COTM PREP #2– 2014-15 October 2014

PREP#2: Consent Learning Objectives Upon completion of the Module, therapists will: 1. Demonstrate an understanding of the principles of obtaining informed consent and how the principles apply to both clinical and non-clinical practice. 2. Gain confidence in making decisions regarding obtaining informed consent. 3. Demonstrate knowledge and application of legislative and regulatory requirements that define occupational therapy professional requirements with regard to Consent to Treatment 4. Recognize and understand some of the ethical and professional dilemmas that can occur in practice that relate to the issue of informed consent and apply the relevant regulations and standards in the decisionmaking process. 5. Demonstrate an awareness of resources, including the government agencies and their roles, which are available to assist members in their decision-making process, for atypical or challenging situations. 6. Demonstrate sound knowledge, understanding, and application of the standards and legislation relevant to the issue of informed consent through a series of practice scenarios.

At the end of this PREP Module Resource Document you will find a quiz comprised of 10 short practice scenarios and multiple choice responses to test your knowledge of this topic. A Worksheet for recording your responses is on the last page of this Module. An online survey quiz is provided individually by email to each COTM member. Answers will be compiled and used to calculate rates of correct responses. Participation in the Online Quiz is required. All registered occupational therapists must complete the Online Quiz for this module by December 31, 2014. Save or print out a copy of your questions and the responses you selected by downloading as a PDF or Word document before you exit the Quiz Survey. Both the Online Quiz and the Worksheet at the end of Module are required documents that will become part of your personal CCP record. (Completion of this PREP Module is required for COTM registration renewal in 2015.)

What this Prescribed Regulatory Education Program (PREP) Module contains: Introduction that explains the intent of the module as well as an overview of the topic

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Definitions for relevant terms in the discussion of consent and protection of privacy

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Principles for obtaining informed consent: describes components of valid consent and principles for ensuring that it is properly obtained

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Application to practice: recommendations for applying the concepts to practice

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Legislative and regulatory requirements for occupational therapy conduct with regard to consent

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Dilemmas and practice challenges related to consent

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Resources

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Practice Scenarios

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PREP#2 Scenario Worksheet

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© 2014, College of Occupational Therapists of Manitoba

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INTRODUCTION To this PREP module: The issue of consent is fundamental to the clientcentred relationship that governs occupational therapy practice. It is referred to explicitly in the COTM Code of Ethics to which all Manitoba occupational therapists must adhere. In order to fully recognize the autonomy of the individual and respect the dignity of clients, occupational therapists are required to obtain informed consent for their professional interactions with clients. Additionally, the issue of assent must be considered in cases where clients are incapable or incompetent to give consent Aside from the ethical responsibility, occupational therapists are required to practise according to expectations laid out in both provincial laws and in employer policies specific to obtaining informed consent and handling personal health information. COTM is aware that the consequences of errors in the obtaining and documenting of consent can be serious. The PREP is not intended to increase anxiety but rather to support positive practice changes by providing practitioners with a resource to increase knowledge of the topic.

WHAT IS THE PROCESS FOR OBTAINING CONSENT? The process of acquiring consent is one involving an exchange of information between the professional and the client whereby the client learns about the planned therapeutic intervention and the professional learns about the client; this allows the information to be meaningful to both so that the professional can provide needed information in a manner that is meaningful to the client and the client can make an informed decision about their care – keeping in mind that this informed decision can include an informed refusal. Clients/patients have the right to refuse treatment or withdraw consent for treatment at any time.

This PREP will review the foundational principles of consent. This will assist you to understand your workplace policies and procedures so that you can be discerning about their application and better develop policies and procedures if you are responsible for them, as is the case for members in independent practice among others. To this topic: In general there are 4 categories or types of consent that require attention for occupational therapy practice: 1. Consent to treatment, 2. Consent for the participation of support personnel, students and others 3. Consent to release information, and 4. Consent to participate in a research project. The last one, research, is only required in very specialized situations and is not regulated by provincial laws or COTM guidelines for practice, but rather by Ethics Boards or Committees associated with academic institutions where occupational therapy research is usually conducted. This type of consent will not be discussed in the PREP module. Many health employers have policies and procedures in place for obtaining and documenting consent. The information in this PREP is not intended to replace these requirements but rather to inform occupational therapists about professional requirements that may extend beyond the workplace requirements and to provide information about resources that can fill the need for additional information. The obtaining of informed consent mainly applies to Clinical work and to Non Clinical occupational therapy practice when supervising Clinical therapists or educating students. However, the concept is so fundamental to occupational therapy practice, it is relevant to all practitioners and is therefore the subject of this required regulatory education module.

