapist and prior to introducing the student (see Involvement of an additional person during a consultation standard)
- the patient is to participate in any research. This will be part of the research ethics process and in addition to consent for any assessment and treatment
- Written consent, along with the patient’s signature, should include the options and risks
7.3. Documenting informed consent: All oral and written informed consent must be clearly documented, dated, and include an explanation of the information provided.
8. Consent of minors
8.1. The Code of Rights does not specify an age for consent and makes a presumption that every consumer of health services is competent to make an informed choice and give informed consent unless there are reasonable grounds for believing that the consumer is not competent.
8.2. Children over the age of 16 are considered legal adults. Consent given by a parent or guardian for the treatment of a child or an impaired adult does not necessarily imply assent to treatment by the patient. Should there be any doubts about consent, care must be exercised before proceeding. The patient must still be provided with information appropriate to their level of ability to understand, and retains the right to make informed choices and give informed consent to the extent appropriate to their level of competence.
8.3. You should assess a child’s competency and form an opinion on whether they are able to give informed consent. A competent child is one who is able to understand the nature, purpose and possible consequences of the proposed investigation or treatment, as well as the consequences of non-treatment.
9. Treatment fees and costs
9.1. If any costs (fees) are involved in providing physiotherapy, before providing treatment, the physiotherapist should ensure, via the informed consent process, that the patient has been informed that fees are involved.
9.2. It is unwise for a physiotherapist to prejudge a patient’s ability to afford a particular treatment.
Aotearoa New Zealand Code of Ethics and Professional Conduct (2018) Principle 2.5, 2.6 and 2.8
Physiotherapy practice thresholds in Australia & Aotearoa New Zealand (2015) Role1 and Key competencies 2, 3.1, and 5.1