Skip to main content

Table 4 Mandatory notifications about healthcare decisions in lack of competence and/or without a valid informed consent

From: Lack of informed consent for surgical procedures by elderly patients with inability to consent: a retrospective chart review from an academic medical center in Norway

  Legally required notifications in the medical records (Patients’ Rights Act. art. 4–3, 4–6, chapter 4A, and Health Personnel Act article 7) NUMBER OF CHARTS (and a short description of relevant notifications found)
1. Reference to that the decisional competence had been assessed? NONE
2. Reference to the lack of ability to provide consent, such as “lack of competence”, “does not understand what the consent entails” or similar wording? ONE CHART stated “lack competence” but no further notifications or information hereto was included
3. Noted that the conclusion on lack of decisional competence had been presented to the patient? NONE
4. Noted that the conclusion on lack of decisional competence had been presented to the relatives or such other person representing the patient? NONE
5. Documentation of information on patient’s preferences with regards to treatment obtained from relatives or another person representing the patient? NONE
6. Noted information that the physicians admitting, treating and/or the surgeon operating the patient had conferred with a colleague or other competent health care professionals on the assessment of decisional competence and the reasons for the decision that was made? NONE
7. Healthcare provided due to a vital emergency (The Norwegian Health Personnel Act art. 7). One chart stated “vital indication”
8. Healthcare provided with the use of coercion (decision provided according to the Patients´ Rights Act chapter 4A, see Table 5) NONE