Consent

38. A person with capacity has the right to refuse treatment or care or to withdraw consent at any time. You must respect their decision even if you believe the treatment or care to be in their best interests.
39. In these circumstances you should clearly explain the consequences of their decision but you must make sure that you do not pressure the patient to accept your advice; if the patient agrees only as a result of pressure they perceive was put on them, then this may not be considered valid consent.
40. You should make a record if a patient refuses or withdraws consent. This should include the discussions that have taken place and the advice you have given. If the patient has given a reason you should include this in your notes. However, the patient is not required to give a reason for refusing or withdrawing consent.
41. If you believe that there is a risk of serious harm to the patient or others due to their decision to refuse a service or treatment, you must raise this issue with appropriate healthcare colleagues or people involved in their care, and your employer (if applicable). Consider getting legal advice if necessary.
42. For young people and children who refuse or withdraw consent, please see relevant legislation outlined for further information.

Recording consent

43. Standard 8(7) (annex 1) relates to maintaining adequate patient records. As a general principle, you must maintain clear, legible and contemporaneous patient records. This must include information on treatment, referrals or advice, including drugs or appliances prescribed, or a copy of the referral letter.
44. You should use your professional judgement to determine when and how to record consent based on proportionality, risk, the patient’s needs and circumstances and type of treatment or care.
45. You should make a record if a patient refuses or withdraws consent.

Legal frameworks: capacity to consent