January 2020 By PsychDB.com

Form 45, 47, and 49 (Community Treatment Order)

A Community Treatment Order (CTO), is a provision under the Ontario Mental Health Act that allows a physician to mandate supervised treatment on a patient when they are discharged from hospital. The overall goal of CTOs is to prevent mental health deterioration due to medication non-compliance. This is especially applicable in patients with a history of deteriorating when off medication, and show improvement when they are back on medications.

In Ontario, an active CTO will allow you to order a patient back to hospital for assessment (by issuing a Form 47). A CTO expires every 6 months, but can be renewed. Each year, there is also a board hearing to justify whether a CTO needs to remain in place to ensure that personal liberties are not infringed. CTOs are used throughout the world, and the specific criteria to be eligible for a CTOs varies between different jurisdictions.

In order to issue a CTO (i.e. - a Form 45) all of following criteria need to be met:

  1. The patient is certifiable (i.e. - the patient currently criteria for Box A or Box B in the Form 1)
  2. Patient must have 2 or more admissions to a psychiatric facility for a cumulative period of 30 days in the last 3 years ( and the reason for admission must be for the same condition (e.g. - schizophrenia) each time when meeting the above criteria).
  3. A community treatment plan must be created by the physician (i.e. - what is the proposed mandated treatment once the patient is discharged from hospital?)
  4. The patient must have been examined within the past 72 hours
  5. Rights advice must given (to both the patient and their substitute decision maker (SDM) if applicable)
Remember the admission period does not include the Form 1 assessment period (i.e. - the first 72 hours)

Form 49

There Is Another Kind of Form 49!

There is a completely different and unrelated Form 49 (Warrant of Committal) issued through the Ontario Review Board (ORB), which is essentially a detention order. Don't confuse the two!

A Form 49 (Notice of Intention to Issue or Renew Community Treatment Order), is the initial notice given to the patient to let them know a physician intends to start or renew a CTO.

Form 45

A Form 45 (Community Treatment Order), is the Form that initiates the CTO formally, details the conditions of the treatment order in the community.

Form 47

A Form 47 (Order for Examination), can be issued by a physician when a patient is non-adherent to an agreed-upon treatment plan as laid out in the Community Treatment Order (Form 45). The patient is brought to a healthcare facility by law enforcement. This does not need to be a hospital emergency room - it can be a clinic, or any other area where a physician works. The patient is then seen for examination and the treatment is then given to the patient. The physician who receives the Form 47 when the patient is brought into hospital can give the treatment, it does not have to be the same physician who issued the Form 47.

Good Practices for Issuing a Form 47

  • You must specify the hospital/location where you want the patient should be brought (e.g. - the patient has health records there and you want them to go there)
  • The patient can be given the medication/treatment as outlined in their CTO, and they cannot contest it or apply for a hearing
  • A Form 45 (CTO) should always go with a Form 47. This is important, because the Form 45 dictates the treatment plan, and the physician receiving the Form 47 needs to know what treatment plan is.

There are several common errors that physicians may make when assessing a patient brought in on a Form 47. Most commonly a patient brought into hospital on a Form 47 are seen in the emergency department.

Form 47 Myths and Common Errors

MD Myth/Error Explanation
“A patient on a CTO is always incapable.” Almost true. Most patients on a CTO are deemed incapable to consent. However, there are patients who are capable who also consent to a CTO as a “safety net.”
“I deem them to be not certifiable at this time.” A patient on a CTO is by definition, certifiable under Box B criteria of the Mental Health Act. Your one-time assessment of the patient at this time does not overturn the certifiability.
“I deem this patient to be capable at this time, and cannot initiate treatment” If the patient was previously found incapable, you cannot overturn a finding of incapacity based on your one-time assessment of the patient when they are brought in on the Form 47. If a patient is incapable (as typically is the case), they continue to be assumed incapable to consent to the treatment outlined in the CTO.
“I have not been able to reach the SDM, therefore I cannot initiate treatment.“ You still need to give the treatment, because there is already a treatment plan in existence as documented in the CTO. You do not need to contact the SDM as they have already given permission.
“I cannot give this person the treatment, because they are refusing it.” The patient cannot refuse treatment because a treatment plan has already been outlined in the CTO. You are legally able to enforce treatment.

Capable or Incapable?

A patient does not need to be incapable to be on a CTO, although the majority of patients are. Therefore, although 99% of the time, patients on a CTO are already deemed incapable, you must keep in mind there are also capable patients on CTOs. An example would be a patient with bipolar I, and episodes of mania where they decompensate rapidly. Patients like these may request the use of a CTO as as “safety net” to enforce treatment on them during a manic episode.

CTO for a Capable Patient vs. Incapable Patient

Incapable patient Capable patient
Can be brought in under a Form 47 and be obliged to accept treatment from previously dictated 6-month treatment plan (Form 45) Can be brought in on a Form 47, and be assessed for capacity and treatment, but ultimately, the patient can cancel the CTO if they want, provided they are still capable. If consent for CTO is withdrawn at any point, (even when they are well, or if the patient says: “by the way cancel that CTO” in a random phone call) you have a 72-hour period to re-assess the patient. You can actually re-issue a Form 47 to compel a patient to come to hospital for that assessment.

For Patients