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teaching:on-mha:home [2019/05/20 16:36]
psychdb
teaching:on-mha:home [2020/05/19 14:52] (current)
psychdb [Substitute Decision Makers (SDMs)]
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 ====== Introduction to Ontario'​s Mental Health Laws ====== ====== Introduction to Ontario'​s Mental Health Laws ======
 +{{INLINETOC}}
 ===== Primer ===== ===== Primer =====
-The **Mental Health Act (MHA)** and **Health Care Consent Act (HCCA)** are two pieces of legislation that guide mental health care and health care in Ontario, Canada. The Mental Health Act (MHA) applies to psychiatric care, and provides rules and a legal process for voluntary, informal and involuntary admissions. The Health Care Consent Act (HCCA) applies to all aspects of health care and provides rules for obtaining informed, voluntary consent for treatment, and involvement from substitute decision makers.+The **Mental Health Act (MHA)** and **Health Care Consent Act (HCCA)** are two pieces of legislation that guide mental health care and health care in Ontario, Canada. The Mental Health Act (MHA) applies to psychiatric care, and provides rules and a legal process for voluntary, informaland involuntary admissions. The Health Care Consent Act (HCCA) applies to all aspects of health care (both medical and psychiatric) ​and provides rules for obtaining informed, voluntary consent for treatment, and involvement from substitute decision makers.
  
 ===== Mental Health Act (MHA) ===== ===== Mental Health Act (MHA) =====
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 The **Mental Health Act**'​s (MHA) purpose is to regulate the involuntary admission and treatment of people into a psychiatric hospital. Major changes were made to the law in 2000, which introduced the role of [[teaching:​on-mha:​form-45-47-49-cto|Community Treatment Orders]]. In broad strokes, the the Mental Health Act in Ontario allows physicians to assess ([[teaching:​on-mha:​form-1-42|Form 1]]) and also to detain ([[teaching:​on-mha:​form-3|Form 3]], [[teaching:​on-mha:​form-4|Form 4]], [[teaching:​on-mha:​form-4#​form-4a|Form 4A]]) patients for set periods of time. The Health Care Consent Act and Mental Health Act also allows for the involuntary treatment of patients if they are incapable ([[teaching:​on-mha:​form-33|Form 33]]). The **Mental Health Act**'​s (MHA) purpose is to regulate the involuntary admission and treatment of people into a psychiatric hospital. Major changes were made to the law in 2000, which introduced the role of [[teaching:​on-mha:​form-45-47-49-cto|Community Treatment Orders]]. In broad strokes, the the Mental Health Act in Ontario allows physicians to assess ([[teaching:​on-mha:​form-1-42|Form 1]]) and also to detain ([[teaching:​on-mha:​form-3|Form 3]], [[teaching:​on-mha:​form-4|Form 4]], [[teaching:​on-mha:​form-4#​form-4a|Form 4A]]) patients for set periods of time. The Health Care Consent Act and Mental Health Act also allows for the involuntary treatment of patients if they are incapable ([[teaching:​on-mha:​form-33|Form 33]]).
  
-The MHA focuses on detention of patients, and thus MHA alone does not allow you to force treatment (there must be a finding of incapacity under the Health Care Consent Act needs be be used in conjunction ​as well). Only emergency psychiatric treatment is allowed in the event of significant morbidity or mortality. Therefore, if there is no emergency and a patient refuses treatment, you **must** respect the wishes of the patient. A patient could //​theoretically//​ be in a situation where they detained under the MHA, but are capable and NOT treated.+The MHA focuses on detention of patients, and thus the MHA alone does not allow you to force treatment (there must be a finding of incapacity under the Health Care Consent Act as well). Only emergency psychiatric treatment is allowed in the event of significant morbidity or mortality. Therefore, if there is no emergency and a patient refuses treatment, you **must** respect the wishes of the patient. A patient could //​theoretically//​ be in a situation where they detained under the MHA, but are capable and NOT treated ​(e.g. - a patient with schizophrenia can be detained under the MHA due to harm to others, but still be capable to make a decision to refuse an antipsychotic).
 </​WRAP>​ </​WRAP>​
 <WRAP half column> <WRAP half column>
-== Mental Health Act Forms == +~~DIR?​tag=form&​hdrs=Mental Health Act and Forms~~
-~~DIR?​tag=form&​noheader~~+
  