COTM 2012

© 2014, College of Occupational Therapists of Manitoba

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DEFINITIONS These definitions (with additions in italics) are taken from the COTM document: Informed Consent in Occupational Therapy Practice (COTM, 2012). assent: To evidence a choice. To show approval or agreement. The ability to understand the information that is relevant to making a capacity: treatment decision; and appreciate the reasonably foreseeable consequences of a decision or lack of a decision. explicit consent: Expressly stated voluntary agreement, permission, compliance. fiduciary duty: Moral or legal obligation of trust. implicit consent:

Implied, though not plainly expressed voluntary agreement or permission.

A legal doctrine based on respect for the principle of autonomy of an informed consent: individual’s right to information required to make decisions; also a matter of respect for personal self-determination. guardian: mental competence:

A parent, step parent, or a person who is appointed by the courts to act as parent or guardian. Does not include foster parents. Adequately qualified or capable mental abilities; decision-making capacity.

An individual, assigned by a capable person who completes a health care proxy: directive to carry out their wishes in the event that they become incapable. Person legally designated to make a decision on behalf of a client who is substitute decision maker: deemed as incapable of giving consent either via the Vulnerable Persons Act or the Mental Health Act. Trustees are persons who handle personal health information. They include: health professionals, health care facilities, regional health trustee: authorities, health services agencies, provincial government departments and agencies, municipal governments, local government districts, school divisions and districts, universities and colleges.

PRINCIPLES FOR OBTAINING INFORMED CONSENT The requirements for Manitoba occupational therapists in obtaining informed consent are described in the COTM Practice Guideline: Informed Consent in Occupational Therapy Practice. They include the essential components of valid consent and general principles for insuring consent is properly obtained.

Components: Valid Consent consists of four main components 1. Capacity: There must be a reasonable assurance that the person has the capacity to give consent by virtue of adequate mental ability (e.g. cognitive function, communication skill) and maturity (age). It is specific to the matter at hand; i.e. the individual may have capacity to make some decisions but not others. © 2014, College of Occupational Therapists of Manitoba

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2. Voluntary/freely given: No coercion or minimization/misrepresentation of likely outcome of treatment. 3. Specific and revocable: relates directly to the treatment to be provided – i.e. not a blanket consent. Clients may revoke consent. 4. Informed: Clients must be provided with sufficient information to make a decision, e.g.  The nature and purpose of the treatment including the likely benefit(s) or hoped-for benefit(s); • The material risks and side-effects of the proposed treatment; • Alternative courses of action; • The consequences of not having the treatment; • More detailed information about these matters, if requested. (COTM 2012, pg.6)

General Principles: 1.

2.

Must be legally competent to consent: the two issues that most impact on this are age and cognitive ability. Manitoba legislation in this area (Health Care Directives Act, Mental Health Act) states that persons 16 years of age and older are able to give consent for health decisions as long as they are mentally capable. The age of majority is not required to provide consent to treat in Canada. (COTM, 2012, page 6). For more information about the Mature Minor Doctrine, please refer to the Manitoba Law Reform Commission 2004 report: Substitute Consent to Health Care. Informed consent may be provided by minors if the occupational therapist is satisfied that the client knows why the treatment intervention is being proposed, understands the treatment and can explain what they know, understands the benefits and risks, understands the options. Mental Capacity to authorize care: Consent discussions should start from the presumption that the client is capable. When there is doubt, two factors need to be considered: fluctuating capacity and whether it is appropriate to seek consent from a substitute decision maker. The Manitoba Government Family Services and Consumer Affairs Department has published A Fact Sheet on Substitute Decision Making. In addition, the Manitoba Health Care Directives Act provides information regarding the definition of capacity, information regarding establishing a directive and information regarding the assignment and roles of proxies. In the event that a client

© 2014, College of Occupational Therapists of Manitoba

does not have the capacity to consent, assent to treatment should be sought and documented providing that consent has been given by the client’s substitute decision maker. The concept of capacity to give consent related to risk and impact of the matter at hand is critical. 3.

