You have a long-time patient with recurrent low back pain, that flares up from time to time. You have established a good chiropractor-patient relationship and are known to be efficient at relieving pain and improving movement whenever their low back pain flares up. The treatment involves adjustments to the spine and pelvis, accompanied by soft tissue work.
The patient shows up at your office with a flare-up, and you fit her in between two scheduled appointments. The patient has come from work and is wearing a bulky dress with layers around the skirt. The patient is familiar with how you treat their low back pain. With less time than you usually have for patients, you are in a rush and you lift the bottom of the patient’s dress up to contact the pelvis as part of the usual treatment. After treatment, the patient thanks you for accommodating them on short notice and stops at the front desk to make a follow-up appointment.
You are surprised to hear from the College a week later the patient has submitted a complaint against you for unprofessional conduct.
The letter of complaint outlines the patient’s experience of feeling alarmed when their clothing was moved. Their letter describes the patient’s reaction—when you lifted their dress, they froze, feeling both vulnerable and uncomfortable. They lost their voice and did not know how to speak up or how to respond when you lifted their dress.
The patient’s health record has no note of the patient’s consent to examine or treat in the area, to move the clothing or to treat on the skin.
The Conduct in Question
The chiropractor failed to obtain informed consent from the patient.
The chiropractor did not inform the patient of:
- the proposed diagnostic and therapeutic procedures to address their health condition.
- where they would be making contact and why they would be making contact.
- the need to treat directly on the tissue/area.
- the need to shift the clothing and did not discuss alternative ways to shift the clothing.
The patient was not provided the opportunity to provide verbal consent for the proposed diagnostic and therapeutic procedures.
The chiropractor’s performance failure demonstrates the risky practice of implied consent.
Advice to the Profession
Chiropractors must have the patient’s written or verbal informed consent prior to providing chiropractic services, including diagnostic and therapeutic procedures.
Ongoing informed consent dialogue during a visit is typically verbal. The chiropractor educates the patient on what the next procedure is or explains where the chiropractor will touch and why and is open to dialogue with the patient so that the patient is able to voluntarily provide or refuse consent. This dialogue must be noted in the patient health record.
It is a requirement to obtain written informed consent using the appropriate CCOA mandatory informed consent document(s) after making treatment recommendations when a new or changed treatment is offered and accepted by the patient. It is reasonable to provide the documents to the patient to read but not endorse before the chiropractor provides treatment recommendations. Written informed consent is complete when signed and dated by the patient and the practitioner.
Informed consent is a continuous dialogue between the chiropractor and patient during a chiropractic visit. It is foundational to the chiropractor-patient relationship. The performance of competent informed consent is demonstrated with two-part communication exchange between the chiropractor and patient and is documented in the patient’s health record. Informed consent is an essential practice requirement when providing safe, competent and ethical chiropractic care.
Informed consent in patient engagement
Informed consent dialogue must occur each time a chiropractor engages with a patient to deliver chiropractic services. Chiropractors must have the patient’s verbal consent prior to providing chiropractic services, including diagnostic and therapeutic procedures.
When should a chiropractor inform the patient?
Before you provide chiropractic services always inform the patient of:
- what diagnostic or therapeutic procedure you are proposing;
- why you are proposing the diagnostic or therapeutic procedure;
- how you will perform the proposed diagnostic or therapeutic procedure;
- where you will contact the patient when performing the diagnostic or therapeutic procedure;
- when you will contact the patient near the pelvis or breast tissue to perform a diagnostic or therapeutic procedure;
- what clothing you may need to shift to perform the diagnostic or therapeutic procedure; and
- their right to tell you to stop the diagnostic or therapeutic procedure at any time.
When should a chiropractor receive informed consent?
Prior to providing any diagnostic or therapeutic procedure in delivering chiropractic services, the chiropractor must have written or verbal consent from the patient.
When should the chiropractor perform the proposed activity?
Chiropractors should only perform the diagnostic or therapeutic procedure activity after the patient provides consent.
How does the chiropractor demonstrate they received the patient’s consent?
The chiropractor must record the patient’s written or/and verbal informed consent in the patient health record. Without a note of the patient’s consent, there is no evidence of informed consent.
The contrast to informed consent is implied consent. Chiropractors must not rely on implied consent in delivering chiropractic services.
Implied consent results from the chiropractor’s failure to provide appropriate information, and receive the patients consent to receive a diagnostic or therapeutic procedure. Examples of implied consent include:
Record keeping and implied consent
If a chiropractor fails to obtain informed consent before providing a diagnostic or therapeutic procedure, by default they have performed implied consent. Despite good intentions on the part of the chiropractor, implied consent may occur during the delivery of chiropractic services. A comprehensive patient health record of the services provided by the chiropractor would include when the chiropractor demonstrates implied consent.
Informed consent for treatment recommendations
Chiropractors must obtain written informed consent when a new or changed treatment recommendation is made. Treatment recommendations occur when the patient receives a new or changed diagnosis or a new treatment recommendation is proposed.
Patients may raise new health complaints during ongoing patient engagement. The chiropractor must consider the patient complaint, complete a history and examination and provide a diagnosis before making a treatment recommendation.
Competencies in performing informed consent
Competence means the combined knowledge, skills, attitudes and judgment required to provide professional services.
A chiropractor’s competence as a communicator is of utmost importance in performing informed consent in practice.
Applicable Standards and Ethics
In this scenario, please refer to several Standards of Practice and Code of Ethics principles and articles that may apply as noted below. Please also visit Informed Consent to support performance of competent informed consent.
Code of Ethics
The importance of receiving informed consent is reflected throughout the Code of Ethics in both the principles and the articles, which outline the chiropractor’s responsibilities to their patients.
- Principle 1 – Patient Autonomy and Informed Choice
- Principle 2 - Nonmaleficence (do no harm)
- Principle 3 - Beneficence
- Principle 4 - Competence
- Principle 5 – Veracity
- Article A1: Service
- Article A2: Current/Continued Competence
- Article A5: Informed Choice of and Consent for Treatment
- Article A6: Provision of Full and Accurate Information
- Article A13: Disclosure of Potential Conflict of Interest
Standards of Practice (SP)
- SP 3.1 Informed Consent
- SP 3.2 Treatment Recommendations and Referrals
- SP 4.0 Provision of Professional Services
- SP 4.9 Performance, Authorization, Competency and Supervision of Restricted Activities
- SP 5.0 Patient Health Records
- SP 5.1 Record Keeping Requirements
- SP 5.2 Clinical Relevance of Treatment Recommendation