Eliciting consent from patients with dementia in general X-ray departments: Law, ethics and interpretation of context [CONFERENCE PAPER]
Katie Kelly, Lisa Booth, Paul K. Miller
United Kingdom Imaging and Oncology Congress 2020: Pathways and Communication, 1-3 June 2020; ACC, Liverpool
Open Access
Abstract
Background
While the numbers of individuals suffering from dementia syndromes in the UK steadily increase, many practitioners in the allied healthcare professions, and particularly junior staff, still feel ill-equipped for face-to-face communicative encounters with such individuals (Miller et al., 2019; Tullo et al., 2016). An elemental feature of effective communication in healthcare contexts is the seeking of proper consent to perform given procedures. The propositions above, however, raise questions regarding how ‘properly’ consent is being acquired when dementia is at stake. This paper, thus, reports findings from a qualitative study of general radiographers’ experiences of acquiring consent from patients with dementia, specifically exploring participants’ interpretations of correct legal and ethical practice therein.
Methods
With institutional ethical approval, N=6 general radiographers with less than ten years of clinical experience were recruited to sit for extended interviews. Verbatim transcripts were analysed using the domain-established techniques of Interpretative Phenomenological Analysis (Miller et al., 2017).
Results
Four key areas of extremely variable interpretation and practice were identified. (1) How to assess capacity for informed consent; (2) How to effectively modify communication when gaining consent; (3) Managing carer involvement during consent-acquisition and; (4) Constituting the ‘best interest’ of the patient.
Conclusion
Participants’ own accounts often indicated that they were often not lawfully implementing the Mental Capacity Act (MCA) when acquiring consent. Moreover, as previously identified by Miller et al. (2019), the situational confusion did little for participants’ confidence, with prospectively damaging import for future encounters. Stronger training in practical application of the MCA is recommended.

Consent conundrums: patient consent in neuroscience nursing
John Finch
British Journal of Neuroscience Nursing, 25 February 2020; 16(1)
Abstract
In BJNN 15(4) and BJNN 15(5), John Finch looked in detail at the role of the Mental Capacity Act 2005 and its accompanying Code in the practice of neuroscience nurses. He concluded, as have others, that the guidance offered by the Act and the Code falls short of what neuroscience nurses need in their practice. In this article, he turns his attention to the treatment of patients who can and do consent to proposed treatment. The law relating to such patients in this matter offers neither an act nor a code. The law is to be found in court decisions. It might, at first sight, appear that a practice situation in which a patient with undoubted mental capacity or, at least, sufficient mental capacity to understand and accept what is proposed, presents no legal problem. But a closer examination of mental processes encountered in patients who may be in pain, distress and pressing need reveals that communication between the treater and the treated may be subtle and complex, and that the meeting of minds required in law to ensure that a patient has genuinely agreed to a detailed proposal is anything but simple.

‘Delusional’ consent in somatic treatment: the emblematic case of electroconvulsive therapy
Original Research
Giuseppe Bersani, Francesca Pacitti, Angela Iannitelli
Journal of Medical Ethics, 13 February 2020
Abstract
Even more than for other treatments, great importance must be given to informed consent in the case of electroconvulsive therapy (ECT). In a percentage of cases, the symbolic connotation of the treatment, even if mostly and intrinsically negative, may actually be a determining factor in the patient’s motives for giving consent. On an ethical and medicolegal level, the most critical point is that concerning consent to the treatment by a psychotic subject with a severely compromised ability to comprehend the nature and objective of the proposed therapy, but who nonetheless expresses his consent, for reasons derived from delusional thoughts. In fact, this situation necessarily brings to light the contradiction between an explicit expression of consent, a necessary formality for the commencement of therapy, and the validity of this consent, which may be severely compromised due to the patient’s inability to comprehend reality and therefore to accept the proposal of treatment, which is intrinsic to this reality. With the use of an electric current, the symbolic experience associated with anaesthesia, and the connection to convulsions, ECT enters the collective consciousness. In relation to this, ECT is symbolic of these three factors and hooks on to the thoughts, fears, feelings and expectations of delusional patients. These are often exemplified in the violent intervention of the persecutor in the patient with schizophrenia, the expected punishment for the ’error’ committed for which the depressed patient blames himself and the social repression of the maniacal patient’s affirmation of his inflated self-esteem.

A review of informed consent and how it has evolved to protect vulnerable participants in emergency care research
Rajpal Nandra, Alan F. Brockie, Faisal Hussain
European Federation of National Associations of Orthopaedics and Traumatology (EFORT) Open Reviews, 3 February 2020; 5(2)
Open Access
Highlights

• A vulnerable participant in research lacks capacity to consent or may be exposed to coercion to participate. Capacity may be temporarily impaired due to loss of consciousness, hypoxia, pain and the consumption of alcohol or elicit substances.
• To advance emergency care, providing life-threatening measures in life-threatening circumstances, vulnerable patients are recruited into research studies. The urgent need for time-critical treatment conflicts with routine informed consent procedures.
• This article reviews ethical considerations and moral obligations to safeguard these participants and preserve their autonomy.
• A particular focus is given to research methodology to waive consent, and the role of ethics committees, research audits, research nurses and community engagement.
• Research on the acutely unwell patient who lacks capacity is possible with well-designed research trials that are led by investigators who are sufficiently trained, engage the community, gain ethical approval to waive consent and continuously audit practice.

Editor’s note: EFORT Open Reviews publishes high-quality instructional review articles across the whole field of orthopaedics and traumatology. It is published by The British Editorial Society of Bone & Joint Surgery (BESBJS).