Full and proper disclosure of information: For valid consent, the opportunity to ask questions and receive answers is essential.

FULL DISCLOSURE INCLUDES: • Treatment or service approach and any risks involved including risks of not treating, • Alternatives or options for treatment • Background of the therapist including a description of training, credentials, specialized skills, • Any costs involved in therapy, • Length of therapy, • Process of termination, • Consultation with colleagues, • Client’s right of access to their medical records, nature and purpose of confidentiality, • Handling of multiple relationships with clients, • Involvement of support personnel, students and others in treatment, • Therapists’ opinion regarding best course of action. COTM 2012

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4.

Specific to the treatment being proposed: The use of a blanket consent form may not be sufficient evidence that fully informed, valid consent has been obtained.

5.

Implicit and Explicit Consent: Consent can be implicit (e.g. holding out a limb for

examination) or explicit (e.g. verbal or written). According to the COTM Practice Guideline on Consent, both are legally acceptable but documentation is of particular value for implicit and verbal consent since both of these forms of consent can be difficult to prove.

APPLICATION TO PRACTICE 1. Obtain consent for assessment as well as for treatment - It is unclear whether separate consent is required for assessment, however, since occupational therapists use a clientcentred approach and consent is an important legal and ethical obligation for provision of this care, it seems best to apply the same approach to obtaining consent for assessment as for performing a treatment intervention. 2. Know the contents of legislation that impacts on your practice situation – Depending on the context, it may be important for you to have first-hand knowledge of one or more pieces of legislation that address consent to treatment or release of health information in Manitoba. 3. Know your employers’ policies on consent – They may provide extra guidance and/or requirements for your actions. 4. Be prepared to assess capacity on more than one occasion – To account for fluctuating capacity, make at least two attempts to discuss consent with clients and consider assent if consent is not possible. Consent is a conversation and may need to happen each time one meets with the client, depending on

© 2014, College of Occupational Therapists of Manitoba

what one is doing. With each of these interactions, capacity evaluation is part of the interaction. 5. Schedule time to have a full and complete consent discussion – It takes time to provide all of the information required for valid informed consent and to answer any additional questions that clients may raise. While it has been considered acceptable to have a student or support staff provide necessary information, it is considered best practice for the person proposing the treatment to obtain the consent (Jacobson, 2013). 6. Document consent discussion – Make a note of the discussion in the client record that includes the fact that a consent discussion took place following provision of information including explicit confirmation that the criteria for valid consent were met. Note whether consent was given, whether it was verbal or written, if the client refuses or withdraws consent and if, in your opinion, the client is not capable of giving consent.

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LEGISLATIVE AND REGULATORY REQUIREMENTS THAT DEFINE OCCUPATIONAL THERAPY PROFESSIONAL CONDUCT WITH REGARD TO CONSENT TO TREATMENT DUAL NATURE OF CONSENT Consent in the context of health service delivery can be considered a dual obligation: ensuring that the client is fully informed and capable to give consent and also protecting client privacy. In Manitoba, the Personal Health Information Act (PHIA) provides access to information and protection of privacy rights concerning personal health information. The office of the Manitoba Ombudsman has prepared a very useful fact sheet entitled: The Personal Health Information Act: Access to Personal Health Information and Privacy. Along with the right to access personal health information, clients also have the right to complain to the Ombudsman if • they think their personal health information should not have been collected or was collected improperly; • they think their personal health information was used improperly or in a way that they did not expect; • their personal health information was disclosed to someone who should not have had this access • their personal health information has not been kept securely so as to protect privacy.

Unlike provinces such as British Columbia, Ontario, New Brunswick and Prince Edward Island; Manitoba does not currently have a Health Care Consent Act (Jacobson 2013). This does not mean that occupational therapists in Manitoba are not required to obtain informed consent. This obligation is outlined in both the Essential Competencies of Practice for Occupational Therapists in Canada and the COTM Code of Ethics as well as in the COTM Practice Guideline on Consent (COTM 2012). In addition, there are legislative requirements for health professionals regarding consent and protection of privacy with which occupational therapists are obligated to comply. There are four Manitoba statutes that prescribe required actions regarding consent and protection of privacy. They are briefly discussed in this section and links to sources for more information are provided.

Table 1 describes the elements of the Essential Competencies and Code of Ethics documents that apply to the issue of consent in occupational therapy practice.

