Guidance for doctors who offer cosmetic interventions

Communication, partnership and teamwork

14

You must communicate clearly and respectfully with patients, listening to their questions and concerns and considering any needs they may have for support to participate effectively in decision making.8 

8
See our Guidance for doctors acting as responsible consultants or clinicians.

Seeking patients' consent

15

You must be familiar with the guidance in Consent: patients and doctors making decisions together. In the following paragraphs, we’ve highlighted key points from the guidance, which are important to protecting patients’ interests in relation to cosmetic interventions.

Responsibility for seeking consent for cosmetic interventions

16

If you are the doctor who will be carrying out the intervention, it is your responsibility to discuss it with the patient and seek their consent – you must not delegate this responsibility. It is essential to a shared understanding of expectations and limitations that consent to a cosmetic intervention is sought by the doctor who will perform it, or supervise its performance by another practitioner.

Responding to requests for cosmetic interventions

17

If a patient requests an intervention, you must follow the guidance in Consent, including consideration of the patient’s medical history. You must ask the patient why they would like to have the intervention and the outcome they hope for, before assessing whether the intervention is appropriate and likely to meet their needs.

18

If you believe the intervention is unlikely to deliver the desired outcome or to be of overall benefit to the patient, you must discuss this with the patient and explain your reasoning. If, after discussion, you still believe the intervention will not be of benefit to the patient, you must not provide it. You should discuss other options available to the patient and respect their right to seek a second opinion.

19

When you discuss interventions and options with a patient, you must consider their vulnerabilities and psychological needs. You must satisfy yourself that the patient’s request for the cosmetic intervention is voluntary.

20

You must explain any monitoring or follow-up care requirements at the outset. You must tell patients if implanted medical devices may need to be removed or replaced and after how long.

21

You must tell prospective patients if alternative interventions are available that could meet their needs with less risk, including from other practitioners.

Discussing side effects, complications and other risks

22

You must give patients clear, accurate information about the risks of the proposed intervention and any associated procedures, including anaesthesia and sedation,9 following the guidance in Consent (paragraphs 28 – 36).

28

Clear, accurate information about the risks of any proposed investigation or treatment, presented in a way patients can understand, can help them make informed decisions. The amount of information about risk that you should share with patients will depend on the individual patient and what they want or need to know. Your discussions with patients should focus on their individual situation and the risk to them.

29

In order to have effective discussions with patients about risk, you must identify the adverse outcomes that may result from the proposed options. This includes the potential outcome of taking no action. Risks can take a number of forms, but will usually be:

  1. side effects
  2. complications
  3. failure of an intervention to achieve the desired aim.

Risks can vary from common but minor side effects, to rare but serious adverse outcomes possibly resulting in permanent disability or death.

30

In assessing the risk to an individual patient, you must consider the nature of the patient’s condition, their general health and other circumstances. These are variable factors that may affect the likelihood of adverse outcomes occurring.

31

You should do your best to understand the patient’s views and preferences about any proposed investigation or treatment, and the adverse outcomes they are most concerned about. You must not make assumptions about a patient’s understanding of risk or the importance they attach to different outcomes. You should discuss these issues with your patient.8 

32

You must tell patients if an investigation or treatment might result in a serious adverse outcome,9 even if the likelihood is very small. You should also tell patients about less serious side effects or complications if they occur frequently, and explain what the patient should do if they experience any of them.

33

You must give information about risk in a balanced way. You should avoid bias, and you should explain the expected benefits as well as the potential burdens and risks of any proposed investigation or treatment.

34

You must use clear, simple and consistent language when discussing risks with patients. You should be aware that patients may understand information about risk differently from you. You should check that the patient understands the terms that you use, particularly when describing the seriousness, frequency and likelihood of an adverse outcome. You should use simple and accurate written information or visual or other aids to explain risk, if they will help the patient to understand.

35

If a patient does not want to know about the possible risks of a proposed investigation or treatment, you must follow the guidance in paragraphs 13 - 17.

36

You must keep up to date with developments in your area of practice, which may affect your knowledge and understanding of the risks associated with the investigations or treatments that you provide.

9

See the Royal College of Anaesthetists’ (accessed 7 March 2016).

