2 Patient Communication and Consent

Start with clear communication

Before collecting a specimen, explain what you plan to do, check that the patient is willing, and give them an opportunity to ask questions. Respectful communication supports informed, voluntary participation and helps prevent misunderstandings.

Introduce yourself and use the patient's preferred name. Explain the procedure in plain language, within your role and based on the information available to you.

Explain what to expect

Explain what you will collect and why, what will happen, what the patient may feel, and what you need the patient to do. For a blood collection, you might explain that you will clean the skin, place a needle in a vein, collect blood into tubes, remove the needle, and cover the site. The patient may feel a brief pinch or pressure; some people feel dizzy or faint. Mention relevant common risks, such as bruising, and follow workplace guidance about which risks to explain.

Ask the patient to follow any needed instructions, such as keeping their arm still and telling you if they feel unwell. Avoid unexplained technical terms, rushing, and promising that the procedure will be painless. If asked something outside your role, do not guess; offer to contact the appropriate clinician.

For example: “I’m here to collect a blood sample that was ordered for your care. I’ll clean your skin, place a small needle in a vein, fill the collection tubes, and cover the site. You may feel a brief pinch. Is there anything you’d like me to explain before we begin?”

Check understanding respectfully

Pause for questions and answer honestly. Invite questions without pressure. Teach-back can help you check whether your explanation was clear: “Just so I know I explained it well, could you tell me what you can expect?” If the patient is unsure, explain the information differently and check again. Teach-back is not a test of the patient.

Support informed, voluntary consent

Informed consent is an ongoing conversation, not merely a signature. The patient should have enough understandable information to decide and should be free to agree or decline without coercion. Follow your organization's procedures for the type of collection and any required documentation.

Ask permission before proceeding, for example: “Would you like me to go ahead?” Do not treat silence, the patient's presence, or a family member's agreement as the patient's consent when the patient can communicate their own choice. Respect the patient's privacy and preferences where practical.

Address communication barriers

Arrange appropriate help before proceeding when there are language or communication barriers. Use a qualified medical interpreter for important discussions when needed, and speak to the patient rather than only to the interpreter. Do not rely on a child or an unqualified companion to interpret.

Provide appropriate communication accommodations for patients who are deaf, hard of hearing, or have other communication needs.

Respond to refusal or withdrawal

A patient may refuse before a procedure or change their mind at any point. If the patient refuses or asks you to stop:

1. Stop or do not begin. If collection is underway, withdraw safely as soon as it is safe to do so and attend to the patient.

2. Listen calmly. Do not argue, threaten, shame, or repeatedly pressure the patient. Ask whether they would like to share a concern or hear more information, and accept their answer.

3. Explain the next step within your role, such as notifying the ordering clinician or supervisor. Do not promise that refusal will have no consequences; explain that the clinician can discuss possible effects of delaying or declining the test.

4. Document and report the refusal or withdrawal, what occurred, and whom you notified, according to workplace policy.

Patients have a right to participate in their care and, where applicable, to refuse it.

Know when to pause and escalate

Do not proceed; seek guidance from the appropriate clinician or supervisor if the patient does not appear to understand after a clear explanation, cannot communicate a voluntary choice, is significantly distressed or impaired, disputes the order or purpose, or raises a clinical concern you cannot answer.

Also escalate uncertainty about who may provide consent, including questions involving a minor or a representative. Do not make your own legal determination of decision-making capacity or substitute consent; follow local law and institutional policy. If there is an immediate safety concern, follow emergency procedures.