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The College of Audiologists & Speech Language Pathologists of OntarioExcellent document, very thorough. My only concern is as follows:
Page 5 line 94
The document states “Physicians are entitled to presume that a patient is capable”. This could be misleading, it could be interpreted that they are also entitled not to presume that a patient is capable. The HCCA is unequivocal:
A person is presumed to be capable with respect to treatment, admission to a care facility and personal assistance services. 1996, c. 2, Sched. A, s. 4 (2).
I have had recurrent, recent and highly relevant experience regarding informed consent. While I am a member of ICRC it is actually in practice that I have observed repeated violations of the proposed and existing policies. The problem is most apparent in the presence of acute mental illness, delirium etc.
I agree completely. It happens all the time, it has happened to me, and it is so refreshing to finally see a member of the medical profession act with some integrity and admit it.
1) Lines 46-47 regarding use of interpreters says “Physicians may consider using family members instead of third-party interpreters; however, physicians are advised to take the potential limitations of doing so into account.” This deserves a stronger recommendation against using family members as interpreters unless there are compelling reasons to do so. The policy clearly outlines all the problems with using family that can completely invalidate the consent process.
2) Lines 84-85 says, “If the patient is capable with respect to a treatment, the physician must obtain consent from the patient directly.” This should be qualified that a patient who is capable has the right to defer decision making to a family member, so there are unique circumstances in which it is appropriate to obtain consent from a SDM despite the patient being capable. This is often, but not always, due to cultural considerations.
Excellent document. We have come a long way in the generation or so since a hospital wanted me to sign a consent to “any medical, surgical or dental procedure” before it would treat my child. When I stroked through this and wrote something related to the specific illness, I was handed a big red card saying “Withhold treatment” to give to the nurses. Fortunately, it was all a sham and nothing was withheld.
I have slight concerns that the language about 1. the best interests of the patient and 2. the detail of description of the treatment.
Both of these seem to leave room for the doctor to rely on his or her judgement of these matters, rather than the patient’s — recognizing that patients or their caregivers, particularly in extremis, may make demands for promises about outcomes that are beyond the doctor’s mortal wisdom to give.
The policy should speak more clearly to the issue of when consent is implied. If ‘treatment’ is defined as virtually everything we do, then the vast majority of activities might require consent, implied or otherwise. Does placement of a catheter in a patient in retention require specific consent? What if cystoscopy is needed because the catheterization is difficult? The policy should also speak to the issue of when a written acknowledgement of consent is needed (commonly and mistakenly referred to as ‘the consent’).
Can someone tell me why dentists don’t get written consents?
In this Draft Policy I noticed a comment about Ending the Physician Patient Relationship, and I followed that up by reading the CPSO guidelines on that issue.
I don’t agree with the paragraph regarding it not being appropriate to end a relationship because the patient does ‘not follow the physician’s advice’ regarding treatment.
I think that this does not apply at all to Psychotherapy, where although ‘advice’ per se is not given, but co-operation with the therapist’s approach is vital, and if that is not present the therapist should feel free to say “I am not the best doctor for you.”
If that was not considered when this policy was drawn up then I think that might have been because psychotherapeutic input was not asked for.
That part should be revised to indicate that psychotherapy may be an exception to the general guideline.
Consent forms are usually used when carrying out procedures. In fact, I think it just as important that an informed consent be obtained each time a patient is prescribed a long term (lifelong) medication and each time they are exposed to medical radiation (CT, nuclear). These have serious implications which are additive over time and likely of more personal impact than a single procedure such as a cholecystectomy. It also emphasizes the importance of the treatment intervention in the eyes of the physician. Patients should be given a copy of the consent form on which they can make notes at the time of the explanation.
I am presently confused about the need for ‘expressed’ or written consent for procedures and so on. Therefore, any attempt to clarify this matter meets with my approval. That said, a blanket statement requiring ‘written consent’ in all cases seems to me excessive.
Delegation of consent to a non-physician who is a regulated health professional may only be a verification of proposed treatment, not informed consent. Perhaps delegation should be removed from the policy?
What aspects or requirements are recommended for office practice where consultation and suggested treatment options are explored with the patient. Should each doctor in each office have a consent form for every patient visit?
How important is a consent form ? Obviously, a form for each encounter not practical—nor likely anticipated from CPSO paper
Yes, they should. I was recently coerced by a physician into taking a medication I did not wish to take because she decided, if I wouldn’t comply, she would limit my access to my other medications (those which I needed to treat a different health condition).
