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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 been experiencing hip pain recently. He is preparing for a marathon next month and decides to seek massage therapy as a way to address his hip pain. When he attends his first appointment, Aisha, his RMT, listens carefully to Luc’s concerns about his hip pain. She asks questions about when the pain began and what makes it worse. Aisha asks Luc if he would allow her to palpate the structures surrounding his hip and to test his range of motion. She explains the actions that she intends to test and describes how this information will help her to create a treatment plan. Luc agrees, eager to understand what is causing the pain.

Once Aisha has completed an assessment and formed a clinical impression, she explains her findings to Luc, describing how she needs to position and drape him for treatment. Aisha 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 his concern and explains how she will adjust her plan to accommodate his needs.

Finally, Aisha empowers Luc to let her know if he feels uncomfortable at any time or wishes to stop or adjust the treatment. Luc thanks Aisha for explaining everything clearly. Aisha smiles and asks if Luc gives his consent to proceed with the assessment and treatment she has described. Since this is the first time that Aisha has met with Luc about this issue, she shows Luc her informed consent form and asks him to sign it so that she can record his consent for her plan. She offers to make Luc a copy of the form once he signed it but Luc declined. 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 the signed consent form within her 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 her treatment plan based on his input. Aisha showed her informed consent form to Luc and asked him to provide his written consent to her proposed treatment plan. Finally, Aisha included this signed consent form within Luc’s clinical record.

Consent standard of practice case studies

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