HDC: Botox consent

Overview

On 5 September 2020, the sole director and owner of a general practice (Dr B) authorised his ‘clinical practice manager’ to assess and administer cosmetic Botox to a new patient. Unfortunately, after a few hours the woman developed side effects, which were probably compounded by anxiety symptoms. Subsequently, she complained to the HDC, because she felt she had not been adequately informed of the procedure’s risks.

Practising cosmetic medicine

All cosmetic procedures (including Botox injections, injectable fillers, chemical peels and platelet-rich plasma) had in the past been carried out under the direction of Dr B. He stated that due to ill health he did not see patients other than in his cosmetic medicine clinic. His Annual Practising Certificate (APC) had expired a month before the incident and has not been reactivated since. Curiously, although the Commissioner made that observation, she did not comment on the fact that he was continuing to write prescriptions for Botox.

The practice did have a policy and procedure document relating to Botox injections, which stated that, “A cosmetic nurse or physician assistant shall be able to assess, consult and treat patients with Botox…” This was essentially a standing order.

The clinical practice manager was in fact a nurse. She was overseas trained and not registered in New Zealand. Like Dr B, she did therefore not have a valid APC, while Dr B plainly thought his standing order covered her under the category of “physician assistant”. The manager minimised her clinical activity, but it was likely that she was carrying out an independent practice under the standing order.

Accessing standing orders

The Commissioner has determined that standing orders should only apply to registered health professionals and in this case, nurses only, and has asked the practice to remove the term “health assistant”. This has implications for other situations where a practice feels that someone other than a registered health professional may be capable of performing a specific clinical task.

The Ministry of Health guidelines do not specifically state who can access a standing order, but they do specifically state the person must have appropriate training and competency. However, there is a New Zealand Society of Cosmetic Medicine, which is apparently the only organisation the Medical Council recognises to train and regulate doctors in cosmetic medicine, and they specify that only appropriately trained doctors or nurses can carry out Botox injections. What are the guidelines around plastic surgeons carrying out these procedures too?

Adequate warnings

Notwithstanding the niceties of APCs and standing orders, this complaint was made because the patient felt she was not adequately warned of the risks of the procedure. Even though the patient signed a consent form, the Commissioner felt it did not give enough information, and the “clinical practice manager” countersigned the document under the heading of “Doctor”.

Obtaining consent for procedures is becoming a much more complicated process, and practices need to be very careful about following the rules. In this particular procedure there is a Medical Council guideline that states that the assessment and the procedure should not be done on the same day so that the patient can carefully reflect on the issue, and consent must be checked again on the day of the procedure.