Informed consent is a foundational principle of veterinary practice, reflecting both ethical obligations to clients and legal duties imposed under New York law. While the doctrine is more extensively developed in human medicine, veterinarians in New York are nonetheless expected to obtain a client’s informed consent prior to undertaking diagnostic or therapeutic procedures, particularly those involving material risk, anesthesia, or significant cost. Failure to receive informed consent prior to treatment may expose a veterinarian to professional discipline or a civil lawsuit.

In New York, while there is not a statute that specifically enumerates what is required for “informed consent,” the Department of Education’s professional practice guidelines require a veterinarian, in the course of providing his or her services, to obtain informed consent. In the veterinarian’s communications with a pet owner, and in “plain English” (i.e., not in “medical jargon”), the veterinarian must clearly explain his or her proposed course of treatment, including what treatment is proposed and the need for the treatment (with a reasonable assessment of the risks and success of such treatment), the alternatives to such treatment, and the cost of the treatment.  While every treatment or procedure contains some level of risk, it is still necessary to explain common risks to the pet owner.

New York does not legally require a signed written consent for veterinary procedures (though, there is currently legislation pending that would require a veterinarian to obtain informed consent prior to any euthanasia of a companion pet); however, it is certainly the best practice to receive a signed written consent from a pet owner especially in circumstances where the recommended and chosen course of action is surgery, use of anesthesia, euthanasia, hospitalization, or an expensive procedure.  A veterinarian should have a written informed consent form in writing and it should include, among other things, the patient’s name and its owner, a description of the procedure or treatment (written in a way that a non-veterinarian can understand), acknowledgement of risks with the procedure or treatment, alternative options, the cost, and should be signed and dated by the patient’s owner. Prior to the written consent being signed, the veterinarian should discuss any of the pet owner’s questions or concerns and should also document such questions or concerns in the written consent (as well as in the patient’s medical record as described below).

In addition to a signed written consent, it is also best practice to keep detailed notes in your patient’s charts. Having a signed written consent does not eliminate the need for proper medical record keeping and, in the worst-case scenario, having both signed written consent and detailed records will best protect you.  In the absence of a signed written consent, and in the event a question ever arises as to whether the patient’s owner had informed consent, your patient’s chart will be the most important piece of evidence.  Thus, it is important to maintain detailed charts that are contemporaneously drafted.  A detailed account of what was discussed should be memorialized in the chart, including any questions the patient owner asked and the response to such questions and whether there were any limitations in the discussion with the pet owner (such as whether there was an emergency). If a patient owner refuses treatment, the veterinarian should also be sure to document such refusal in the chart and, if the veterinarian can, should try to obtain a written refusal.

In emergency situations, where immediate treatment is medically necessary, in the veterinarian’s medical judgment, to prevent death or further injury, and the patient’s owner is unavailable, a veterinarian can proceed without informed consent.  However, the veterinarian must use reasonable efforts to try and contact the owner, limit treatment to what is necessary under the circumstances, and document the emergency and attempts to obtain informed consent.  In the event of any disputes, having detailed documentation will be critical for the veterinarian’s case.

In New York, where the legal framework for informed consent relies heavily on general professional standards, clear and thorough communication is essential to both ethical practice of veterinary medicine and risk management. From a practice standpoint, it is best to develop informed consent forms for common procedures and make client-facing staff aware of informed consent protocols. By implementing consistent consent procedures and maintaining detailed records, veterinarians can protect themselves while providing high-quality, client-centered care.