If she had had to obtain my written consent for the new med, I would have been able to refuse more easily. Although I complained verbally and repeatedly, the doctor is the only one who is able to put anything down in writing. Needless to say, my medical notes contain no mention of her coercion or my complaints.
Doctors routinely refuse to follow appropriate policies around consent because they falsely assume that they know what is best for the health of other competent adults. The College never disciplines physicians who don’t obtain proper consent (heck, you don’t discipline physicians at all), so what’s the point of having a policy in the first place??? It’s just a charade unless you enforce it…and you don’t.
A miniscule percentage (3%) of complaints forwarded to the College ever end up before your Disciplinary Committee, and the results of all others are kept secret from the public and involve no real sanction. How exactly is your present system supposed to function as a deterrent to doctors who indulge in the type of behaviour I experienced at the hands of my unethical physician?
Influence of narcotics (oral and parenteral) as well as physician administered sedatives, prior to the consent process. Is this still informed?
“Informed consent” can be problematic in many situations,where the patient may not be able to process information (when properly presented) such as sleep deprivation, medical condition + potential effect on Cognition, psycho-active medications (Prescribed or OTC, THC, etc. JM
Regarding the use of third-party interpreters when a language barrier exists: I work in a hospital where there are resources to provide timely interpreters, but what do Physicians working in small clinics or private offices do to be compliant with so many languages used in Canada today?
Please see attached PDF with my comments.
I fully agree on the provisions of this draft policy because in order to save a life a trained physician and surgeon must do everything to effectively execute it without fear we Canadians valued our statutory right that we forget that there is a right higher than that which is the right to life or the right to continue to live we have a lot of whimsical apprehension about the right of physicians and doctors to administer cures that go against our beliefs. These doctors did not spend time and money going to school if they do not know what is good for you do not presumed that you are better than them in knowing what is good treatment for you and you If this draft policy won’t be approved let us just dissolve this organization and just be to each own in curing once self we are a bunch of hypocrites that tends to know we are better than the doctors if that is the case never go with them if you have issues just do it yourself
Good as is
Doctors must be truthful and give patients their full and honest opinion with no pressure to consent. The patient must have full knowledge of the treatment proposed in order to consent to it. Respect on both sides is essential.
Office of the Information and Privacy Commissioner of OntarioResponse in PDF format.
Human beings possess an inherited quality called conscience regardless of cultural, creed or race. Their conscience can be shaped by these factors but are not the fundamental source of their conscience. To deny physicians of this existential and fundamental human right is an assault and a trampling on their fundamental human right. Forcing this policy on physicians compromises their integrity and convictions. who wants a doctor who does not live by his convictions even if these are against the social public opinion of du jour.
Please take into consideration this appeal of not forcing this on physicians as they are precious and deeply appreciated.
Professional Association of Residents of OntarioResponse in PDF format.
Implied consent is inferred from the words or behaviour of the patient, or surrounding
224 circumstances, such that a reasonable person would believe that consent has been given,
225 although no direct, explicit, and unequivocal words of agreement have been given. This is a big legal loophole with implied consent. I would want to make sure that I brought legal papers with me before I entered the hospital. Implied can be very misleading as cognitive science has shown. Both for the patient who is under stress and the observer. If it is implied there should be more than one consensus.
This update of previous CPSO Consent to Treatment policy is generally helpful, particularly the summary table on page 4 and the specific recommendations on what to document on page 11.
Lines 244-8 outline new requirements for situations mandating written documentation in the medical record. Additional specific guidance from the CPSO would be welcome for procedures that are often proposed and carried out in acute care situations, such as those in the intensive care unit where I work. Examples include central venous cannulation, arterial line insertion, endotracheal intubation, bronchoscopy, and chest drain insertion. It is not clear to me whether this policy would mandate written consent for these procedures. In any case, sometimes they must be performed emergently, in which case the relevant section of HCCA applies. At many other times, however, these procedures are urgent but not truly emergent. Obtaining separate and specific consent for each procedure from the SDM (as the patient is often incapable of decision-making due to acute severe illness) at a stressful time for the patient and SDM has the potential to delay life-saving care and turn urgent situations into emergent situations. In my experience, SDMs who have consented to ICU admission for their loved ones, as proposed by the intensivist, generally want a brief overview of short-term anticipated treatments, and then want the physicians to get on with conducting urgent procedures and implementing these treatments. SDMs are generally happy to hear about the details of the procedures and treatments later, after initial stabilization.
