Presentation on theme: "LMCC Part 1 preparation Tabitha Rogers MD, MSW PGY 2 Psychiatry"— Presentation transcript:
1LMCC Part 1 preparation Tabitha Rogers MD, MSW PGY 2 Psychiatry Consent and CapacityLMCC Part 1 preparationTabitha Rogers MD, MSWPGY 2 Psychiatry
2Objectives To review the different types of consent. To review the criteria for informed consent.To discuss the roles of the:Health Care and Consent ActSubstitute Decisions Makers ActMental Health ActTo discuss the role of Substitute decision makers and Power of Attorneys
3Types of Consent Implied Expressed: oral or written It should be obtained when the treatment is likely to bemore than mildly painful, when it carries appreciable risk,or when it will result in ablation of a bodily function.
4You are going to remove someone’s appendix what type of consent should you get? Implied or Expressed
5A mother brings her two year old daughter to you for her annual check-up. What type of consent do you get?Implied or Expressed
6Elements of Consent Consent must relate to the treatment Consent must be informedConsent must be given voluntarilyConsent must not be obtained through misrepresentation or fraud.
7Elements of Consent Consent must relate to the treatment Consent must be informedThis implies that the person giving consent must be CAPABLE of giving consent.Consent must be given voluntarilyConsent must not be obtained through misrepresentation or fraud.
8Requirements for Informed Consent The patient must have been properly informed.The patient must have the capacity to consentThe patient must be able to understand the nature and anticipated effect of proposed medical treatment and alternatives, and to appreciate the consequences of refusing treatment.
9Presumption of Capacity The patient is presumed to be capable with respect to treatmentThere is no age of capacity in Ontario.Health practitioners may rely on the presumption of capacity unless they have reasonable grounds to believe that a person is incapable with respect to the treatment.
10Who is capableA person is capable with respect to a treatment if the person is:able to understand the information that is relevant to making a decision about the treatment, ANDable to appreciate the reasonably foreseeable consequences of a decision or lack of decision
11Evaluating CapacityCapacity depends on treatment A person may be incapable with respect to one treatment and capable with respect to another. Capacity depends on time A person may be incapable at one time and capable at another.
12Who assesses capacity for treatment? The health practitioner proposing the treatment must assess whether the individual is capable of giving consent
13Elements of Consent Consent must relate to the treatment Consent must be informedConsent must be given voluntarilyConsent must not be obtained through misrepresentation or fraud.
14A consent is informed if the patient receives the information that a reasonable person in the same circumstances would require about:The nature of the treatmentThe expected benefitsMaterial risks & side effectsAlternative courses of actionThe likely consequences of not having the treatment
15CaseSara is 14 and has come to your clinic requesting the birth control pill. What do you do?
16Age of ConsentOnly in the province of Quebec has an established age of 14 years been assigned to Capacity to Consent. Below which consent of the parent /guardian or the court is necessary for the purposes of treatment.All other provinces rely on the maturity of the individual in assessing capacity to consent to treatment.
17CaseDanny is a 37 y.o. man who is developmentally delayed and lives in a group home. He has come to you as his family doctor and you discover he has pneumonia and you prescribe an antibiotic. One week later the radiologist suggests that there is a tumor in the RLL on the CXR. You suggest to Danny he needs a biopsy and possible treatment. Danny says he doesn’t like needles and says he won’t have the biopsy.
19Evaluating CapacityCapacity depends on treatment A person may be incapable with respect to one treatment and capable with respect to another.
20Danny has been on antibiotics before and he knows that they treat a “bug” in his lungs and he will feel better. He also knows that antibiotics can cause his tummy to feel bad, and that sometimes they make him “poop” too much. He knows that if he doesn’t take the antibiotics he won’t feel better and he may get worse.
21Danny does not understand what a biopsy means and what a tumor is Danny does not understand what a biopsy means and what a tumor is. Despite your attempts to educate Danny about these issues, he is still unable to understand and appreciate the nature of his illness.You now need to find an alternative decision maker(we will talk about this a little later)
22Which Act describes Informed Consent Health Care and Consent ActSubstitute Decisions ActMental Health ActPersonal Health Information Protection Act
23Which Act describes Informed Consent Health Care and Consent ActSubstitute Decisions ActMental Health ActPersonal Health Information Protection Act
24In what area can you treat a patient without informed consent?
