Informed Consent


REFERENCES: Medicare COP 418.62; JCAHO RI1.1; CHAP CI.4, HII.4a, HII.1e; NHPCO ARE3.2

PURPOSE: To ensure that patient has given informed consent prior to participating in the hospice program and for certain invasive procedures and HIV antibody testing

AFFECTED AREAS: Clinical staff and volunteers


1.       Patients will receive information about hospice services, treatments, or procedures prior to receiving such services, treatments, or procedures. There are three conditions that must be met before a patient’s consent can be considered valid, as follows:

A.    Capacity: Anyone over the age of majority (18) is legally permitted to give consent for medical treatments and procedures, providing he/she has the mental capacity to make choices and understand their consequences. (See policy “Patient Decision-Making Capacity.”)

B.    Information: The patient must receive enough information to make an intelligent decision. The patient should receive information that any reasonable practitioner would disclose under the same or similar circumstances.

C.    Voluntariness: The patient must sign the consent form voluntarily. This should be done without force, fraud, coercion, deceit, duress, or any other form of constraint.

2.    Patients and families are given an explanation of the hospice focus on palliative care during the admission visit and the informed consent form is signed and witnessed by the hospice staff member.

3.    If the patient is in a state that compromises his/her decision-making capability, consent will be obtained from a surrogate decision maker.

4.    The patient/caregiver is involved in the planning of care, including:

        A.    Scheduling of visits

        B.    Determination of care to be delivered

        C.    Personnel who will be involved in care

5.    The patient may refuse all or part of his/her care, to the extent permitted by law, and shall be informed of the potential consequences of such action.

6.    The patient receives information regarding technical procedures, such as:

        A.    The nature and purpose of the procedure

        B.    The expected benefit of the procedure

        C.    Potential problems related to the procedure

        D.    The likelihood of success of the procedure.

8.    The patient participates in decisions regarding changes in his/her plan of care, to the extent possible, and will be informed verbally or in writing of any reduction or cancellation of services at least five days prior to the change.

9.    Specific written informed consent must be obtained before the HIV antibody test may be performed.

A.    A competent adult may be tested only after specific written informed consent has been obtained.

B.    An incompetent patient, who, for whatever reason (comatose, mentally not competent) is unable to comprehend the nature and consequences of the proposed tests, may be tested after obtaining the substitute written consent of an individual with specific legal authority to consent (e.g., parent, guardian, conservator, or holder of a Durable Power of Attorney for Health Care Decisions) or, failing that, from the closest available relative.

C.    Deceased patients may be tested only after obtaining consent from the relative authorized to control disposition of the remains. Consent to autopsy or organ donations in accordance with the Uniform Anatomical Gift Act also authorize such HIV testing. Relatives authorized to control disposition of remains are as follows, in descending order of priority:

(1)  An “Attorney in Fact” appointed under Durable Power of Attorney for Health Care

(2)  The spouse

(3)  An adult son or daughter

(4)  Either parent

(5)  An adult brother or sister

(6)  A guardian or conservator of the descendant at the time of death

(7)  Any other person authorized or under obligation to dispose of the body


1.       Clinical staff performs the following:

A.    Explains the hospice focus on palliative care and the services available

B.    Explains the procedures to be performed and the outcomes expected

C.    Answers questions and concerns of the patient/caregiver

D.    Requests the patient to sign the consent form

E.    Witnesses the signature on the form

2.       Clerical staff performs the following:

A.    Receives and enters the date the forms were received into the tracking system

B.    Files the consent from in the patient’s central file

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