Written Consent and Proper Record Keeping Key for Veterinarians

A recent case before the Health Professions Appeal and Review Board (“Board”), confirming a decision of the Complaints Committee (the “Committee”) of the College of Veterinarians of Ontario, provides guidance for veterinarians and indeed all health professionals regarding the importance of obtaining informed consent and record keeping.

Background

The case involved a complaint regarding the veterinary care provided to the Applicants’ cat, Smokey. The Applicants brought Smokey to the Respondent veterinarian’s clinic with concerns about lethargy and loss of appetite. The vet prescribed an antihistamine and sent Smokey home for monitoring. Smokey’s condition had not improved and the next day, the veterinarian examined Smokey and noted a suspected abdominal mass. The veterinarian, with the assistance of a technician, sedated Smokey and collected blood and urine samples. While Smokey was under sedation, the veterinarian also performed a fine needle aspiration of the abdominal mass for cytological examination.

Unfortunately, Smokey’s condition deteriorated further following this procedure, and he died.

The Applicants complained to the College about the manner in which the veterinarian handled Smokey’s case, and specifically that the veterinarian failed to adhere to obtain informed consent for the procedures and did not tell them about Smokey’s dangerously low platelet values until after the event.

The veterinarian submitted that the Applicants had provided oral consent for all diagnostic tests and the anaesthesia, and that she did not tell the Applicants about the low platelet values because she believed that the test results were inaccurate due to a machine malfunction.

The Committee’s Decision:

The Committee accepted that the veterinarian had the Applicants’ oral consent, but was concerned about the lack of informed written consent before the procedure. The Committee was also concerned about the lack of proper record keeping with regard to the anesthesia protocol and monitoring. Furthermore, the Committee noted that it was the veterinarian’s responsibility to ensure that the equipment at the clinic was in working condition. The Committee decided to advise the veterinarian of its concerns in this regard (but not to impose any other order).

The Review

The Applicants requested a review of the decision.

The Board found that the decision to advise the Respondent of the panel’s concerns regarding obtaining informed consent in writing as required before proceeding with clinical intervention, ensuring that equipment is in working condition and regarding proper record keeping falls within a range of possible acceptable outcomes and was reasonable.

The Board also noted that this situation highlights the importance of a detailed written consent and that it was reasonable for the Committee to have so advised the Respondent.

We note that the veterinarian in this case was not sanctioned for proceeding on the basis of oral rather than written consent, but we also note the Committee’s clear advice (which the Board found to be reasonable) that obtaining written consent before an invasive procedure was recommended in this case. Veterinarians and all health professionals are advised, therefore, to document the consent discussion, either with the aid of a consent form or with a detailed chart note.

Please contact us if you have questions about complaints or other regulatory proceedings.