25In what area can you treat a patient without informed consent? Emergency Situation
26Emergency treatmentThe general rule is that consent must always be obtainedbefore any treatment is administered, there is animportant exception. In cases of medical emergencywhen the patient (or substitute decision maker) is unableto consent, a physician has the duty to do what isimmediately necessary without consent.For the physician to declare any clinical situation anemergency in which consent is not required, there must bedemonstrable severe suffering or an imminent threat to thelife or health of the patient.
27Competency vs Capacity Competency suggests all or nothing.Capacity implies varying levels of ability on a variety of decision making tasksThe primary issue in evaluating capacity to make a choice should be the process of making the decision and not the decisions itself.
28What happens if you treat a patient without Consent?
30What do you do when the patient cannot provide consent? Consider:Substitute Decision Maker (SDM)vs.Power of Attorney (POA)
31Who is the SDMThe law chooses the substitute decision-maker (Health Care Consent Act)– the health care provider identifies them.
32Who is the SDM A Court appointed Guardian of the person Power of AttorneySpouse/PartnerParent/childSiblingAny other relative by blood, marriage or adoptionThe Public Guardian and Trustee if:There is no one else for the job, ORNo one else wants the job, ORTwo or more potential substitutes of the equal (and highest) ranking claim the job but disagree as to the decision
33Power of AttorneyA Power of Attorney (POA) is a written document. In it you give someone the authority to act for you in relation to your property, financial affairs and/or personal care.
34Who is the SDM A Court appointed Guardian of the person Power of AttorneySpouse/PartnerParent/childSiblingAny other relative by blood, marriage or adoptionThe Public Guardian and Trustee if:There is no one else for the job, ORNo one else wants the job, ORTwo or more potential substitutes of the equal (and highest) ranking claim the job but disagree as to the decision
35Substitute decision-makers must follow a strict set of rules that tell them how to make decisions. They are to make decisions in the best interests of the patient and that are in keeping with the patient’s prior wishes.
36Prior wishes if expressed when the person was at least 16. if it is the person’s most recent capable wish.if it is relevant in the circumstances.if it is not impossible to comply withWishes may be written/verbal/expressed inany other manner.
37CaseElsie is a 72 y.o. Woman with long standing history of recurrent Major Depression. She has become depressed over the past 6 months and she has been admitted to hospital as she is now catatonic. The treating psychiatrist feels Elsie should receive a course of ECT and he has asked the SDM to provide consent.
38Elsie is widowed, and she has no children Elsie is widowed, and she has no children. Her brother Ed is living in Toronto, and her sister Martha is in LTC and is suffering from Dementia. Her Nephew Phil lives in Ottawa.Who do you ask to make treatment decisions?
39Elsie has told her brother in the past that she would never have ECT Elsie has told her brother in the past that she would never have ECT. She did not like the idea of Shock Treatments and she believed they caused the death of her mother Mildred.
41We know that: Consent must be Informed A SDM or POA can make decisions on a person’s behalf if they are incapable of consenting.The SDM or POA must respect a person’s prior wishes whether written or not.
42CaseBill is a 54 y.o. Unemployed gentleman who is living on the street and has an addiction to Alcohol. He comes to the ER with an alcohol level of 68 mmol/L. He is known to have Hepatitis C and his liver functions and worsening with an increase in his enzymes and INR.He is refusing all treatment and after he sobers up, he wants to leave the ER.
47If you believe Bill has a Mental Illness that requires further assessment you can complete a Form 1. Can you treat Bill if he refuses to take medication?
48ConclusionsConsent must be made by a capable person who is informed about the treatment.Consent is specific to the treatment.If the person cannot consent then you look for a SDM or a POA.On deciding on an SDM, you must follow the hierarchy of decision makers listed in theSubstitute Decisions Act.A Form 1, 3, or 4 does not allow you to treat a person against their will.Remember Hippocrates: Do no harm.
49Conclusion Health Care and Consent Act Consent Substitute Decisions Act SDM or POAMental Health Act Form 1, 2, 3, 4 etc...