Policy/Procedure Title Informed Consent/Consent to Treat Policy # 9500-1.

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Manual Location(s) Administration Effective Date May 1985
Department(s) Generating Policy Administration Page 1 of 6
Affected Departments Organization Wide
Approval Chain Signature, Credentials and Title Date Signed
Prepared by Mona Daigle, Risk Manager

Rationale to Policy: To ensure that a patient’s right to be informed and to participate in decision-
making is protected and defined.

To ensure compliance with applicable federal, state statues, HIPAA and any
other regulating bodies.

Policy Statement: No medical or surgical procedures should be performed on a patient without

obtaining a consent, unless an emergency circumstances exists.

Consent to treatment that is recommended by a physician, and in whose

competent medical judgment the proposed surgical or medical treatment
or procedures are reasonable necessary, is implied where an emergency
exists and no person authorized to consent is readily available.

Emergency circumstances exist where:

1) Any delay in treatment could reasonably be expected to jeopardize

the life or health of the person affected, or could reasonably result in
disfigurement or impair faculties; OR
2) A person is transported to a hospital from a licensed health care
facility in a condition such that the patient is incapable of giving
consent, and any delay in treatment would be injurious to the health
and well-being of the patient.

Definitions: CONSENT TO TREAT:

Express permission given by a patient to a caregiver, or given by an eligible
person on behalf of a patient, agreeing to undergo medical treatment.

INFORMED CONSENT:
The permission for a procedure after consequences, risks, and alternatives have
been described. It is the physician’s or surgeon’s responsibility to give the
patient sufficient information regarding the planned procedure so that the patient
gives an informed consent.

LEGAL QUESTIONS:
Any legal questions that may arise in connection with this guideline (and/or
consents in general), should be directed to the hospital risk manager, the
 employee’s immediate supervisor, or in their absence, to the hospital attorney at
Stockwell Sievert Viccellio Clements & Shaddock, LLP.

Procedures:

I. No medical or surgical procedures should be performed on a patient without

obtaining consent. The employee responsible for coordinating the patient’s
admission into the hospital is responsible for obtaining and witnessing the patient’s
signature on the medical consent form. The patient’s consent will be evidenced by
the patient’s signature on the consent form with date and time.

The following is a list of individuals who may consent to medical or surgical

treatment, in addition to any other individuals who may be authorized or empowered
specifically to consent on behalf of a patient. Each class of individuals is listed in
order of its priority, and if there is no person in a prior class who is reasonably
available, willing, and competent to authorize medical or surgical treatment
recommended by a physician, an individual from the next class may consent for the
patient:
1) Any adult or emancipated minor for themselves;
2) A court appointed tutor or curator of the patient;
3) An individual holding Medical Power of Attorney or agent acting pursuant to a
valid mandate authorizing them to make health care decisions for the patient;
4) The patient’s spouse, as long as they are not legally separated;
5) The patient’s adult child;
6) The patient’s parent, whether that parent is an adult or minor;
7) A sibling;
8) The patient’s grandparent or grandchild;
9) An adult friend of the patient.*
10) Any person temporarily stating in the place of a parent may consent for a minor
under that person’s care.

If there are multiple individuals within a class, then the consent for treatment shall require
a majority of those members of the class available to be consulted.

**Adult Friend- An adult friend is someone who has exhibited special care and
concern for the patient, who is generally familiar with the patients’ health care
desires, and who is willing and able to become involved in the patient’s health care
decisions and to act in the patient’s best interest. The adult friend, prior to
consenting for the patient, must sign and date the acknowledgement attached to this
policy for placement in the patient’s medical record.

If none of the above individuals are reasonably available than the attending
physician shall have the discretion to provide or perform any surgical or medical

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 treatment or procedures and may also make decisions regarding continued services
needed by the patient, such as approving the placement or transfer of the patient to
another facility. Prior to taking such action, the attending physician shall:
1) Document in the patient’s chart the facts that establish the medical
decisions that need to be made and why those decisions need to be made
without any unnecessary delay;
2) Document in the patient’s chart the steps taken to obtain consent from the
patient or another person authorized by law to give consent*;
3) Obtain confirmation from another physician, preferably the patient’s
primary care physician, of the patient’s condition and the medical necessity
for such action, including why it is appropriate and consistent with the
patient’s condition and why it cannot be omitted without negatively affecting
the patient’s condition or the quality of the medical care rendered. The
confirming physician must personally examine the patient and document in
the patient’s chart his assessment, findings, and recommendations prior to
the proposed treatment or procedures being performed.

*Justification: To justify that no authorized or able individuals are reasonably available

to consent to the treatment or procedure, the attending physician shall:
A. When no contact persons are included in the individual’s
records:document the following the patient’s record:
1) That the attending physician or representative of the attending
physician or a representative of the attending physician or the facility
has made a documented good-faith effort to inquire from the
following as to the existence of any advance directive made by the
patient or any information that would enable the physician to
contact a person authorized to consent on behalf of the patient:
-The Louisiana Secretary of State’s Living Will Registry
- The patient’s primary care physician or any known provider of
medical treatment in the previous 180 days;
-Any known facility in which the patient has resided in the
previous 180 days
2) That no advance directive or other information is available that
would enable the physician to locate an individual authorized to
consent for the patient
B. When the names of potentially authorized persons are included in the
individual’s records or are otherwise obtained: document the following in
the patient’s record:

[1)] The name of each potentially authorized person that the

physician or a representative of the physicianorphysician or
facility attempted to contact;
1)[2)] The manner and date of the attempted contact; and

Informed Consent Page 3 of 6

 2)[3)] The result of the attempted contact.

