Toronto Public Health
Hello,
The survey was submitted yesterday however I received some additional feedback I thought might be helpful to send forward. Apologies for the delay.
Expectations are clearly written for physicians in a concise format
The use of case scenarios are practical and help guide decision making within the context of the policy
For the Consent to Treatment Policy, on line 64-66, it is stated that "Physicians must use their professional judgment to determine whether it is appropriate to use family members as interpreters and only do so where it is in the patient’s best interests", but in the Advice to Profession Document from line 22-30 "In many cases, using a family member as an interpreter will be the most accessible, convenient, practical, and comfortable option for patients. At the same time, using family members as interpreters can present challenges, such as language limitations, difficulty understanding medical terms, inter-family dynamics and conflict, and important information being deliberately or accidentally omitted. As a result, and where the patient is in agreement, physicians are advised to use a formal or third-party interpretation service where available. The Policy and Advise to Profession is not aligned in regards to their messaging regarding use of family members for interpretation and may cause confusion.
On line 71-73 "5. Where a patient is incapable with respect to a treatment, physicians must, where possible, inform the incapable patient that an SDM will assist them in understanding the proposed treatment and will be responsible for the final decision." --> "5. Where a patient is incapable of consent with respect to a treatment, physicians must, where possible, inform the incapable patient that an SDM will assist them in understanding the proposed treatment and will be responsible for the final decision."
For line 31-34 of the policy, might be useful to hyperlink the Health Care Consent Act and Guide to the Health Care Consent Act companion documents.
Guide to HCCA – in regards to the hierarchy SDM chart, might want to add to Line 70-81 (Using the Hierarchy) that if there are 2 or more SDM's within the same rank, they must make a decision jointly.
This policy only relates to consent and not delegation, so we didn’t see any impact to us in regards consent and MD’s. It did mention that if the MD requests another HCP to obtain consent from a client for treatment, that the HCP must have the knowledge, skill and judgement to obtain consent. This is consistent with the CNO and the TB Program consent and confidentiality P&P.
Thank you for the opportunity to provide feedback.
Ontario Trial Lawyers Association (OTLA)
Please find attached OTLA's submission to the CPSO regarding the Draft Consent to Treatment.
Response in PDF format:
Note: Some content has been edited in accordance with our posting guidelines.
In the absence of being able to access the official survey and running out of time before the deadline, I am thanking you in advance for the opportunity to make a few comments as a community member speaking on behalf of many parents in similar situations.
I am a mother of an adult daughter, well educated but diagnosed in 2018 with Schizophrenia. My daughter suffers from Anosognosia or lack of insight or lack of knowledge she is ill. While the psychosis may come and go, the Anosognosia never wavers. She would never voluntarily consent to treatment “because I am not ill” but when treated involuntarily she does quite well except for the Anosognosia. This condition prevents the individual recognizing any change in their mental health status. Psychiatrists never fail in diagnosing incapacity in my daughter, “very sick” they say yet the laws allow her to contest the Doctors decisions even when placed on a CTO. Then, after weeks of good care, she is declared competent and all the efforts to treat go down the drain and treatment stops. The “revolving door’” which the CTO was supposed to resolve is alive and well. This is a story to which all my colleagues in the group Mothers for Mental Health Care Reform can relate. We believe that Anosognosia must rise to the top of psychiatric decision making with more comprehensive tools, already available but mostly unused. [redacted]
Education about the neurological condition of Anosgnosia must be developed and shared with legal professionals, some of whom I suspect understand it all too well but use it to their advantage at the Consent and Capacity Board to win their defence case. It should be essential for all mental health practitioners especially ER physicians and Psychiatrists to understand this condition to the same extent that parents learn to understand it. Anosognosia needs a special place in Mental Health legislation because it is a condition present in over 50% of all people with Schizophrenia (some claim up to 90%) and because it is in the best interest of the patient that it be thoroughly understood.
How can our adult children who truly do not believe they have an illness, provide valid consent to medication and hospitalization.? There has been much written but not enough scientific research conducted to enable treatment to address this complex condition. As has been already noted, Drs need to spend more time determining capacity with a thorough knowledge of Anosognosia driving that decision. Recognition must be given by the funders of our system to the additional time and associated expense required for practitioners to accommodate for Anosognosia in making decisions around capacity and consent.
Thank you again for the opportunity to submit these notes, Regards [redacted]
I am a mature member of the public, invited to review the background documents with option to share feedback.
The discussion comments were few.
The October 1 2024 discussion comment stating “patients need to take some responsibility” is one I agree with.
Currently my adult daughter has been in [redacted] Hospital since October 30 with a very severe bacterial pneumonia requiring intense treatment. This is very unexpected in a healthy woman with no prior lung history.
Her husband and I were both with her in ICU as she named both of us as decision makers when ventilator was considered although she responded to intense oxygen and IV antibiotics.
As well informed, English speaking adults we - mostly her now - have been consenting to multiple treatments offered while in hospital now and for future referral to specialist out of town.
This is the ideal with respect to informed consent.
Language, comprehension, reliability and trust of family member decision maker/interpreter are all complicated. Patient safety is an important consideration.
In Ontario, English is the language associated with medical care. For the patient in Ontario they do need to take some responsibility.
This may seem harsh however ethical, safe medical care requires patient-doctor communication.
Today, November 10, my daughter remains on oxygen therapy in hospital on Day 12 of her admission for very acute bacterial pneumonia however has improved. My son-in-law and I share our time so that one of us is with her from mid morning to mid evening and most days I am with her when her doctors make rounds. I’ve been very aware of the many examples of informed consent we three provided very recently as well as one example of our unanimous refusal to consider treatment option (ventilator - based on my previous power of attorney experience - ventilator for family member 15 years ago).
Our experience is among the ideal however much is far more complex than ours. Doctors must rely on documenting, access to resources, protection as they do their best under the stresses and constraints. Patients and their families have obligations too.
HIV & AIDS Legal Clinic Ontario (HALCO)
Please accept the attached comments from the HIV & AIDS Legal Clinic Ontario (HALCO) for the CPSO’s Consent to Treatment – General Consultation.
Thank-you for your consideration.
College of Nurses of Ontario (CNO)
CNO had the opportunity to review the Consent to Treatment and Closing a Medical Practice draft policies posted on your consultation page. We greatly appreciate the opportunity to review and provide feedback on the draft policies and practice supports. Overall, both draft policies are clearly written, easy to understand and relevant. The accountabilities set out in the policies are helpful for articulating the practice expectations of the profession.
We have shared below one consideration that may support your update of this Consent policy and supporting material:
Under obtaining consent #3 it states ‘consent be given voluntarily and not under duress’ and ‘…must take reasonable steps to ensure that there has been no coercion.’ It may be helpful to provide further details in the policy under definitions or in the Advice to the Profession document around what might constitute duress or coercion. It may be helpful to include that aspects of duress or coercion could be from family members/friends or from the health care team. We have received information from the Chief Coroners Office regarding a few MAID cases they have reviewed where the concept of ‘voluntary consent’ was not clearly understood and are currently looking at clarifying our language.
