Health Care (Consent) and Care Facility (Admission) Act (HCCCFAA) (BC)

Primer

The British Columbia Health Care (Consent) and Care Facility (Admission) Act, or HCCCFAA contains the laws for medical treatment, and consent for health care (excluding mental health care) in British Columbia. The HCCCFAA outlines what a patient’s rights are, the elements of informed content, when consent is required, and what to do if a patient is found to be incapable. Similar to other jurisdictions, there are general principles that guide consent:

  1. Adults are presumed to be capable of giving consent unless proven otherwise
  2. Adults can only be given health care with their prior given consent
  3. Adult must be approached first for a decision about health care

Personal Care Capability

Documentation

Sample Documentation for Capacity Assessment

Over course of assessments from [DATE(S)], patient is [CAPABLE/INCAPABLE] to make an admission decision.

Patient has [MMSE/MOCA scores], and [HAS/DOES NOT HAVE] insight into their cognitive limitations. Due to [DIAGNOSIS], patient is [ABLE/UNABLE] to understand information presented to them. Patient currently [HAS/DOES NOT HAVE] the ability to retain information and convey this back to demonstrate that they have understood.

When discussing the topics of staying at home versus moving to a long term care facility, patient is [ABLE/UNABLE] to answer questions regarding consequences of staying at home versus going to long term care. When the patient was asked about what problems they are currently having, pt [DENIED/ADMITTED] to all concerns. Specifically questioned about insight into cognitive abilities, replied [“ ”] on repeated occasions.

It is evident that the patient [DOES/DOES NOT] understand the extent of their cognitive deficits, and/or how these deficits are affecting their safety. When asked about admission to a nursing home to help with any problems, patient [WAS/WAS NOT] able to discuss this rationally. It is evident that patient is [ABLE/UNABLE] to appreciate any consequences of living independently versus in a nursing home. Regarding other ways to look after one's condition, patient [DOES/DOES NOT] feel that the cognitive problems interfere with function. When questioned regarding what would happen if patient indeed chose to move into a nursing home, they responded [“ ”]. The patient [IS/IS NOT] willing to accept help in the community for support where necessary. With respect to the patient's medical conditions and medications, they are [ABLE/NOT ABLE] to understand the need for monitoring of their medical conditions (e.g., blood sugar monitoring for diabetes), and/or medications (e.g., INR levels for warfarin). The patient [IS/IS NOT] able to state that they need to call 911 during a medical emergency.

Patient is deemed [CAPABLE/INCAPABLE] to make decisions regarding admission to long term care. The patient has a [medical/neurodegenerative disorder] that is a [permanent and irreversible brain disorder]. [IF INCAPABLE: The appropriate forms were completed, and the patient was given the rights information sheet. This sheet was explained in detail, should the patient wish to appeal this finding. Patient [DID/DID NOT] indicate an intent to appeal this. The patient [DOES/DOES NOT] have a POA in place already, which [can/cannot] be formally enacted.