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teaching:on-mha:consent-capacity [2019/05/19 22:04]
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teaching:on-mha:consent-capacity [2020/04/30 22:17] (current)
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 ====== Informed Consent and Capacity Assessment ====== ====== Informed Consent and Capacity Assessment ======
 +{{INLINETOC}}
 ===== Primer ==== ===== Primer ====
-**Consent and Capacity** are two central tenets in modern medicine and critical to patient autonomy, the respect for personal dignity, and the delivery of ethical care by physicians.+**Consent and Capacity** are two central tenets in modern medicine and critical to patient autonomy, the respect for personal dignity, and the delivery of ethical care by physicians. ​This page focuses specifically on [[teaching:​on-mha:​home|legislation and laws in the province of Ontario, Canada]]. The basic principles can be applied throughout Canada, because of the 2003 Supreme Court ruling ([[https://​scc-csc.lexum.com/​scc-csc/​scc-csc/​en/​item/​2064/​index.do|Starson v. Swayze]]) but please be aware of your own jurisdiction'​s specifics.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​17696026|Sklar,​ R. (2007). Starson v. Swayze: The Supreme Court speaks out (not all that clearly) on the question of “capacity”. The Canadian Journal of Psychiatry, 52(6), 390-396.]])]
  
 ===== Consent ===== ===== Consent =====
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-<callout type="​danger"​ title="​Attention!"​ icon="​true">​This page focuses specifically on legislation and laws in the province of Ontario, Canada. The basic principles can be applied throughout Canada, because of the 2003 Supreme Court ruling (Starson v. Swayze) but please be aware of your own jurisdiction'​s specifics. This page is not legal advice!</​callout>​ 
 <callout type="​warning"​ title="​Consent is Also Required Before You Disclose Patient Information!"​ icon="​true">​Separate from treatment consent, communication/​disclosure consent must also be obtained from patients prior to divulging personal health information to the patient'​s family or friends.</​callout>​ <callout type="​warning"​ title="​Consent is Also Required Before You Disclose Patient Information!"​ icon="​true">​Separate from treatment consent, communication/​disclosure consent must also be obtained from patients prior to divulging personal health information to the patient'​s family or friends.</​callout>​
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-<panel type="​info"​ title="​Sample Documentation for Informed Consent for a Medication Class" no-body="​true">​+<panel type="​info"​ title="​Sample Documentation for Informed Consent for a Medication Class" no-body="​true" icon="​fa fa-pencil">
 ^ Class     ^ Documentation ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             ^ ^ Class     ^ Documentation ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             ^
 | **Antipsychotics** ​  | Consent was obtained to start the antipsychotic. The benefits of treatment were discussed, including reduction of psychotic symptoms, improved insight, judgment, and reduction in maladaptive behaviours. We also discussed the likely possibility of worsening symptoms and the clinical course without treatment. The rare risk of death/CVA, NMS, parkinsonism,​ involuntary movements due to EPS were also discussed. We discussed possible side effects including falls, sedation, metabolic syndrome, and QTc prolongation/​arrhythmia. We also discussed the importance of ongoing monitoring for metabolic syndrome and side effects such as hyperlipidemia,​ and elevated glucose. ​ | | **Antipsychotics** ​  | Consent was obtained to start the antipsychotic. The benefits of treatment were discussed, including reduction of psychotic symptoms, improved insight, judgment, and reduction in maladaptive behaviours. We also discussed the likely possibility of worsening symptoms and the clinical course without treatment. The rare risk of death/CVA, NMS, parkinsonism,​ involuntary movements due to EPS were also discussed. We discussed possible side effects including falls, sedation, metabolic syndrome, and QTc prolongation/​arrhythmia. We also discussed the importance of ongoing monitoring for metabolic syndrome and side effects such as hyperlipidemia,​ and elevated glucose. ​ |
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-<panel type="​info"​ title="​Sample Documentation for Informed Consent for a Specific Medication"​ no-body="​true">​+<panel type="​info"​ title="​Sample Documentation for Informed Consent for a Specific Medication"​ no-body="​true" icon="​fa fa-pencil">
 ^ Medication ​                                                                                                                                                                                                                                                                                                                                        ^ Documentation ​                                                                                                                                                                                                                                                                                                                                                                                                                ^ ^ Medication ​                                                                                                                                                                                                                                                                                                                                        ^ Documentation ​                                                                                                                                                                                                                                                                                                                                                                                                                ^
 | **Clozapine**[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2652805/​|Parsons B, Kennedy M. A review of recorded information given to patients starting to take clozapine and the development of guidelines on disclosure, a key component of informed consent. Journal of Medical Ethics. 2007;​33(10):​564-567. doi:​10.1136/​jme.2006.016808.]])] ​ | Consent was obtained to start clozapine for the patient. We discussed the risks and benefits of treatment with clozapine, including side effects such as agranulocytosis,​ myocarditis,​ weight gain, hypersalivation,​ as well as metabolic side effects. We also discussed the benefits of treatment, including reduction in symptoms of psychosis. We also discussed the role of ongoing blood work and monitoring involved. ​ | | **Clozapine**[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2652805/​|Parsons B, Kennedy M. A review of recorded information given to patients starting to take clozapine and the development of guidelines on disclosure, a key component of informed consent. Journal of Medical Ethics. 2007;​33(10):​564-567. doi:​10.1136/​jme.2006.016808.]])] ​ | Consent was obtained to start clozapine for the patient. We discussed the risks and benefits of treatment with clozapine, including side effects such as agranulocytosis,​ myocarditis,​ weight gain, hypersalivation,​ as well as metabolic side effects. We also discussed the benefits of treatment, including reduction in symptoms of psychosis. We also discussed the role of ongoing blood work and monitoring involved. ​ |
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 A finding of incapacity need to be documented on the medical record. In Ontario, if incapacity is for psychiatric reasons, a notice to the patient (Form 33) must be given, and rights advice must be notified. For non-psychiatric purposes, one does not need to give a Form 33 to the patient nor notify a rights adviser. However, the physician should provide rights information to the patient. After a finding of incapacity, you should continually assess capacity and document this; this is considered good practice! ​ A finding of incapacity need to be documented on the medical record. In Ontario, if incapacity is for psychiatric reasons, a notice to the patient (Form 33) must be given, and rights advice must be notified. For non-psychiatric purposes, one does not need to give a Form 33 to the patient nor notify a rights adviser. However, the physician should provide rights information to the patient. After a finding of incapacity, you should continually assess capacity and document this; this is considered good practice! ​
  