Considering any procedure (not just ICU prodecures), although there are elements of risk and benefit specific to individual patients, many risks are common. Provincially or nationally available consent forms detaining material risks and benefits for common procedures, with space to individualize them as needed, would likely improve patient understanding (see for example Ann R Coll Surg Engl 2010 Apr;92:246-9) and meet the requirements of the CPSO policy and of the HCCA. Although I assume that it is not the CPSO’s role to create such forms, advocacy could be helpful.
ARCH Disability Law CentreResponse in PDF format.
Advocay Centre for the ElderlyResponse in PDF format.
Mental Health Legal Committee (MHLC)Response in PDF format.
College of Physicians and Surgeons of AlbertaResponse in PDF format.
College of Physicians and Surgeons of SaskatchewanWe found this draft policy to be comprehensive and very clearly written. No suggestions for change.
Critical Care Medicine - OMA SectionThank you for allowing us to submit feedback on the CPSO’s Draft Policy on Consent to Treatment from the Section on Critical Care Medicine of the Ontario Medical Association. We hope the committee will consider this feedback when reviewing the draft policy and make the changes necessary to guide physicians who practice in the specialty of critical care medicine.
The HCCA defines “treatment” as including a “course of treatment” and/or “plan of treatment.”
The HCCA also indicates that consent to treatment may be express or implied.
We believe that by consenting to admission to the intensive care unit the patient/SDM is also consenting to an intensive care unit “course of treatment” or “plan of treatment.”
The patient or SDM is providing express (if possible) or implied consent to the various common treatments provided to the majority of critically ill patients.
The list of common treatments provided to these patients can include (but is not limited to) the following treatments:
1. Endotracheal intubation
2. Naso-/Oro- gastric tube insertion
3. Arterial Line insertion
4. Central venous catheter insertion
In isolation, each of the above procedures can be considered a separate treatment. However, in the care of the critically ill patient, they are standard, nearly universal treatments the majority of critically ill patients require as part of an intensive care unit plan of treatment.
Lines 244-48 lists the criteria which, if met, require the physician to document in the patient’s record information regarding consent to treatment.
Having to obtain and document consent for each individual component of treatment which comprises a standard intensive care unit plan of treatment would be unnecessarily onerous and will lead to delays in the provision of urgent treatment where the “emergency treatment” definition does not yet apply. In such situations, delaying urgent (yet non-emergent) treatment to find an SDM to obtain consent will place the patients in danger.
Please consider the following areas where we are seek guidance:
1. Please confirm that we are making a reasonable assumption by concluding that consenting to admission to the intensive care unit is equivalent to consenting to an intensive care unit plan of treatment.
2. Since the intensive care unit plan of treatment (in and of itself) meets the criteria for documenting consent (all patients will have ablation of at least one bodily function), is the intensive care unit plan of treatment the only treatment which requires consent? If so, would one still have to obtain consent for the standard component treatments of an intensive care unit treatment plan (see sample list of five treatments above)?
Example: When a surgeon consents a patient to receive a bowel resection – he/she consents the patient to the entire plan of treatment. The patient is not asked to consent to (and the surgeon is not required to document separately) each component of the plan of treatment such as, incising the skin, retracting the fascia, removing the bowel, re-connecting the bowel etc. We see the intensive care unit plan of treatment similarly. There are standard treatments embedded within this plan which are necessary to perform on the patient to execute the overall treatment plan effectively.
To assist in the process of revising the draft policy we offer the following:
1. If the College accepts our conclusion that consenting to admission to the intensive care unit is equivalent to consenting to an intensive care unit plan of treatment, we are happy to provide the College with representatives from the critical care community to help define the standard components of such a plan.
2. We also offer the following friendly addendum to the existing draft policy:
‘ The College recognizes that provision of high quality urgent or emergent care for critical or life threatening conditions may require multiple urgent procedural interventions over a short period of time, and that care in specialized units is often positioned, accepted and provided as a package or plan of treatment. The College endorses physicians’ use of their judgment as to how much discussion and documentation is reasonably feasible in proximity to interventions short of major surgical procedures in such care settings. The College supports positioning and viewing acceptance of admission to a special care unit as encompassing all medically necessary and appropriate percutaneous procedures and drug therapy to provide optimal care in such settings, where the situation may render prolonged discussion and documentation impractical and/or unsafe.’
Thanks you for considering our feedback.
Interdepartmental Division of Critical Care Medicine - University of TorontoResponse in PDF format.