{"id":48711,"date":"2020-10-01T09:13:09","date_gmt":"2020-10-01T08:13:09","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=48711"},"modified":"2020-10-12T18:54:17","modified_gmt":"2020-10-12T17:54:17","slug":"daniel-sokol-new-guidance-from-the-gmc-what-constitutes-meaningful-dialogue","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2020\/10\/01\/daniel-sokol-new-guidance-from-the-gmc-what-constitutes-meaningful-dialogue\/","title":{"rendered":"Daniel Sokol: New guidance from the GMC\u2014what constitutes meaningful dialogue?"},"content":{"rendered":"<p><span style=\"font-weight: 400\">Some 12 years after the 2008 version, the General Medical Council (GMC) has just published new guidance on <a href=\"https:\/\/www.gmc-uk.org\/ethical-guidance\/ethical-guidance-for-doctors\/decision-making-and-consent\">decision making and consent<\/a>, which will come into effect on 9<\/span><span style=\"font-weight: 400\">\u00a0November 2020.<\/span><\/p>\n<p><span style=\"font-weight: 400\">On two occasions, the new GMC guidance uses a phrase not found in the previous version: consent as a &#8220;<\/span><i><span style=\"font-weight: 400\">meaningful dialogue<\/span><\/i><span style=\"font-weight: 400\">&#8221; between doctor and patient.\u00a0\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">The ethicist in me nods in agreement: <\/span><i><span style=\"font-weight: 400\">adieu<\/span><\/i><span style=\"font-weight: 400\"> to the one-way, hurried, mini-lecture by the doctor to the patient.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">The barrister in me contemplates suitable wording for my next &#8220;lack of consent&#8221; case:\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">&#8220;Although a brief discussion did take place on 10<\/span><span style=\"font-weight: 400\"> November 2020, the doctor failed adequately or at all to engage in a <\/span><span style=\"font-weight: 400\">meaningful dialogue <\/span><span style=\"font-weight: 400\">with the Claimant in relation to the operation, in breach of Principle 2 of the GMC\u2019s Guidance on Consent (2020).&#8221;\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">What constitutes &#8220;meaningful dialogue&#8221; is the subject of much of the new GMC document.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Thus, paragraph 17 states: &#8220;<\/span><i><span style=\"font-weight: 400\">You should try to find out what matters to patients about their health\u2014their wishes and fears, what activities are important to their quality of life, both personally and professionally\u2014so you can support them to assess the likely impact of the potential outcomes for each option.&#8221;\u00a0<\/span><\/i><\/p>\n<p><span style=\"font-weight: 400\">The next paragraph adds &#8220;<\/span><i><span style=\"font-weight: 400\">You must seek to explore your patient\u2019s needs, value and priorities that influence their decision making, their concerns and preferences about the options and their expectations about what treatment or care could achieve.&#8221;<\/span><\/i><\/p>\n<p><span style=\"font-weight: 400\">Early in the guidance, the authors note in an apparent attempt to reassure their medical readership: &#8220;<\/span><i><span style=\"font-weight: 400\">Obtaining a patient\u2019s consent needn\u2019t always be a formal, time-consuming process\u2019&#8221;<\/span><\/i><span style=\"font-weight: 400\">(para 6)<\/span><i><span style=\"font-weight: 400\">. <\/span><\/i><span style=\"font-weight: 400\">Quite right, as some interventions are trivial\u2014for example, the routine auscultation of the chest\u2014but for any significant procedure or intervention it is difficult to see how obtaining consent could be anything but formal and time-consuming. In my lectures to doctors, the lack of time is often mentioned as a barrier to obtaining high quality consent and it is likely to remain so in light of the new guidance.<\/span><\/p>\n<p><span style=\"font-weight: 400\">In the section on discussing benefits and harms, paragraph 21 states that doctors must give patients &#8220;<\/span><i><span style=\"font-weight: 400\">clear, accurate and up-to-date information, <\/span><\/i><i><span style=\"font-weight: 400\">based on the best available evidence<\/span><\/i><i><span style=\"font-weight: 400\">, about the potential benefits and risks of harm of each option, including the option to take no action.