23

You must talk to the patient about any adverse outcomes that may result from the proposed intervention, paying particular attention to those the patient is most concerned about.10 You must talk about the potential adverse physical and psychological impact of the intervention going wrong or failing to meet the patient’s expectations. 

10

Medical research involving children (pdf) (Medical Research Council, 2004), Guidelines for the ethical conduct of medical research involving children (Royal College of Paediatrics and Child Health: Ethics Advisory Committee, 2000), Guidelines on the practice of ethics committees in medical research with human participants (Royal College of Physicians, 2007).

Giving patients time for reflection

24

You must give the patient the time and information they need to reach a voluntary and informed decision about whether to go ahead with an intervention.

25

The amount of time patients need for reflection and the amount and type of information they will need depend on several factors. These include the invasiveness, complexity, permanence and risks of the intervention, how many intervention options the patient is considering and how much information they have already considered about a proposed intervention.

26

You must tell the patient they can change their mind at any point.

27

You must consider whether it is necessary to consult the patient’s GP to inform the discussion about benefits and risks. If so, you must seek the patient’s permission and, if they refuse, discuss their reasons for doing so and encourage them to allow you to contact their GP. If the patient is determined not to involve their GP, you must record this in their notes and consider how this affects the balance of risk and benefit and whether you should go ahead with the intervention.

Being clear about fees and charges

28

You must explain your charges clearly, so patients know the financial implications of any decision to proceed to the next stage or to withdraw.

29

You must be clear about what is included in quoted prices and what other charges might be payable, including possible charges for revision or routine follow up.

Treating adult patients who lack capacity

30

If you consider providing an intervention for an adult who lacks capacity to make the decision about whether to go ahead with the intervention, you must follow the advice in paragraphs 62 - 79 of our Consent guidance. The advice in these paragraphs takes account of the legal requirements across the UK that govern decision-making with adults who lack capacity.

62

Making decisions about treatment and care for patients who lack capacity is governed in England and Wales by the Mental Capacity Act 2005, and in Scotland by the Adults with Incapacity (Scotland) Act 2000. The legislation sets out the criteria and procedures to be followed in making decisions when patients lack capacity to make these decisions for themselves. It also grants legal authority to certain people to make decisions on behalf of patients who lack capacity.13 In Northern Ireland, there is currently no relevant primary legislation; and decision-making for patients without capacity is governed by the common law, which requires that decisions must be made in a patient’s best interests.14 There is more information about legislation and case law in the legal annex to this guidance.15 

63

The guidance that follows is consistent with the law across the UK. It is important that you keep up to date with, and comply with, the laws and codes of practice that apply where you work. If you are unsure about how the law applies in a particular situation, you should consult your defence body or professional association, or seek independent legal advice.

64

You must work on the presumption that every adult patient has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment. You must only regard a patient as lacking capacity once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes.

65

You must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision that you disagree with.

66

A patient’s ability to make decisions may depend on the nature and severity of their condition, or the difficulty or complexity of the decision. Some patients will always be able to make simple decisions, but may have difficulty if the decision is complex or involves a number of options. Other patients may be able to make decisions at certain times but not others, because fluctuations in their condition impair their ability to understand, retain or weigh up information, or communicate their wishes.

67

If a patient’s capacity is affected in this way, you must follow the guidance in paragraphs 18–21, taking particular care to give the patient the time and support they need to maximise their ability to make decisions for themselves. For example, you will need to think carefully about the extra support needed by patients with dementia or learning disabilities.

68

You must take all reasonable steps to plan for foreseeable changes in a patient’s capacity to make decisions. This means that you should:

  1. discuss treatment options in a place and at a time when the patient is best able to understand and retain the information
  2. ask the patient if there is anything that would help them remember information, or make it easier to make a decision; such as bringing a relative, partner, friend, carer or advocate to consultations, or having written or audio information about their condition or the proposed investigation or treatment
  3. speak to those close to the patient and to other healthcare staff about the best ways of communicating with the patient, taking account of confidentiality issues.
69

If a patient is likely to have difficulty retaining information, you should offer them a written record of your discussions, detailing what decisions were made and why.

70

You should record any decisions that are made, wherever possible while the patient has capacity to understand and review them. You must bear in mind that advance refusals of treatment may need to be recorded, signed and witnessed.