 </​WRAP>​ </​WRAP>​
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 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
-The **Health Care Consent Act (HCCA)** applies to all aspects of health care in Ontario and provides rules for obtaining informed, voluntary consent from a substitute decision maker. Section 4 of the HCCA outlines the guidelines for consent and capacity (one shall not administer ​medications ​without a patient'​s consentotherwise it is battery or assault).+The **Health Care Consent Act (HCCA)** applies to all aspects of health care in Ontario and provides rules for obtaining informed, voluntary consent from a substitute decision maker. Section 4 of the HCCA outlines the guidelines for consent and capacity (one shall not administer ​treatment ​without a patient'​s consent ​otherwise it is battery or assault)
 + 
 +The HCCA is what allows you to determine whether treatment can be imposed on an individual if you do not think they are capable. Only a finding of incapacity under the HCCA allows you to treat the patient against their wishes (i.e. - involuntary treatment). Remember, [[teaching:​on-mha:​consent-capacity|capacity]] is treatment-specific.
  
-The HCCA is what allows you to determine whether treatment can be imposed. Only a finding of incapacity under the HCCA allows you to treat the patient against their wishes. Remember, capacity is treatment-specific. An individual with schizophrenia can be detained under the MHA due to harm to self, but still be capable to make a decision to refuse an anti-psychotic. 
 </​WRAP>​ </​WRAP>​
 <WRAP half column> <WRAP half column>
-== Consent and Capacity Assessments == +~~DIR?​tag=capacity&​hdrs=Capacity Assessment and Laws~~
-~~DIR?​tag=capacity&​noheader~~+
  
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
  
 +==== Psychiatric vs. Medical Incapacity in Ontario ====
 +
 +<panel type="​info"​ title="​Incapacity for Mental Health vs. Medical Treatment"​ subtitle=""​ no-body="​true"​ footer="">​
 +^                                          ^ Incapacity for Mental Health Treatment ​                                                                 ^ Incapacity for Medical Treatment ​                                                                                                                                                                         ^
 +^ Example Diagnosis ​                       | Schizophrenia ​                                                                                          | Diabetic Ketoacidosis ​                                                                                                                                                                                    |
 +^ Cause of Incapacity ​                     | Delusions and hallucinations leading to inability to appreciate that treatment is needed ​               | Delirium and decreased level of consciousness leading to inability to understand and appreciate that treatment is needed ​                                                                                 |
 +^ Treatment ​                               | Antipsychotics ​                                                                                         | Insulin ​                                                                                                                                                                                                  |
 +^ Mental Health Act (MHA) Applies? ​        | Yes                                                                                                     | No                                                                                                                                                                                                        |
 +^ Health Care Consent Act (HCCA) Applies? ​ | Yes                                                                                                     | Yes                                                                                                                                                                                                       |
 +^ [[teaching:​on-mha:​form-33|Form 33]]      | Required ​                                                                                               | Not required (Rights Advisor does not need to be not notified. Rights Advice only needs to be provided by the health practitioner) ​                                                                       |
 +^ Leaving Against Medical Advice ​          | Can leave if status is a voluntary patient. Otherwise, cannot leave if on a Form 1, Form 3, or Form 4.  | Can leave if status is a voluntary patient. If there is a legitimate safety concern about the patient leaving, you would thus need to issue a Form 1 (e.g. - trying to leave during an episode of delirium) ​ |
 +</​panel>​
 +
 +<callout type="​warning"​ title="​Grey Areas" icon="​true">​
 +There may be situations where a patient may have both medical and psychiatric issues (e.g. delirium + schizophrenia,​ substance intoxication + schizophrenia,​ diabetic ketoacidosis + schizophrenia),​ and it is unclear which underlying issue is causing the incapacity. In this case, you will want to carefully document your reasoning (e.g. - why you think it is primarily psychiatric or primarily medical).
 +</​callout>​
 ==== Substitute Decision Makers (SDMs) ==== ==== Substitute Decision Makers (SDMs) ====
 <WRAP group> <WRAP group>
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   * **The SDM(s) must be available, capable, and willing**   * **The SDM(s) must be available, capable, and willing**
   * Multiple SDMs of the same rank can be involved   * Multiple SDMs of the same rank can be involved
-  * If SDMs of the same rank disagree on a treatment (i.e. - feuding SDMs) and cannot come to an agreement, then the decision will automatically go to the PGT. Therefore, it is in the existing SDM(s) best interest to come towards an agreed decision.+  * If SDMs of the same rank disagree on a treatment (i.e. - feuding SDMs) and cannot come to an agreement, then the decision will automatically go to the Public Guardian and Trustee (PGT). Therefore, it is in the existing SDM(s) best interest to come towards an agreed decision.
   * SDMs must comply with the most recent expressed capable wishes of the patient (or if unknown, the best interests)   * SDMs must comply with the most recent expressed capable wishes of the patient (or if unknown, the best interests)
   * If the MD thinks the SDM not acting in accordance with principles of HCCA, the PGT can be contacted   * If the MD thinks the SDM not acting in accordance with principles of HCCA, the PGT can be contacted
-  * Even if an SDM is involved, you should still involve the patient as much as possible! (e.g. - tell patient that SDM will assist them and make the final decision, ​but still involve patient as much as possible in discussions ​with SDM+  * Even if an SDM is involved, you should still involve the patient as much as possible! (e.g. - tell patient that SDM will assist them and make the final decision, ​and still involve patient as much as possible in treatment ​discussions) 
-  * If patient disagrees with having a specific SDM, the MD can try to find another substitute of the same or senior rank, or advise the patient to apply for a review through a [[teaching:​on-mha:​consent-capacity-board-hearings|Consent and Capacity Board (CCB) Hearing]]+  * If patient disagrees with having a specific SDM, the MD can try to find another substitute of the same or senior rank, or advise the patient to apply for a review through a [[teaching:​on-mha:​consent-capacity-board-hearings|Consent and Capacity Board (CCB) Hearing]]
 </​WRAP>​ </​WRAP>​
  