The process for collection and dissemination of personal health information gathered for occupational therapy service provision should be discussed with the client as part of obtaining informed consent.

© 2014, College of Occupational Therapists of Manitoba

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Table 1: REFERENCES TO CONSENT FROM THE COTM CODE OF ETHICS AND THE ACOTRO ESSENTIAL COMPETENCIES DOCUMENTS

CONSENT-RELATED ISSUE

COTM CODE OF ETHICS

ACOTRO ESSENTIAL COMPETENCIES

Adequate knowledge of policies and legislation

C.4. Practise within the scope of the profession, with knowledge of, and adherence to, national and provincial legislation, regulations, standards of practice and policies relevant to the practice of occupational therapy.

COMPETENCY 3.4: Demonstrates awareness of legislative and regulatory requirements relevant to the province and area of practice. COMPETENCY 7.3: Contributes to a practice environment that supports client-centered occupational therapy service, which is safe, ethical and effective. Non Clinical COMPETENCY A.3: Adheres to the Code of Ethics recognized by the provincial regulatory organization. COMPETENCY C.2: Maintains confidentiality and security in the sharing, transmission, storage, and management of information

Alternative (substitute) decision makers

B.15. When a client lacks decision-making capacity, confirm the scope and authority of alternative decision makers and obtain consent for occupational therapy services from the alternate decision-maker, subject to the laws in the jurisdiction. Commit to building trusting relationships with alternative decision makers as one would with the client.

Assent

B.11. Provide opportunities for people to make choices and maintain their capacity to make decisions, even when illness or other factors reduce the client’s capacity for selfdetermination. Occupational therapists seek assent of the client when consent is not possible.

Full disclosure by OT

B. 4. Provide complete and accurate information to enable the client to make an informed decision regarding the need for, and nature of, occupational therapy services, including information about the anticipated benefits and risks of accepting or refusing such services.

COMPETENCY 4.1: Clarifies the role of occupation and enablement when initiating services.

Obtain and document consent

B.7. Obtain and document informed consent for occupational therapy services. Consent can be established orally, or in writing, or where this is not possible it may be implied. Occupational therapists recognize that persons have the right to refuse or withdraw consent for care or treatment at any time. B.9. Obtain informed consent for occupational therapy services provided by those under the occupational therapist’s supervision, such as students and support personnel.

COMPETENCY 4.3: Ensures informed consent prior to and throughout service provision. COMPETENCY 5.2: Communicates using a timely and effective approach.

© 2014, College of Occupational Therapists of Manitoba

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CONSENT-RELATED ISSUE

Sharing of information

ACOTRO ESSENTIAL COMPETENCIES

COTM CODE OF ETHICS G.1. Comply with all provincial legislation and professional regulations regarding confidentiality. G.5. Share personal health information with others only with the authorized consent of the client, or where failure to disclose would cause significant harm, or if legally required.

Even though there is no umbrella legislation in Manitoba regarding consent, there are other pieces of legislation that impact on requirements for obtaining consent and protection of privacy in Manitoba, depending on the context of practice. They include: 1. Manitoba Health Care Directives Act : provides information regarding the definition of capacity (s.2), information regarding establishing a directive (s.4, s.5) and information regarding the assignment and roles of proxies (s.12-16). 2. Mental Health Act : provides information about consent in the case of persons who fall under the jurisdiction of the Act including the boundaries of a Public Guardian or Trustee: e.g. if a Health Care Directive has been properly executed prior to the person becoming incapable, the Proxy gives or refuses consent s.63(3). 3. Personal Health Information Act (PHIA) : establishes rules governing the collection, use, disclosure, retention and destruction

© 2014, College of Occupational Therapists of Manitoba

Non Clinical COMPETENCY C.2: Maintains confidentiality and security in the sharing, transmission, storage, and management of information.

of personal health information in a manner that recognizes (i) the right of individuals to privacy of their personal health information, and (ii) the need for health professionals to collect, use and disclose personal health information in order to provide health care to individuals. The material in the Act that is most relevant to consent is found in Part 3: Protection of Privacy, especially in Division 2.1, Consent Re Personal Health Information. 4. Vulnerable Persons Act : concerns the appointment, responsibilities and limitations of Substitute Decision Makers for vulnerable persons living with a disability. The Act specifies that providing capacity to decide exists, the vulnerable person should make decisions on their own behalf. The material of most interest regarding Health Care Decisions is found in s.68 and s.69. Material regarding the role of Substitute Decision Makers with respect to consent to release of information is in s.78.