&#8221; <\/span><\/i><span style=\"font-weight: 400\">The phrase &#8220;based on the best available evidence&#8221; is a new addition.<\/span><\/p>\n<p><span style=\"font-weight: 400\">At paragraph 22, the guidance acknowledges that &#8220;<\/span><i><span style=\"font-weight: 400\">it wouldn\u2019t be reasonable to share every possible risk of harm, potential complication or side effect<\/span><\/i><span style=\"font-weight: 400\">&#8221; although at paragraph 24(c) it recommends disclosing any risk of serious harm, <\/span><span style=\"font-weight: 400\">however unlikely it is to occur<\/span><span style=\"font-weight: 400\">. I have concerns about this. Some tiny risks can be material to a particular patient, but others are so negligible that it would be plain silly to mention them. As far as I know, there is no legal authority for the proposition that doctors should disclose a risk that is negligible and immaterial, even if serious harm could result if it eventuates.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400\">On the topic of patients wanting to record a discussion with the doctor, paragraph 27(c) advises doctors to &#8220;<\/span><i><span style=\"font-weight: 400\">accommodate a patient\u2019s wishes if they would like to record the discussion.&#8221; <\/span><\/i><span style=\"font-weight: 400\">That recording is then owned by the patient and does not have to be stored with their records (paragraph 53). However, if a doctor makes a visual or audio recording, this forms part of the medical record and should be treated in the same way as other records (paragraph 52).<\/span><\/p>\n<p><span style=\"font-weight: 400\">A notable tightening of language relates to checking the understanding of patients, which in practice can be challenging.\u00a0 The new guidance, at paragraph 30, states &#8220;<\/span><i><span style=\"font-weight: 400\">you <\/span><\/i><i><span style=\"font-weight: 400\">must<\/span><\/i><i><span style=\"font-weight: 400\"> check whether patients have understood the information they have been given.&#8221;<\/span><\/i><span style=\"font-weight: 400\"> The old rule used the milder &#8220;<\/span><i><span style=\"font-weight: 400\">you <\/span><\/i><i><span style=\"font-weight: 400\">should<\/span><\/i><i><span style=\"font-weight: 400\"> check\u2026&#8221;<\/span><\/i><\/p>\n<p><span style=\"font-weight: 400\">The new guidance issues a caveat about the use of consent forms, reflecting some judicial comments in past cases: &#8220;<\/span><i><span style=\"font-weight: 400\">filling in a consent form isn\u2019t a substitute for a meaningful dialogue tailored to the individual patients\u2019 needs<\/span><\/i><span style=\"font-weight: 400\">.&#8221; A consent form may suggest that some sort of interaction took place, but it is a far cry from evidencing the &#8220;meaningful dialogue&#8221; envisioned by the GMC guidance.<\/span><\/p>\n<p><span style=\"font-weight: 400\">Finally, I must mention the first ever reference in the guidance to seeking advice from a clinical ethics committee in the event of disagreement about the best interests of a patient lacking capacity (paragraph 92(c)).\u00a0 Let us hope more hospitals will set up such committees.<\/span><\/p>\n<p><span style=\"font-weight: 400\">The new guidance merits careful reading by doctors. It will now be the key document by which the quality of their consent is measured.<\/span><\/p>\n<p><i><span style=\"font-weight: 400\"><strong>Daniel Sokol<\/strong> is a medical ethicist and barrister at 12 King\u2019s Bench Walk, London. He is the author of &#8220;Tough Choices: Stories from the Front Line of Medical Ethics&#8221; <\/span><\/i><span style=\"font-weight: 400\">Book Guild, 2018). <strong>Twitter<\/strong>: <\/span><a href=\"https:\/\/twitter.com\/danielsokol9?lang=en\"><i><span style=\"font-weight: 400\">@danielsokol9<\/span><\/i><\/a><\/p>\n<p><em><strong>Competing interests<\/strong>: None declared.\u00a0<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Some 12 years after the 2008 version, the General Medical Council (GMC) has just published new guidance on decision making and consent, which will come into effect on 9\u00a0November 2020. 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