Scenario Interprofessional Collaboration and Consent

A pre-term infant has been admitted to the Neonatal Intensive Care Unit (NICU). The infant requires Total Parenteral Nutrition (TPN). Mom is unconscious and being treated at another hospital due to severe blood loss. The baby’s father is at his wife’s bedside. The physician you work with has proposed TPN treatment to the infant’s father. What is the role of the RD to obtain consent in an interprofessional team?
 
The role of the dietitian for obtaining consent depends on who is proposing and providing the treatment. In this scenario, the physician has proposed and ordered the treatment. The dietitian can assume that the physician has also obtained informed consent for the treatment and should be able to verify this by looking at the physician’s documentation in the client’s health record.  The College’s Standard of Consnet 1 (V), states that , “When another health care practitioner proposes nutrition treatment and obtains informed consent, RDs must:
a) Be reasonably confident that the practitioner obtained informed consent;
b) Obtain informed consent if it is determined that the informed consent process for treatment was incomplete; and
c) Answer any additional questions that clients/substitute decision-makers may have regarding the nutrition treatment being proposed.
 
Had the dietitian proposed the treatment and had parenteral nutrition ordering authority in the NICU, then the RD would be responsible for obtaining informed consent from the father. Whenever an RD obtains express consent, they must document this in the client health record.

Informed consent is required for all treatment unless there is an emergency as defined under the Health Care Consent Act, 1996 (HCCA). There is an emergency if the person for whom the treatment is proposed is apparently experiencing severe suffering or is at risk of sustaining serious bodily harm if the treatment is not administered promptly (HCCA, 1996).  Dietitians would need to consult with their health care team and/or organization’s legal counsel to determine what components of nutrition care, if any, present as an emergency situation for incapable clients under the Health Care Consent Act, 1996. If deemed an emergency, then nutrition treatment can be provided without consent (College of Dietitians of Ontario, Standard of Consent 8 ).

Informed consent can be given for a multi-faceted treatment plan and course of treatment. The HCCA, 1996 specifies that a health care practitioner is entitled to presume that consent includes adjustments to the treatment that are not significantly different from the original treatment. If adjustments are needed during the course of the TPN treatment, the dietitian can use professional judgement to assess whether the expected benefits, risks or side effects of the TPN adjustments (e.g. rate or formula changes) warrant further consent from the baby’s father.    

For more information on obtaining consent in an interprofessional environment, please refer to the Guidelines (Collaborative Care Professional Practice Guidelines) which outline the knowledge and behaviours that a dietitian must demonstrate when working in Collaborative Care Teams and in Collaborative Care environments. In addition, the Standards (Professional Practice Standard: Consent to Treatment and for the Collection, Use and Disclosure of Personal Health Information) outline professional responsibilities to obtain informed consent for nutrition treatment. This video reviews dietitian responsibility to obtain consent in three different collaborative care practice settings.