What are some decision making strategies to ensure the client is able to make an informed consent?

• the medical condition
• the recommended treatment (including the other treatment options available) 
• the benefits, risks and possible complications of the recommended treatment. 

These explanations are essential so that a person can make an informed decision. 

This is known as ‘informed consent’. Once the information is given, the doctor may ask the person (or their guardian) to sign a consent form. When signed, this form gives the doctor or other healthcare professional legal permission to perform the treatment or procedure.

Every care relationship is different. In many cases, the person being cared for can make their own decisions about their own medical treatment. As a carer of someone who can make their own decisions, you can provide support to the decision-making process. This can include helping with meeting preparation, attending meetings and asking questions and discussing the information you have learned.Some people, for a variety of reasons, are unable to make decisions regarding their own treatment. Often these people will have a Medical Enduring Power of Attorney. Once appointed, the Medical Enduring Power of Attorney can give consent on behalf of the person in care.In the case of an emergency, doctors and other healthcare professionals can make authorisations for treatment. They do not have to consult with partners, family and loved ones, but it is considered best practice to take a carer’s opinions into account at this time.

As a carer, you may have been given authorisation to access the medical records of the person you are caring for. You may have been granted Medical Enduring Power of Attorney, or you may simply be the person who drives your friend to their appointments. Regardless of the nature of your care relationship, you can always work closely with the person you care for, their healthcare professionals and their family and friends.

Before making medical treatment decisions

Before making a decision about medical treatment, it is a good idea to get information about the treatment and give yourself enough time to think about it. Ask the health professionals for written information to take home to read or trustworthy resources you can find online.

The information that must be given to a person includes: 

• the diagnosis and likely outcome (‘prognosis’) of the condition 
• an explanation of the recommended treatment 
• the risks of the treatment and common side effects 
• possible complications of the treatment
• specific details of the treatment; for example, where it will be done and who will do it 
• any other options for treatment and their chances of success.

If you are making the decision on behalf of another person, consider what you think they would want or follow their instructions if they have written them down such as in an advance care plan.

Read more on the Making decisions about surgery fact sheet.

If you are having trouble making a decision

Sometimes it is difficult to decide whether or not to undergo a particular medical procedure. It is important to remember that it is okay to ask more questions or to look for second opinions.

If you and the person you care for are having trouble making a decision, you could:

• Make a further appointment with the doctor or surgeon to discuss your concerns and get more information. 
• Ask the doctor or healthcare professional to explain the information to you again in a way you can understand and if either of you does not fully understand the information the doctor or surgeon gives, say so.
• Ask for a referral to another specialist to get a second opinion. 
• Ask the doctor or surgeon for information in another language or ask for a professional  interpreter if you prefer another language to English.
• Find a support group and talk to someone who has had the treatment or procedure. It can help to learn from other peoples’ experiences.

Before a planned treatment, surgery or procedure, the doctor will ask the person (or their legal guardian) to sign a consent form. The doctor, not the nurse, must obtain the person’s (or their legal guardians) consent.

The consent form will have information about the procedure. A typical consent form usually includes: 

• the person’s surname, given names, date of birth, sex and referring doctor 
• whether or not they need an interpreter 
• an explanation of the condition, in plain language 
• an explanation of the treatment, surgery or procedure, in plain language 
• general risks of anaesthesia (if being used), which may be included in a separate form 
• general risks of surgery 
• specific risks of this particular procedure, listed by the doctor 
• whether or not the doctor has explained the risks and possible complications 
• whether or not the doctor has explained the risks of not having the proposed treatment 
• the person’s agreement that information has been provided 
• the person’s agreement that they understand that the procedure may not work or may make the condition worse
• the person’s dated signature to confirm that they understand all of the above and want to have the procedure.

Understanding consent is crucial

The signed consent form is considered a legal document. However, according to the High Court of Australia, a person’s signed consent is legal only if the person was adequately warned about possible risks and complications and has understood those warnings. 

Generally speaking, ‘informed consent’ depends on whether or not a person would have agreed to the surgery if they had known and understood the possible risks and complications. 

Consent can be withheld or withdrawn

The final decision is always the person receiving medical treatment or their authorised agent. They have the legal right to refuse consent or withdraw consent for any proposed treatment. 

Where to get help 

This page has been produced in consultation with and approved by:

This page has been produced in consultation with and approved by:

Content on this website is provided for information purposes only. Information about a therapy, service, product or treatment does not in any way endorse or support such therapy, service, product or treatment and is not intended to replace advice from your doctor or other registered health professional. The information and materials contained on this website are not intended to constitute a comprehensive guide concerning all aspects of the therapy, product or treatment described on the website. All users are urged to always seek advice from a registered health care professional for diagnosis and answers to their medical questions and to ascertain whether the particular therapy, service, product or treatment described on the website is suitable in their circumstances. The State of Victoria and the Department of Health shall not bear any liability for reliance by any user on the materials contained on this website.

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Venn diagram showing the multiple overlapping purposes of informed consent.

Image courtesy of Daniel Hall