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 </​WRAP>​ </​WRAP>​
  
-===== Psychiatric vs. Medical Incapacity in Ontario ===== 
- 
-<panel type="​info"​ title="​Incapacity for Mental Health vs. Medical Treatment"​ subtitle=""​ no-body="​true"​ footer="">​ 
-^                                          ^ Incapacity for Mental Health Treatment ​                                                                 ^ Incapacity for Medical Treatment ​                                                                                                                                                                         ^ 
-^ Example Diagnosis ​                       | Schizophrenia ​                                                                                          | Diabetic Ketoacidosis ​                                                                                                                                                                                    | 
-^ Cause of Incapacity ​                     | Delusions and hallucinations leading to inability to appreciate that treatment is needed ​               | Delirium and decreased level of consciousness leading to inability to understand and appreciate that treatment is needed ​                                                                                 | 
-^ Treatment ​                               | Antipsychotics ​                                                                                         | Insulin ​                                                                                                                                                                                                  | 
-^ Mental Health Act (MHA) Applies? ​        | Yes                                                                                                     | No                                                                                                                                                                                                        | 
-^ Health Care Consent Act (HCCA) Applies? ​ | Yes                                                                                                     | Yes                                                                                                                                                                                                       | 
-^ [[teaching:​on-mha:​form-33|Form 33]]      | Required ​                                                                                               | Not required (Rights Advisor does not need to be not notified. Rights Advice only needs to be provided by the health practitioner) ​                                                                       | 
-^ Leaving Against Medical Advice ​          | Can leave if status is a voluntary patient. Otherwise, cannot leave if on a Form 1, Form 3, or Form 4.  | Can leave if status is a voluntary patient. If there is a legitimate safety concern about the patient leaving, you would thus need to issue a Form 1 (e.g. - trying to leave during an episode delirium) ​ | 
-</​panel>​ 
  
