Patient Consent Form - Treatment (Hawaii)

PATIENT CONSENT TO TREATMENT

(Hawaii – Statutory Informed Consent Form)

I. PURPOSE AND STATUTORY BASIS

This form documents the informed consent process required by HRS § 671-3 and the standards adopted by the Hawaii Medical Board. Under HRS § 671-3(b), the clinician must provide the Patient (or the Patient's guardian or legal surrogate) with the following information in language the Patient can understand:

1. The condition to be treated;
2. A description of the proposed treatment or procedure;
3. The intended and anticipated results of the proposed treatment;
4. Recognized alternative treatments or procedures, including the option of no treatment;
5. The recognized material risks of serious complications, injury, or mortality associated with the proposed treatment and with each recognized alternative;
6. The recognized benefits of each recognized alternative treatment; and
7. The recovery process to be expected, including the recognized serious possible side effects.

Per Bernard v. Char, 79 Haw. 362 (1995) and Carr v. Strode, 79 Haw. 475 (1995), Hawaii applies a patient-oriented (materiality) standard for the scope of disclosure and an objective causation standard (would a reasonable person in the patient's position, with the patient's particular fears, age, medical condition, and beliefs, have consented if properly informed). A signed consent form does not substitute for the clinician's affirmative duty to inform.

II. DEFINITIONS

• "Capacity" means the ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health-care decision (HRS § 327E-2).
• "Surrogate" means an adult authorized under HRS ch. 327E to make health-care decisions for a Patient who lacks capacity.
• "Material Risk" means a risk that a reasonable person in the Patient's position would consider significant in deciding whether to undergo the proposed treatment.
• "Emergency" means a circumstance in which obtaining consent is not reasonably feasible without adversely affecting the Patient's health (HRS § 671-3(d) exception).

III. INFORMATION DISCLOSED TO PATIENT

A. Patient's Condition / Diagnosis

[DESCRIBE CURRENT CONDITION OR WORKING DIAGNOSIS IN PLAIN LANGUAGE]

B. Proposed Treatment / Procedure

[DESCRIBE PROCEDURE, INCLUDING ANATOMIC SITE, ANESTHESIA, AND DURATION]

C. Intended Benefits / Anticipated Results

[DESCRIBE EXPECTED CLINICAL OUTCOME]

D. Material Risks Disclosed

E. Recognized Alternatives (HRS § 671-3(b)(4))

☐ Alternative 1: [DESCRIBE] — Benefits: [____]; Risks: [____]
☐ Alternative 2: [DESCRIBE] — Benefits: [____]; Risks: [____]
☐ No treatment / watchful waiting — Likely course if untreated: [____]

F. Recovery Process and Expected Side Effects

[DESCRIBE EXPECTED RECOVERY TIMELINE, ACTIVITY RESTRICTIONS, AND COMMON SIDE EFFECTS]

IV. PATIENT ACKNOWLEDGMENTS

The Patient (or Representative) initials each item:

• [____] I have been told my diagnosis or condition.
• [____] The proposed treatment has been explained to me.
• [____] I have been told the recognized material risks, including the risk of serious complications and death where applicable.
• [____] I have been told the recognized alternatives, including the option of no treatment.
• [____] I have been told the expected benefits and recovery process.
• [____] I had the opportunity to ask questions and all my questions were answered to my satisfaction.
• [____] I have not been promised or guaranteed any particular result.
• [____] I understand that medicine is not an exact science and outcomes cannot be guaranteed.

V. SCOPE OF CONSENT

☐ I consent to the procedure described in Section III.B above, performed by the Treating Clinician identified in the header.

☐ I consent to such additional or different procedures as the Treating Clinician determines are advisable during the operation/procedure based on findings encountered, except the following, to which I do not consent:
[___________________________________________]

☐ I consent to participation by residents, fellows, students, and qualified assistants under the supervision of the Treating Clinician.

☐ I consent to administration of anesthesia as recommended (separate anesthesia consent attached, if applicable).

☐ I consent to the use, disposal, or retention of removed tissue/specimens for diagnostic purposes and, as permitted by law, for research/teaching:
☐ Yes ☐ No

☐ I consent to photography/video for medical record, education, or quality-assurance purposes (de-identified):
☐ Yes ☐ No

VI. CAPACITY, SURROGATE, AND ADVANCE DIRECTIVES (HRS ch. 327E)

VII. MINOR PATIENTS (Hawaii Statutory Framework)

Default rule: A parent or legal guardian must consent for a minor under 18 (general parental consent at common law, codified in various Hawaii provisions including HRS ch. 577).

Statutory exceptions allowing the minor to consent on the same basis as an adult:

• ☐ Minor is married or has been married — emancipated for medical consent purposes.
• ☐ Minor is a parent consenting for self or own child.
• ☐ HRS ch. 577A — Female minor age 14–17 who is or professes to be pregnant; minor seeking family planning services; minor with sexually transmitted infection. Minor may consent to medical care and services on same basis as an adult.
• ☐ HRS § 577-26 — Minor who is or professes to suffer from alcohol or drug abuse may consent to substance-abuse counseling services.
• ☐ HRS § 577-29 — Minor age 14 or older may consent to mental health treatment or counseling by a licensed mental health professional, where the professional determines the minor is mature enough; parental consent still required to prescribe medication or place into out-of-home/residential treatment.
• ☐ HRS ch. 577D — "Minor without support" age 14–17 may consent to primary medical care services.
• ☐ Emergency under HRS § 671-3(d) where consent not reasonably feasible.

VIII. RIGHT TO REFUSE OR WITHDRAW CONSENT

The Patient has the right to refuse any treatment and to withdraw this consent at any time before the treatment is rendered. Withdrawal will not affect the Patient's right to other care. Refusal of recommended treatment may be documented on a separate Against-Medical-Advice form.

IX. INTERPRETER / LANGUAGE ACCESS

The Patient confirms the consent discussion was conducted in a language the Patient understands.

X. CLINICIAN ATTESTATION

I, the undersigned Treating Clinician, attest that I personally provided the disclosures required by HRS § 671-3 and the Hawaii Medical Board standards, answered the Patient's questions, and confirmed the Patient's (or Representative's) understanding before obtaining the signature below.

XI. PATIENT / REPRESENTATIVE SIGNATURE

XII. SOURCES AND REFERENCES

• HRS § 671-3 — https://www.capitol.hawaii.gov/hrscurrent/vol13_ch0601-0676/HRS0671/HRS_0671-0003.htm
• HRS ch. 327E (Uniform Health-Care Decisions Act)
• HRS ch. 577, 577A, 577D — Minor consent provisions
• Bernard v. Char, 79 Haw. 362, 903 P.2d 667 (1995)
• Carr v. Strode, 79 Haw. 475, 904 P.2d 489 (1995)
• Hawaii Medical Board, Informed Consent Standards (HAR ch. 16-85, as amended)