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Establishing patient consent in accordance with the standard of practice on consent

Case study: Establishing patient consent in accordance with the standard of practice on consent

Luc is a runner who has recently experienced hip pain. He is preparing for a marathon next month and seeks massage therapy to address his hip pain. At his first appointment, Aisha, his new RMT, describes her clinical framework to Luc. She explains her scope of practice, her initial intake process (including a comprehensive medical history), and she describes how each treatment will include assessment, treatment and suggestions for helpful home care including exercise and possibly adjustments to daily activities including hydrotherapy. She invites Luc to ask questions about massage therapy, and explains that after she learns more about his presenting complaint, she will create a treatment plan with his input, built around his goals for treatment. Luc asks about treatment frequency; Aisha replies that it will depend on what she discovers during assessment and that her recommendation will be consistent with his training program leading up to the marathon. Luc signs the consent form. She offers to make Luc a copy of the signed form but he declines.

Aisha listens carefully to Luc’s concerns about his hip pain and asks when the pain began and what makes it worse. She asks Luc if she may palpate the structures surrounding his hip and test his range of motion. She explains the actions that she intends to test and describes how this assessment will help her to create a treatment plan. Luc agrees, eager to understand what is causing him pain.

Once Aisha completes her assessment and forms a clinical impression, she explains her findings to Luc. She describes how she needs to position and drape him for treatment, and cautions Luc that if she performs certain techniques, he may feel somewhat tender for a day or two afterward. Aisha asks Luc if he has any questions about what she proposes.

Luc says that her plan makes sense to him but that he doesn’t want any deep work because he has to be at his best for a meeting the following day and he doesn’t want to be in pain. Aisha thanks Luc for this information and explains how she will adjust her plan to address his needs. She outlines alternate forms of care available that may help with his hip pain but he interrupts to say he’s tried alternatives and is keen to proceed with massage therapy.

Finally, Aisha empowers Luc to let her know that if he feels uncomfortable at any time or wishes to stop or adjust the treatment, he simply needs to tell her. Luc thanks Aisha for explaining everything clearly. She smiles and asks if Luc consents to the assessment and treatment she has described. He agrees. Throughout the treatment Aisha checks in with Luc regarding comfort and ensures that her actions continue to support his care. Following the treatment, Aisha includes Luc’s signed consent form in his clinical record.

Did Aisha’s actions meet the Consent Standard of Practice?

Yes. Aisha engaged in shared decision-making with Luc. She respected his right to make decisions about his care and adapted the treatment plan based on Luc’s input. Aisha explained her clinical framework for massage therapy, and received Luc’s signed consent on the initial consent form which she added to his clinical health record.  Aisha sought Luc’s input to the treatment plan designed to address his presenting complaint of hip pain, and advised Luc that he should speak up if he was uncomfortable at any time during treatment, or wishes to discontinue treatment. Luc is fully informed, is aware of the alternatives to Aisha’s care, and has consented to treatment.

Consent standard of practice case studies

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