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Gaining consent for health assessments

This article explores how healthcare professionals should gain consent for health assessments
A person with an intellectual disability with a folder of papers.

A key part of a health assessment, after you have designed your Easy Read materials, is to consider how you can gain consent from a patient with an intellectual disability. All healthcare practice is underpinned with ethical principles. As healthcare professionals we want to do good, and if we cannot do good, above all we will do no harm. The patient has the right to be treated with fairness, dignity and privacy in a confidential manner.

You as a practitioner have a responsibility to be a competent practitioner above reproach. To undertake any procedure with the patient no matter how small, for example taking their blood pressure, you must first gain their consent.

Take a look at this graph. It is a graphical representation about how ethical principles apply to both you as a practitioner and the patient.

A Venn diagram showing the ethical responsibilities of practitioners and patients and where they overlap

On the left hand side we can see that the practitioner should be competent, show integrity, honesty and be responsible. On the right hand side we can see what patient rights must be upheld. They have the right to justice, dignity, privacy and confidentiality. But we can see in the middle of the graph, there are three underpinning principles of consent: non-maleficence (do no harm), beneficence (to do good), and autonomy that relates to both patients and professionals.

Patient rights

All patients have the following rights:

  • Right to have __ taken/done
  • Right to be heard
  • Right to refuse
  • Right to stop at any time
  • Right not to do a particular part they don’t want to
  • Right to further clarity and explanation
  • Right to their results

The following procedure can be used when the patient has to undergo any procedure at your clinic. I am using the example of taking blood pressure. Whilst many of your patients will instinctively know what you are doing by just seeing the equipment, it is good practice to seek permission and explain the procedure. This is especially true for the person with intellectual disability.

  • First, always assume capacity
  • Explain what you are going to do and why you are doing the assessment
  • Explain their rights
  • Explain the procedure and use the accessible material to support this explanation
  • Go through the consent form (where appropriate) which should be easy read and supported with an easy read information booklet
  • Explain the risks and benefits
  • Emphasise their privacy
  • Obtain signature or mark, if needed, or verbal consent or affirmation
  • Where written signature is required and the person is unable to write but has affirmed they will take part, obtain a witness signature from the carer with the permission of the person with intellectual disability
  • Keep accurate and clear notes

In the next step, we will be taking you through a complete health assessment. Consent is one of the key elements of this procedure.

© Trinity College Dublin
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Improving Health Assessments for People with an Intellectual Disability

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