II. Before a patient gives his consent, the physician who will actually perform the
medical or surgical procedure must clearly explain to the patient and when
appropriate, to the family, the following:

1) The nature of the relevant injury, illness, or condition;

2) The general nature of the proposed treatment or procedure;
3) The purpose of the proposed treatment or procedure;
4) The Material Risks of the proposed treatment or procedure;
5) The potential problems with recuperation;
6) The likelihood of success;
7) The possible results of not proceeding with treatment;
8) The risks involved with any reasonable therapeutic alternatives;
9) The answers to any questions that the patient has, answered to the patient’s
satisfaction.

III. Only a competent adult can refuse treatment.

When a competent adult refuses or withdraws consent, the physician or hospital or

both should obtain written acknowledgement of the refusal from the patient and a
release from liability. The signed document must be placed in the patient’s medical
record. If the patient refuses to sign the form, then complete documentation of the
refusal should be recorded in the patient’s chart.

In extenuating circumstances arise, causing the hospital to challenge the competent

adult’s decision, the hospital may take the matter to court and request a court order
to administer treatment. In this situation, the hospital administrator must be informed
and authorize intervention in the matter through the court.

A. Hospital Care Consent

This completed form is good for the length of the patient’s hospitalization and is designed
to cover all routine procedures in the hospital for which a surgical or special consent
form is not required.

B. Surgical and/or Special Consent

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 The medical staff surgeon is responsible for discussing with the patient the contemplated
surgery and for obtaining the patient’s informed consent for that surgery, and for placing
documentation of the discussion and the patient’s informed consent in the patient’s
medical record. The patient’s signature, with date and time, on the surgical consent form
should be obtained as near as possible to the day prior to surgery.

If the consent form contains an error, a new consent form should be obtained by the
surgeon prior to surgery.

Completed Surgical Consent forms should be used for the following:

1) Major and/or minor surgery involving entry into the body (either through incision or
natural body opening);
2) Procedures involving the use of general, regional block, or spinal anesthesia,
regardless of whether the procedure involves entry into the body;
3) Non-surgical procedures, such as the administration of medicine, dye (either
injectable or oral contrast), and any other material that involves a risk of harm to the
patient or that may cause a change in the patient’s body structure. Such procedures
include, but are not limited to:
- Chemotherapy
- Hormone Treatments
- Myelograms
- Arteriograms
- Pyelograms
4) All forms of radiological therapy;
5) Any and all other procedures that the Medical Staff determines require a specific
explanation to the patient; and
6) When the treating physician determines that blood and/or blood product transfusion
will be required.

C. Anesthesia Consent

The Anesthesiologist is responsible for discussing the contemplated administration of

anesthesia with the patient, for obtaining the patient’s informed consent for the
administration of that anesthesia, and for placing appropriate documentation of these
discussions and receipt of the patient’s informed consent in the patient’s medical record.
The patient’s signature, with date and time, on the anesthesia consent form should be
obtained as near as possible to the day prior to surgery.

A CRNA, in consultation with an anesthesiologist, may discuss the contemplated

administration of anesthesia with the patient for obtaining the patient’s informed consent

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 to that anesthesia’s administration, and for placing the appropriate documentation of
these discussions and the patient’s informed consent in the patient’s medical record.

D. Special Procedure Consent

The physician is responsible for discussing contemplated special procedures with the
patient, and for obtaining the patient’s informed consent for these procedures.

* Therapeutic Privilege:

There will be situations in which, in the judgment of the physician, a full disclosure to the
patient is not medically desirable. A physician’s decision to withhold information in these
cases has been referred to a “therapeutic privilege”. A physician who intends to exercise
the therapeutic privilege to withhold information from a patient should document that the
patient’s sensitivity to the receipt of the information was significantly above the norm.
To document a patient’s high susceptibility to anxiety, confirmation of the attending
physician’s observation should be made by the physician, another physician, and/or
relative or close friend of the patient, and should be entered in the patient’s treatment
record.

REFERENCES:
Lake Charles Memorial Hospital Medical Records Department. Revised 5/2012

Opinion 8.08 - Informed Consent American Medical Association November 2006” therapeutic privilege”
American Medical Association

2006 Louisiana Laws – RS 40:1299.40 – Consent to medical treatment; exception; Louisiana medical
disclosure panel; availability of lists to establish necessity and degree, JUSTIA US Law, justia.com

Dates Approved or Amended

Reviewed Revised
July 1994; February 2000; April 2006; 3/21 December 1987; August 1991; October 1995,
February 1997; March 2003; June 2012, July
2013; May 2016; April 2020, July 2023

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