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CHALLENGES AND DILEMMAS The topic of consent is a complex one and COTM recognizes that interpreting the information within practice settings and workplaces can be challenging. Occupational therapists are encouraged to continually seek to improve their practice in this area by giving themselves permission to ask questions and seek clarification about how consent challenges and dilemmas should be addressed within their own practice setting. Some of the questions that are suggested: 1. What are the policies that apply in your workplace? 2. What are the consequences of failing to obtain informed consent? 3. Are there any exceptions to obtaining informed consent in your workplace? 4. How should capacity to make a decision about consent be assessed? 5. What procedure/s should be followed regarding decision makers other than the client (proxies, public guardian, parent, others [See Section 60 of PHIA.])?

6. How should fluctuating capacity be dealt with when obtaining consent? 7. How should assent be obtained and documented? 8. What process/s should be followed when the legal guardian is not the caregiver (e.g. foster parent vs social worker) These all need to be viewed through the combined lens of autonomy of the client, legal requirements, and the policies and procedures that apply within the practice setting.

Suggestions for obtaining more information:  PHIA Information Officer  Director of Health/Medical Records  Manager/Supervisor  Ethics Consultant  COTM  Legal Advice via CAOT (for occupational therapists participating in the CAOT Professional Liability Insurance Program)

RESOURCES 1. Association of Canadian Occupational Therapy Regulatory Organizations. (2011). Essential Competencies of Practice for Occupational Therapists in Canada, Third Edition. 2. College of Occupational Therapists of Manitoba. (2012). Practice Guideline: Informed Consent in Occupational Therapy. 3. College of Occupational Therapists of Manitoba. (2012). Practice Guideline: Occupational Therapy Assessment. 4. College of Occupational Therapists of Manitoba. (2010). Code of Ethics. 5. College of Occupational Therapists of Ontario. (2008). Prescribed Regulatory Education Program: Consent. 6. Jacobsen, Anita. (2013). Informed Consent: Principles, Ethics and Legalities. CAOT Lunch and Learn, April 30, 2013. 7. Manitoba Law Reform Commission. (2004). Substitute Consent to Health Care. 8. Province of Manitoba. (2005). The Occupational Therapists Act. 9. Province of Manitoba. PHIA Online Training Program. Obtained on September 26, 2014 from http://www.gov.mb.ca/health/phia/training.html. © 2014, College of Occupational Therapists of Manitoba

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COTM PRACTICE CHECKLIST- CONSENT This checklist is provided to assist you to assess your practice. It is optional and not a required task for meeting the PREP requirement. Practice reflection regarding consent and protection of privacy

Practice Behaviour Demonstrated Always

Sometimes

Never

N/A

Plans for Change

1. I know which legislation applies to my practice setting and what the implications and requirements are for my practice regarding consent and protection of privacy. 2. I am fully informed of all my employer’s policies regarding consent and protection of privacy. 3. I assess capacity before obtaining informed consent. 4. Upon determining incapacity, I identify a substitute decisionmaker and inform the client that the substitute decision-maker will make the final decision related to the OT services… keeping in mind that clients may have capacity to consent to low risk / low impact decisions but not have capacity for high risk / high risk decisions. 5. I provide my clients with information on the risks, benefits and alternatives related to my service, including the consequences of not participating. 6. I provide information to inform my client of their right to make concerns or complaints known to the employer/facility, patient advocate, Ombudsman or to COTM. 7. I obtain full and proper informed consent from the client or from a substitute decision-maker for any service (assessment, intervention, consultation). 8. I provide an opportunity for my clients to ask questions and answer them in a manner that they can understand. 9. I regularly seek ongoing consent if the scope of my involvement includes ongoing service. 10. I document that I have received consent. Figure 1: Adapted with permission, from COTO PREP Module: Consent (College of Occupational Therapists of Ontario, 2008) © 2014, College of Occupational Therapists of Manitoba