71

You must assess a patient’s capacity to make a particular decision at the time it needs to be made. You must not assume that because a patient lacks capacity to make a decision on a particular occasion, they lack capacity to make any decisions at all, or will not be able to make similar decisions in the future.

72

You must take account of the advice on assessing capacity in the Codes of Practice that accompany the Mental Capacity Act 2005 and the Adults with Incapacity (Scotland) Act 2000 and other relevant guidance. If your assessment is that the patient’s capacity is borderline, you must be able to show that it is more likely than not that they lack capacity.

73

If your assessment leaves you in doubt about the patient’s capacity to make a decision, you should seek advice from:

  1. nursing staff or others involved in the patient’s care, or those close to the patient, who may be aware of the patient’s usual ability to make decisions and their particular communication needs
  2. colleagues with relevant specialist experience, such as psychiatrists, neurologists, or speech and language therapists.
74

If you are still unsure about the patient’s capacity to make a decision, you must seek legal advice with a view to asking a court to determine capacity.

75

In making decisions about the treatment and care of patients who lack capacity, you must:

  1. make the care of your patient your first concern
  2. treat patients as individuals and respect their dignity
  3. support and encourage patients to be involved, as far as they want to and are able, in decisions about their treatment and care
  4. treat patients with respect and not discriminate against them.
76

You must also consider:

  1. whether the patient’s lack of capacity is temporary or permanent
  2. which options for treatment would provide overall clinical benefit for the patient
  3. which option, including the option not to treat, would be least restrictive of the patient’s future choices
  4. any evidence of the patient’s previously expressed preferences, such as an advance statement or decision16 
  5. the views of anyone the patient asks you to consult, or who has legal authority to make a decision on their behalf,17 or has been appointed to represent them18 
  6. the views of people close to the patient on the patient’s preferences, feelings, beliefs and values, and whether they consider the proposed treatment to be in the patient’s best interests19 
  7. what you and the rest of the healthcare team know about the patient’s wishes, feelings, beliefs and values.
77

You should aim to reach a consensus about a patient’s treatment and care, allowing enough time for discussions with those who have an interest in the patient’s welfare. Sometimes disagreements arise between members of the healthcare team, or between the healthcare team and those close to the patient. It is usually possible to resolve them, for example by involving an independent advocate, consulting a more experienced colleague, holding a case conference, or using local mediation services. You should take into account the different decision-making roles and authority of those you consult, and the legal framework for resolving disagreements.20 

78

If, having taken these steps, there is still significant disagreement, you should seek legal advice on applying to the appropriate court or statutory body for review or for an independent ruling. Patients, those authorised to act for them, and those close to them, should be informed as early as possible of any decision to start such proceedings so that they have the opportunity to participate or be represented.

79

When an emergency arises in a clinical setting21 and it is not possible to find out a patient’s wishes, you can treat them without their consent, provided the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition. The treatment you provide must be the least restrictive of the patient’s future choices. For as long as the patient lacks capacity, you should provide ongoing care on the basis of the guidance in paragraphs 75–76. If the patient regains capacity while in your care, you should tell them what has been done, and why, as soon as they are sufficiently recovered to understand.

31

You must seek and take account of the views of people close to the patient, as well as any information you and the healthcare team may have about the patient’s wishes, feelings, beliefs and values. Your approach to consulting with those close to the patient should follow the advice on sharing information set out in paragraphs 18 - 25 of our Consent guidance.

18

How you discuss a patient’s diagnosis, prognosis and treatment options is often as important as the information itself. You should:

  1. share information in a way that the patient can understand and, whenever possible, in a place and at a time when they are best able to understand and retain it
  2. give information that the patient may find distressing in a considerate way
  3. involve other members of the healthcare team in discussions with the patient, if appropriate6 
  4. give the patient time to reflect, before and after they make a decision, especially if the information is complex or what you are proposing involves significant risks
  5. make sure the patient knows if there is a time limit on making their decision, and who they can contact in the healthcare team if they have any questions or concerns.
19

You should give information to patients in a balanced way. If you recommend a particular treatment or course of action, you should explain your reasons for doing so. But you must not put pressure on a patient to accept your advice.

20

You may need to support your discussions with patients by using written material, or visual or other aids. If you do, you must make sure the material is accurate and up to date.