 ===== Summary of Laws and Acts in Ontario ===== ===== Summary of Laws and Acts in Ontario =====
 <panel type="​info"​ title="​Health Laws and Acts in Ontario"​ no-body="​true">​ <panel type="​info"​ title="​Health Laws and Acts in Ontario"​ no-body="​true">​
 ^ Act/​Law ​                                            ^ What It Does                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 ^ ^ Act/​Law ​                                            ^ What It Does                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 ^
-^ Mental Health Act (MHA)                             | • Mental health/​illness-related admissions (voluntary, involuntary,​ and informal), and rights advice, plus CCB hearings. \\ • Community Treatment Orders ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    ​|+^ Mental Health Act (MHA)                             | • Mental health/​illness-related admissions (voluntary, involuntary,​ and informal), and rights advice, plus [[teaching:​on-mha:​consent-capacity-board-hearings|Consent and Capacity Board hearings]]. \\ • [[teaching:​on-mha:​form-45-47-49-cto|Community Treatment Orders]]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    ​|
 ^ Health Care Consent Act (HCCA) ​                     | • Capacity determinations regarding treatment decisions, care facility admissions and personal service decisions \\ • HCCA presumes capacity for all ages; no age of consent in Ontario \\ • Rules for informed consent from capable person or SDM \\ • SDM hierarchy \\ • Emergency decisions ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              | ^ Health Care Consent Act (HCCA) ​                     | • Capacity determinations regarding treatment decisions, care facility admissions and personal service decisions \\ • HCCA presumes capacity for all ages; no age of consent in Ontario \\ • Rules for informed consent from capable person or SDM \\ • SDM hierarchy \\ • Emergency decisions ​                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              |
 ^ Substitute Decisions Act (SDA)                      | • Legal framework for POA for personal care and property decisions and challenges to same \\ • Considered a piece of companion legislation to the MHA and HCCA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               | ^ Substitute Decisions Act (SDA)                      | • Legal framework for POA for personal care and property decisions and challenges to same \\ • Considered a piece of companion legislation to the MHA and HCCA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               |
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 ===== Resources ===== ===== Resources =====
 +<WRAP group>
 +<WRAP third column>
 ==== For Providers ==== ==== For Providers ====
-  * {{:​canada:​mental_health_act_flow_chart.pdf|Mental Health Act Flow Chart}} 
   * {{:​canada:​what_is_the_mental_health_act-_ontario_.pdf|What is the Mental Health Act?}}   * {{:​canada:​what_is_the_mental_health_act-_ontario_.pdf|What is the Mental Health Act?}}
   * {{ :​teaching:​on-mha:​a_practical_guide_to_mental_health_law_in_ontario_2016_september_revised.pdf |A Practical Guide to Mental Health Law}}   * {{ :​teaching:​on-mha:​a_practical_guide_to_mental_health_law_in_ontario_2016_september_revised.pdf |A Practical Guide to Mental Health Law}}
 +</​WRAP>​ 
 +<WRAP third column>​ 
 +==== For Patients ==== 
 +  * [[https://​www.sse.gov.on.ca/​mohltc/​ppao/​en/​default.aspx|Psychiatric Patient Advocate Office (PPAO)]] 
 +    * [[https://​www.sse.gov.on.ca/​mohltc/​ppao/​en/​Pages/​InfoGuides/​2016_CommunityTreatmentOrders.aspx?​openMenu=smenu_InfoGuides|Community Treatment Orders]] 
 +</​WRAP>​ 
 +<WRAP third column>
 == Legal == == Legal ==
   * [[https://​www.lco-cdo.org/​en/​our-current-projects/​legal-capacity-decision-making-and-guardianship/​funded-research-papers-legal-capacity-decision-making-and-guardianship/​health-care-consent-and-advance-care-planning-in-ontario-2/​iii-capacity-and-informed-consent-to-treatment-ontario/​|Law Commission of Ontario: III. Capacity and Informed Consent to Treatment (Ontario)]]   * [[https://​www.lco-cdo.org/​en/​our-current-projects/​legal-capacity-decision-making-and-guardianship/​funded-research-papers-legal-capacity-decision-making-and-guardianship/​health-care-consent-and-advance-care-planning-in-ontario-2/​iii-capacity-and-informed-consent-to-treatment-ontario/​|Law Commission of Ontario: III. Capacity and Informed Consent to Treatment (Ontario)]]
 +</​WRAP>​
 +</​WRAP>​
 +
 {{tag>​form}} {{tag>​form}}