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PRACTICE SCENARIOS The PREP has been designed to help occupational therapists stay up to date in their professional practice. This PREP Module, Consent, was developed to assist occupational therapists to understand and comply with their legal and professional obligations regarding the legislation and guidelines that apply to occupational therapy practice in Manitoba. The Module encourages therapists to consider and evaluate the practice strategies that are used to address meeting legislation requirements, both as an occupational therapist and as a regulated professional in the workplace. PREP Modules are designed as self-directed learning tools. Occupational therapists confirm that significant learning occurs from engaging in the process of completing a Module. Reading and reflecting on their answers and their rationale for the answers reinforces learning and may help occupational therapists identify further learning needs. Reviewing the answers and rationale with other therapists may enhance your learning experience. It is a professional responsibility to take follow-up action if learning needs are identified. You are encouraged to incorporate any learning needs into your Professional Development Plan. The Worksheet provided at the end of the Module allows you to document completion of the PREP learning process and link the results with your Professional Development Plan. Use the Worksheet to compare your answers with the answers provided, to comment on differences in assumptions or rationale, and to record whether you have any further learning needs. It is recommended that you keep this completed Worksheet with the PREP Module, Consent, in

© 2014, College of Occupational Therapists of Manitoba

your COTM Binder (Tab 7). Include any identified learning needs on your Professional Development Plan for 2014/15. During Competency Review, COTM will require this information as evidence that you have learned from completing the Module, or have acted to improve your understanding when necessary.

Keep the following things in mind as you review the answers to the ten practice scenarios that follow: 1. The practice scenarios are brief and only provide key information. You may have made some additional assumptions. As you read the answers, you may realize that your assumptions were different than those COTM used and therefore you arrived at a different answer. It is important to decide if your understanding and rationale were sound. While not all choices are wrong, there is one “best” or most complete answer based on the information provided and the assumptions COTM made. 2. If you identify that your reasoning was not sound, or you did not fully understand the material and have a learning need, record on your COTM Professional Development Plan any actions you need to take. 3. Mark your choices and make notes before clicking the link provided by email to enter your responses on the online PREP Quiz. Your online Quiz score sheet is a required CCP document. Please remember to print out or download as a PDF or Word document before you exit the Quiz and retain with your CCP records.

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Scenario A You are employed by a long term care facility to work one day a week. One of your clients is an elderly gentleman with severe dementia. Lately he has become immobile and is using a wheelchair provided by the facility. The facility’s policy is that residents purchase their own wheelchairs. The resident’s proxy decision-maker is his wife, who visits weekly. You telephone the wife to explain why the resident is using the chair and to request her consent to proceed with an assessment to determine if longer term need for a wheelchair exists; further explaining that following the wheelchair assessment, a wheelchair will likely need to be purchased. Communication by phone is difficult and you suspect a hearing problem, however, the wife consents to the wheelchair assessment, saying, “Whatever you think best, dear.” How should you proceed? Option 1:

Document in the medical record that the wife has given consent to the assessment, carry out the assessment and order the wheelchair purchase to be billed to the wife.

Option 2:

Document that the wife, as substitute decision maker, has provided verbal consent for the assessment but that you are concerned about her capacity to consent based on a possible hearing impairment. Do not proceed with the assessment.

Option 3:

Make a second telephone call to the wife to request a face to face meeting with her to further discuss the assessment. Suggest the wife be accompanied by another family member.

Option 4:

Proceed with the assessment and plan to meet with the wife to discuss the assessment findings in person. Provide the wife with written assessment results that include recommendations for wheelchair purchase, costs and consequences of not purchasing a wheelchair

Scenario B Mr. B. is an existing client, referred by a disability insurer. You have been asked to perform a worksite visit in preparation for his return to work. Mr. B. had previously signed a blanket consent form, administered by the insurer, for treatment and disclosure of information. The client is unable to attend the visit but you are aware of the client’s functional limitations from previous assessments. The employer has provided permission for you to attend the worksite and has asked for a copy of the recommended worksite modifications. What is the best course of action? Option 1:

Proceed with the assessment as consent is not required because it will be at a workplace and the client won’t be present. Recommendations can be forwarded to the employer as long as no personal health information is disclosed.

Option 2:

Proceed with the assessment as consent is not required because the visit is for an assessment and not treatment.

Option 3:

Proceed with the assessment as the client signed a blanket consent form from the insurer, but do not forward the recommendations to the employer until further consent is provided.

Option 4:

Obtain consent from the client prior to performing the assessment and advise you will be forwarding the recommendations to the employer without any personal health information.