21

You should check whether the patient needs any additional support to understand information, to communicate their wishes, or to make a decision. You should bear in mind that some barriers to understanding and communication may not be obvious; for example, a patient may have unspoken anxieties, or may be affected by pain or other underlying problems. You must make sure, wherever practical, that arrangements are made to give the patient any necessary support. This might include, for example: using an advocate or interpreter; asking those close to the patient about the patient’s communication needs; or giving the patient a written or audio record of the discussion and any decisions that were made.

22

You should accommodate a patient’s wishes if they want another person, such as a relative, partner, friend, carer or advocate, to be involved in discussions or to help them make decisions. In these circumstances, you should follow the guidance in paragraphs 7 - 21.

23

It is sometimes difficult, because of pressures on your time or the limited resources available, to give patients as much information or support in making decisions as you, or they, would like. To help in this, you should consider the role that other members of the healthcare team might play, and what other sources of information and support are available. These may be, for example, patient information leaflets, advocacy services, expert patient programmes, or support groups for people with specific conditions.

24

You should do your best to make sure that patients with additional needs, such as those with disabilities, have the time and support they need to make a decision. In all cases, you must treat patients fairly and not discriminate against them.

25

If you think that limits on your ability to give patients the time or information they need is seriously compromising their ability to make an informed decision, you should raise your concerns with your employing or contracting authority. See paragraph 25b of Medical practice and the explanatory guidance Raising and acting on concerns about patient safety.7 

Treating children and young people

32

If providing treatment to children, you should be familiar with the detailed advice in 0–18 years: guidance for all doctors, which includes the key points set out in this section of guidance. You should take particular care if you consider providing cosmetic interventions for children or young people – you should make sure the environment for practice is appropriate to paediatric care, and work with multidisciplinary teams that provide expertise in treating children and young people where necessary.

33

You must only provide interventions that are in the best interests12 of the child or young person. If a young person has capacity to decide whether to undergo an intervention, you should still encourage them to involve their parents in making their decision.

12

See paragraphs 12 - 13 of 0–18 years: guidance for all doctors for guidance on assessing best interests.

34

A parent13 can consent to an intervention for a child or young person who does not have the maturity and capacity to make the decision, but you should involve the child in the decision as much as possible. If you judge that the child does not want to have the cosmetic intervention, then you must not perform it.

13

‘Parents’ are people with parental responsibility.

35

Your marketing activities must not target children or young people, through either their content or placement. 

Providing continuity of care

36

You should consider whether you or a colleague will need to review the patient’s response to the intervention and make sure the patient understands whether you recommend a follow-up appointment.

37

You must make sure the patient has the medicines or equipment they need to care for themselves after an intervention.

38

You must make sure that your patients know how to contact you or another named14 suitably-qualified person if they experience complications outside your normal working hours.

14

See our Guidance for doctors acting as responsible consultants or clinicians

39

You should give patients written information that explains the intervention they have received in enough detail to enable another doctor to take over the patient’s care. This should include relevant information about the medicines or devices used. You should also send this information, with the patient’s consent, to their GP, and any other doctors treating them, if it is likely to affect their future healthcare. If the patient objects to the information being sent to their doctor, you must record this in their notes and you will be responsible for providing the patient’s follow-up care.

40

You should organise your records in a way that allows identification of patients who have been treated with a particular device or medicine in the event of product safety concerns or regulatory enquiries.

41

You must keep records that contain personal information about patients securely and in line with:

  1. any data protection law requirements
  2. our Confidentiality: good practice in handling patient information guidance guidance
  3. guidance published by the UK health departments, even when the interventions are provided outside the National Health Service.

Working with colleagues

42

You must make sure that anyone you delegate15 16 care to has the necessary knowledge, skills and training and is appropriately supervised.

15

'Colleagues' include anyone a doctor works with, in and outside their team, whether or not they are also doctors.

16

See our guidance Delegation and referral.

43

You must work effectively with healthcare professionals and others involved in providing care. You must respect the skills of colleagues within multidisciplinary teams and support them to deliver good patient care.

44

You must ask for advice from colleagues if the patient has a health condition that lies outside your field of expertise and that may be relevant to the intervention or the patient’s request.

45

You must make sure you build a support network of experienced professional colleagues who can support and advise you. You should ask for advice when you treat patients who may need psychological or other expert assessment or support.