SOP 1.3 Patient refusing part of the eye test
Patient refuses part of the Eye Test
A patient’s right to be fully involved in decisions about their care must be respected.
Consent must be obtained before a physical examination, referral, or starting treatment.
Consent can be given verbally, in writing, or implied by their behaviour, for example resting their chin on the chin rest after explaining slit lamp biomicroscopy.
Compliance when the patient does not know what the procedure entails is not consent.
Most tests conducted during an eye test are safe and non-invasive, and implied consent is normally sufficient for these. In the case of drops or applanation tonometry, explicit consent is required after the risks have been discussed.
Professional judgement should be exercised to decide how and when to record consent. This should be based on proportionality, risk, the patient’s needs and circumstances as well as the type or treatment.
Information about the procedure should be explained in a balanced way for any course of action recommended.
Reasonable care must be taken to ensure the patient has understood the material risks of any treatment and has also presented with reasonable alternatives. Material risk depends on the patient’s perception of the risk, what they would consider significant as well as what is significant for the patient. Information should not be withheld for the patient to make a decision. A record of these discussions should be annotated on the patient records.
The patient can withdraw their consent at any part of the examination. If this happens:
The procedure should be stopped immediately, where possible
Find out the patient’s concerns, although they are not required to give their reasons
Establish if this is an expression of anxiety rather than withdrawal of consent
Reassure the patient
Explain the consequences of the incomplete procedure
Alternative methods should be used where possible to elicit the same test result. For example, a patient with family history of glaucoma refuses IOPs using NCT however there is an iCare available in the practice.
Where a patient has refused a particular test or treatment, you must continue to provide other appropriate care to which they have consented.
Should the patient refuse any clinical test outside the test room, team members should remind the patient that the test is an important part of the eye test, but the patient choice is to be respected and the Optometrist should be informed at the handover. Ultimately, it is the responsibility of the Optometrist to explain the importance of any test.
Refusal of any procedure must be clearly documented on the patient record eg Optix, Iclarti or paper) by the Optometrists or DO, detailing:
the patient’s reason(s) for refusal,
any advice or information given for the importance of the procedure by the Optometrist
and the final outcome
Team members should not make notes about refusal on a patient record. The patient should be offered the chance to return and have the procedure completed should they later change their mind.
What if there are health concerns?
If there are any concerns about the patient’s ocular health that are not able to be investigated due to refusal of a procedure, there is a duty of care required to refer the patient for further tests. However, the patient must give permission for referral. This needs to be documented on the patient record. Should the patient refuse referral this should also be documented, and you should raise this with the Safety & Standards Team (SAS@hakimgroup.co.uk) so that we can engage our legal advisors.
Most adults are presumed to have the capacity to consent. You should not forget that just because a patient lacks capacity on one occasion, that they lack capacity to make decisions at all times.
Young people (those aged 16 and 17) and children (those aged under 16) should be involved as much as possible in decisions about their care, even when they are unable to make decisions on their own. For young people, the guidelines for judging capacity to consent follows the same criteria as in adults. Children are not presumed to have capacity to consent – rather, the issue is whether the child can demonstrate their (Gillick) competence. When a decision is made by a child with Gillick competence, it is good practice to involve the child’s carer or guardian by seeking consent from the child. However, that consent cannot be overridden by a person with parental responsibility. If a competent young person or child declines consent for something that you consider is not in their best interests, you should consult colleagues and get legal advice before proceeding.