© 2014, College of Occupational Therapists of Manitoba

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Scenario C You work as an occupational therapist in a paediatric hospital setting. You recently completed an initial assessment with a 3 year old girl who demonstrated significant developmental delay and behavioural issues. She attended with her foster mother who was very engaged in the session, receptive to suggestions and requesting a copy of your report. You have faxed a consent for release of information form to the child’s legal guardian (a social worker with another agency), and have left a follow-up voicemail when the form was not returned 1 week later. It still has not arrived. What is the best course of action? Option 1:

Provide only home program suggestions to the foster mother until a consent is signed and received.

Option 2:

Provide the report to the foster mother anyways, as she is the primary care provider.

Option 3:

Provide the report to the physician and social worker (legal guardian) to distribute as they choose.

Option 4:

Call the social worker’s supervisor.

Scenario D A referral is received by the community OT from the manager of a local group home run by a private agency. The request is for an assessment of transfers of a client with Osteoarthritis and Down's Syndrome. The group home wishes to know what equipment is needed and what transfer assist methods are appropriate. It is also requested that the OT provide any training to staff that may be required as a result of the assessment. The referral does not specify where authority for consent to treatment rests. What next step should the OT take? Option 1: Assume that the group home manager is authorized to provide consent which has been implied via making the referral. Option 2: Obtain written consent from the substitute decision maker before conducting the assessment. Option 3: Arrange a home visit and ascertain whether the client has the capacity to give consent to the assessment. Option 4: No consent is required since the client is under the Vulnerable Persons Act.

Scenario E Thomas is a 14 year old boy who has a fourth metacarpal fracture. He saw a plastic surgeon two weeks ago who referred him to OT for a splint and range of motion exercises. He attends his initial OT appointment on his own. What do you do? Option 1: Complete the assessment and treatment with him including obtaining consent, but have him take a consent form home to his parents for them to sign. Option 2: Call Thomas’ parents and tell them that a guardian must attend with him for each appointment, wait for a parent to arrive before beginning the assessment. Option 3: Obtain consent for assessment and treatment from Thomas, ensuring he understands the risks and benefits and answering any questions he has. Then complete the assessment and treatment and provide your contact information should he or his parents have any questions. Option 4: Send him home without treatment, telling him he must attend with a parent or guardian. Call the parents to let them know. © 2014, College of Occupational Therapists of Manitoba

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Scenario F A teacher has requested a referral for services for a grade 2 student who has been identified as having a learning disability. The teacher has discussed the need for a referral with the principal and resource teacher. All parties agree that an OT assessment would be appropriate in order to provide suggestions for classroom set-up/modification. What is the best process for the OT to follow? Option 1: Collect the relevant information from the teacher then obtain informed consent to conduct the assessment from the student’s parent or guardian. Option 2: Obtain consent from the student’s parent or guardian to share the recommendations with the teacher. Option 3: Obtain consent from the principal to share information with the parent/guardian about your assessment. Option 4: Document that the referral was received and note that you will be providing consultation services to the teacher.

Scenario G You are an Occupational Therapist on an inpatient rehabilitation unit. You receive a consult to see a new client with a severe traumatic brain injury. The resident has increased tone and his physician has written an order for bilateral resting hand splints to prevent hand contractures. The resident is minimally conscious, unresponsive to any stimuli and unable to communicate. How will you proceed? Option 1:

Consent is not required as the physician has written an order.

Option 2:

The client needs to sign a consent form agreeing to your services before you can proceed.

Option 3:

Assess and provide the splints – if the resident does not show signs of discomfort or opposition to wearing them, he is assenting to the intervention.

Option 4:

Contact the substitute decision maker to obtain consent for the assessment and proposed treatment/interventions.

Scenario H The rehab department receives a referral for the community occupational therapist to assess the home management ability of a client who has just returned home from hospital following the pinning of a hip fracture. The inpatient OT had discussed this referral with the client prior to discharge from hospital and the client was in agreement with the assessment. This was documented in the inpatient chart and was part of the discharge report provided to the home care case coordinator who initiated the referral. What process does the community OT need to follow regarding obtaining informed consent for their assessment? Option 1: None. Informed consent was obtained by the inpatient OT. Option 2: Contact the client to review the referral, explain the assessment process and obtain consent to proceed with a home visit. Option 3: Confirm the appointment time by phone and on arrival at the visit, request the client sign an OT department consent form stating that it is just a formality. Option 4: Obtain consent from the Home Care Case Coordinator.