-<panel type="​info"​ title="​Sample Documentation for Capacity Assessment"​ no-body="​true">​+<panel type="​info"​ title="​Sample Documentation for Capacity Assessment"​ no-body="​true" icon="​fa fa-pencil">
 A capacity assessment was done today. [Patient] agreed/​disagreed with a provisional diagnosis of [mental disorder]. [Patient] agreed/​disagreed that they had a mental disorder. [Patient] was able/unable to understand the side effects of treatment with an antipsychotic such as paliperidone. When asked how these medications relates to the diagnosis of psychosis/​schizophrenia,​ [Patient] could not apply it to their own situation. Furthermore,​ when asked in detail about what would happen if they were to stop taking medications,​ they said [patient quote]. A capacity assessment was done today. [Patient] agreed/​disagreed with a provisional diagnosis of [mental disorder]. [Patient] agreed/​disagreed that they had a mental disorder. [Patient] was able/unable to understand the side effects of treatment with an antipsychotic such as paliperidone. When asked how these medications relates to the diagnosis of psychosis/​schizophrenia,​ [Patient] could not apply it to their own situation. Furthermore,​ when asked in detail about what would happen if they were to stop taking medications,​ they said [patient quote].
  
 [Patient] was unable to appreciate the foreseeable consequences of taking antipsychotics or lack of taking antipsychotic medications. [Patient] COULD NOT apply the relevant information provided to them to their own circumstances or weigh foreseeable risks and benefits. In particular, they could not appreciate that their non-adherence to medication would likely lead to [symptoms of disorder]. Based on this assessment, [Patient] fails the SECOND BRANCH of the capacity test. [Patient] was unable to appreciate the foreseeable consequences of taking antipsychotics or lack of taking antipsychotic medications. [Patient] COULD NOT apply the relevant information provided to them to their own circumstances or weigh foreseeable risks and benefits. In particular, they could not appreciate that their non-adherence to medication would likely lead to [symptoms of disorder]. Based on this assessment, [Patient] fails the SECOND BRANCH of the capacity test.
 </​panel>​ </​panel>​
 +
 +==== Psychiatric vs. Medical Incapacity ====
 +{{page>​teaching:​on-mha:​home#​psychiatric-vs-medical-incapacity-in-ontario&​nouser&​noheader&​nodate&​nofooter}}
  
 ==== Substitute Decision Makers (SDMs) ==== ==== Substitute Decision Makers (SDMs) ====