5 Informed Consent and Client Decisions
Understand how informed consent, decision-making capacity, surrogate authority, and nursing responsibilities support clients’ health care choices.
is a communication process through which a client voluntarily authorizes a specific health care intervention. It protects the client’s right to make decisions about their own care; it is more than signing a form. A valid decision depends on the client receiving and understanding relevant information, having capacity for that choice, and deciding freely without coercion.
The clinician responsible for recommending or providing the intervention explains the relevant information in language the client can understand. This includes the health problem or diagnosis, when known; the intervention’s purpose and what it involves; expected benefits and significant risks and burdens; and reasonable alternatives. Alternatives include declining or postponing treatment and the likely consequences of each option.
Clients may ask questions, refuse a proposed intervention, or withdraw consent. For example, if a client asks about alternatives and says they do not understand a major risk before a procedure, the consent discussion is not complete. The responsible clinician should answer the questions before asking the client to decide.
is specific to both the decision and the time when it is made. It is not an all-or-nothing judgment about a person: a client may be able to make some decisions but not others, and capacity may change with illness, medication, pain, delirium, or other circumstances. A diagnosis, disability, or disagreement with recommended treatment does not by itself establish incapacity.
For the decision at hand, the client should be able to understand relevant information, appreciate how it applies to their situation, compare options in light of their values, and communicate a choice. The responsible qualified clinician assesses capacity according to applicable law and facility policy. Nurses who notice possible confusion or a sudden change in understanding should report it and request reassessment rather than independently treating the client as incapable.
If a client lacks capacity for a specific decision, the care team should identify an appropriate surrogate under applicable law and policy. This may be someone the client named in an advance directive or health care power of attorney, or another legally authorized person. A relative does not automatically have authority, and rules vary by jurisdiction.
The surrogate should use the client’s known wishes, values, and prior statements to make the decision the client would have made; this is . If those wishes cannot reasonably be determined, the surrogate should choose the option that best promotes the client’s well-being, using reasoning and considering likely benefits, harms, burdens, and the client’s values.
The client should still be included and supported to participate as much as their abilities allow. Their expressed preferences or agreement may be relevant even when they cannot provide legal consent. For example, if a client who cannot currently understand a complex treatment decision previously documented a clear preference about it, the surrogate and team should consider that preference rather than substitute the surrogate’s own choice.
The nurse’s role in consent
The nurse supports an informed, voluntary choice while working within professional scope, state law, and facility policy. The clinician responsible for the intervention leads the informed-consent discussion; obtaining a signature does not replace that discussion.
The nurse’s responsibilities include:
Support understanding: Help the client access information in an understandable language and format, arrange qualified interpretation or communication assistance as needed, and reinforce teaching within the nurse’s role.
Check readiness and voluntariness: Ask whether the client has questions, understands what will happen, and feels free to decide. Do not pressure the client to sign or treat a signature as a substitute for discussion.
Pause and escalate concerns: If the client appears confused, raises unanswered questions, expresses uncertainty, refuses, or withdraws consent, notify the responsible clinician and follow policy before the intervention proceeds, except when a lawful emergency exception applies.
Follow documentation and witnessing policy: Document relevant observations and actions. If asked to witness a signature, follow facility policy. Witnessing generally confirms the signing process, not that the nurse personally supplied or verified every element of the clinician’s consent discussion.
Protect the client’s rights: Respect the client’s decision, privacy, and right to have chosen support persons involved. Report concerns about surrogate authority, coercion, or decisions that may not reflect the client’s known wishes through the appropriate chain of communication.
In a true emergency, treatment may sometimes proceed without prior consent when the client cannot decide and an authorized surrogate is unavailable. This is a limited exception governed by law and policy. The team should seek consent for ongoing care as soon as possible.