How to Avoid Complaints (Part 2) – my incomplete but growing understanding of consent

(as continued – for Part 1 please go here)

Consent, consent, consent.  It was not even mentioned when I was an undergraduate, but it’s all the rage these days.  I know we need it.  But what does it mean?  At COPA in June of this year, I made my way to a talk entitled An Osteopath’s Guide to Consent.  This guidance  is sorely needed.   I have recently read speculation in the media that the U.S. is heading towards the need for written consent to have sex (and I thought badly matched underwear was a passion killer).  It is a hot topic.  And important.  And all complaints, we were told, have an undercurrent of poor communication or consent.  Just so we know exactly what we’re talking about, the formal definition of consent is (as I recall from the talk)

A way of gaining agreement from the patient to perform a technique or treatment

Consent is a process, not an event

I used to have a sheet I gave to patients to read and fill out before the first consultation.  It explained that they might be sore, stiff or tired for up to 72 hours after treatment, and also that there was a teensy tiny risk of a stroke from cervical spine manipulation. I also informed them that at any time, for any reason, they could withdraw this consent.  Many patients signed my form without reading it; a fair proportion of those that did read it specified that they didn’t want neck manipulation. But I naively felt that their signature had given me carte blanche, (neck thrust notwithstanding),  to treat people however I saw fit until they stopped me. Who could argue with a signed and dated consent form?  Surely this would stand up in any court of law? Well, this is absolutely not the case. It’s a little bit more involved than that.

A signature is needed only for intimate or internal areas

Gerogina Leelodharry, complaints supremo of the iO, told us  that the patient does not need to sign anything  unless you are delving into their nooks and crannies, or are overtly close to erogenous zones.  If you do this kind of treatment YOU MUST GET A SIGNATURE.  For all other osteopathic treatment, verbal consent has the same validity as written consent.  However this obviously opens you up to the possibility that it will be their word against yours.  Congratulations on your unusually computer-like memory if you can remember the details of what you said in every  treatment over the last couple of years.  Often I can hardly remember what I said the day before. So you do need to record the fact that consent was obtained AT EACH TREATMENT and for each technique.

You can use an acronym

This was possibly one of the best pieces of advice of the whole talk, and I have taken to writing CORBE in my notes at every treatment. This is my own acronym for Consent Obtained, Risks and Benefits Explained, which is the kind of phrase that Georgina used over and over again.   (The consent is apparently not VALID unless risks and benefits are explained.)  My notes now look like something is missing without it.  It serves as a reminder to me to obtain the consent and explain risks and benefits.  (I know that we don’t always actually know what all the risks and benefits are at this point, but that’s another story.  Watch this space..).   Georgina is not an osteopath, and when she blithely told us to gain consent each time we changed the sort  of treatment we used, or introduced a new technique, I must say it sounded unworkable in practice. The idea of explaining the risks and benefits of suboccipital inhibition, followed by obtaining consent for cervical spine articulation, followed by obtaining consent for a biceps stretch, which turns into a kind of functional shoulder technique for which you need to explain the risks and benefits,.. well, you get the picture. It would be impossible in real life.  However when I broke it down, I realised I can group many techniques into ‘ soft tissue and mobilisation’ which all have similar risks and benefits.  I now have 3 standard kinds of patter in development:  one, for soft tissue and gentle articulations and stretches, one for HVT and one for cranial.  I will write in my notes CORBE Soft tissue/artic, or CORBE HVT Lsp and cranial, for example.  This indicates that I have gained consent for that particular genre of treatment, as it were.  The iO website categorizes things differently, and recommends the acronym DROP (Discussed risks and options with patient) and then whichever of the following is appropriate

RG1 – commonly expected reactions to treatment (for the majority of patients)

RG2 – for less common reactions to treatment (for those at risk of rib frature/bruising, of the elderly etc)

RG3 – those patients where treatment has included manoeuvres such as osteopathic manipulation of the cervical spine or similar in the lumbar spine where you have queried an underlying disc condition for example

RG4 – This covers dry needling and includes low to high risk reactions of treatment by acupuncture or dry needling

The iO provide patient information leaflets for each of these, but I couldn’t locate them on the website.  (And despite two emails haven’t managed to get a response from them.  They might be good at helping with complaints, not maybe quite so hot on responding to email enquiries). You can use  whatever works for you, but just handing out a leaflet in lieu of explaining consent isn’t enough.  Whatever you do, make sure you actually DO DO IT and DO RECORD IT in some form.

Make it an automatic part of each treatment

I now try to pause before I begin treatment and say, a little more systematically and formally than I used to, I’m going to use soft tissue and articulation techniques and some cranial work today as I think they will achieve such and such a positive effect.   This type of treatment might also make you feel like this or this so take extra care if you are driving, and don’t be surprised if you feel like this for a couple of days.  There is also a small chance that if you have a weakness here it could cause this. Are you happy for me to go ahead with that?  It actually feels like a useful ritual to me now, a reminder to centre myself and concentrate my mind on the treatment.  Later I can record in my notes CORBE soft tissue and cranial, for example. I have always said things similar to this, but not systematically, and I have not recorded it. It can feel a little stilted, and some very familiar patients are momentarily taken aback by the slightly formal air that it creates, but I am getting better at communicating more smoothly and adapting to the patient.  In fact, if I sound a little abrupt I often clarify that we have to go through this process for legal reasons.  People seem used to this kind of regulation, even eye-rollingly bored by it, but they do understand that we have to do it.  The recording of consent in the notes, I repeat because I cannot say it enough, seems to be crucial.  Georgina says that some osteopaths have come a cropper because they just forgot on that particular day to obtain or note consent, even though they normally do it all the time.  And if a malicious patient decides to complain about you, your failure to have noted consent will not be helpful.

An afternote:
Spencer vs GOsC – You cannot be found guilty of unprofessional conduct just due to poor notes

In passing, this case from 2012 was mentioned.  I think what it says is that in the absence of “incompetence or negligence to a high degree”, complaints about note taking and record keeping alone do not meet the threshold criteria for establishing unacceptable professional conduct.  You can download a GOsC document here which might shed more light on this.


5 thoughts on “How to Avoid Complaints (Part 2) – my incomplete but growing understanding of consent

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