© 2014, College of Occupational Therapists of Manitoba

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COTM PREP #2– 2014-15 October 2014

Scenario I Mr. Jones resides in a personal care home. He is diagnosed with severe dementia. The staff find it increasingly difficult to provide his morning and evening care. The therapist, who visits the personal care home one day a week, has been asked to assess Mr. Jones’s activities of daily living during his morning care in order to help the staff find ways to meet Mr. Jones’s care needs. The therapist telephones Mr. Jones’s daughter, his proxy, to inform her of the referral. The daughter provides verbal consent on the telephone. When the occupational therapist goes to Mr. Jones’s room while the staff are helping him to get dressed, Mr. Jones screams at the occupational therapist, demanding that she leave his room. The therapist attempts to explain why she is there, but Mr. Jones grows more agitated. How should the therapist proceed? Option 1: Remain in the room and observe the rest of Mr. Jones’s care routine. Option 2: Meet with Mr. Jones a few times over the following weeks so that he gets to know her and then ask him to let her help him get dressed the next time she comes to the facility. Again attempt the assessment. Option 3: Consult with the Health Care Aides and nursing staff without conducting a hands on assessment to develop a care plan for Mr. Jones’s morning routine. Document the plan discussed. Option 4: Call the daughter and tell her that her father has refused the assessment and ask for her assistance.

Scenario J You have been asked to perform a functional assessment on a client on behalf of a long-term disability insurer. As part of obtaining informed consent, you explain the nature of the assessment and ask the client to review and, if in agreement, sign a consent form to participate; a process that is required by your clinic. The client reviews the form and states that he believes “the insurer wants him back at work” and asks if the results of the evaluation will be used to end his benefits. He then verbally agrees to participate in the evaluation but refuses to sign the consent form. Which of the following describes the best action to carry out next? Option 1: Advise the client of your role and that you do not know how the results of the assessment will be used by the insurer; recommend he contact his claims representative for further information. Proceed with performing the evaluation, as verbal consent was given, and document that the client refused to sign the consent form. Option 2: Advise the client that refusing to sign the consent form constitutes a refusal to participate in a rehabilitation plan and may have negative consequences on his disability benefits. Provide the client with another opportunity to sign the consent form. Option 3: Do not perform the evaluation, as refusing to sign the consent form constitutes non assent, regardless if verbal consent was provided. Advise the client that he should contact his insurer for further information regarding the potential consequences of the results of evaluation and refusal to participate. Option 4: Proceed with the assessment as consent is not required because the evaluation is an assessment and not treatment, and, as such, does not legally require informed consent.

© 2014, College of Occupational Therapists of Manitoba

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COTM PREP #2– 2014-15 October 2014 Use this form to assess your learning needs based on your responses to the Practice Scenarios in the PREP Module and the provision of the best answers and rationale from the College. This Worksheet is required for submission at Competence Review along with a copy of your online score sheet. Record your answers from your online Quiz score sheet and complete the remaining columns with the PREP answers and rationale provided to you with your acknowledgement of completion.

Instructions: 1. Review your responses from the PREP Module – Consent: either note in margin or draft onto the Worksheet below.

6. Note discrepancies between your answer and the best answer. Comment on your assumptions and rationale as compared to those of COTM.

2. Click the link provided to you by email to enter your answers into the Prep Online Quiz. Print or save a copy of your completed Online Quiz score sheet.

7. Identify any learning needs based on gaps in your understanding of the material covered in the Module and complete the “Learning Need?” column.

3. An acknowledgement of completion of the Online Quiz will be sent to you by email within 2 weeks of completing. If you do not receive it within this time, please contact [email protected] to discuss.

8. Consider these learning needs as you create your Professional Development Plan for the upcoming year.

4. Review the best answers and rationale provided by COTM after you have completed the Quiz.

9. Save this completed Worksheet and a copy of your online score sheet with your personal CCP materials.

5. Record the best answers on your Worksheet or transfer them into this sheet if recorded elsewhere.

10. Email [email protected] at any time if you have questions or would like advice.

PREP MODULE WORKSHEET

Consent and Protection of Privacy Scenario #

My Answer

Best Answer

Comments

Learning Need? (Yes/No)

A B C D E F G H I J

© 2014, College of Occupational Therapists of Manitoba

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