Decision-Making Framework, 2021

Occupational therapists can be faced with both simple and complex decisions daily in their practice setting. The implications of these can have significant impacts on clients, occupational therapists, colleagues, organizations, and the healthcare system at large. 

Gathering and contemplating all the relevant factors involved in decision-making can be overwhelming. Information may be contradictory and incomplete, those involved in the decision-making can express intense feelings, and the consequences and risks can be very high. To help ensure that relevant aspects have been considered, this framework offers key considerations for occupational therapists when faced with practice decisions. 

Practical experience has been blended with current research to develop this framework. Because this process is not linear, the Prism Model of Ethical Decision-Making by VanderKaay and colleagues (2020) has been incorporated in steps three and four below. This descriptive model recognizes the dynamic nature of the decision-making process and reflects occupational therapy in the Canadian context.

The College’s decision-making framework refers to, and is designed to work in tandem with, the Standards for Practice and other College resources. 

To get down to the most important considerations, take some time to briefly describe the situation. Answering several key questions can help. There is an example below each question to help apply it to occupational therapy practice. In this example, the occupational therapist has received information about a client’s ability to drive safely and is faced with the decision on how to proceed. 

Question: What are the key elements of the situation? 

Example: An older adult is living alone and has been diagnosed with dementia. There has been recent cognitive and overall functional decline. He drives the car short distances for essential needs like groceries and medical appointments. Recently he got lost returning home from a medical appointment at new location. The occupational therapist is concerned about his driving and his ability to remain safe and independent. 

Question: What are the potential risks associated with the situation? 

Cueing questions: What could happen? How likely is it to occur? How severe would the outcome be? How can the chance of occurrence or the impact of the event be reduced? 

Example: The client got lost while driving an unfamiliar route and he demonstrates limited insight into the possible harm. The client has poor memory and is unable to recall emergency contact information such as his home address or his daughter’s cell phone number. With the progressive nature of the condition, another incident in the future is likely. Risk to the client could be severe if he is lost or in a car accident. 

Question: What is the decision to be made? 

Example: Does a discretionary report about fitness to drive need to be submitted right away? 

Question: Are there personal assumptions, biases, or cultural differences that could impact decision-making? (Fornari, 2015) 

Example: The occupational therapist reflects on their own assumptions about older adults and driving ability; on the importance of driving for independence, a sense of purpose, and socialization, but also thinks about the significant risk to the public if driving skills deteriorate and something harmful happens. 

Listed below are six contributing factors that influence an OT’s decision-making processes (VanderKaay et al., 2020). The factors have been expanded upon with relevant practice examples. Consider each one as it relates to the situation. 

Client and Family 

Remaining client centered sometimes requires occupational therapists to recognize the push and pull that can exist when attempting to respect both the autonomy and the safety of the client. Influencers such as client goals, preferences, lived experience, values, beliefs, and desired quality of life (van Bruchem-Visser et al., 2020) need to be articulated in the decision-making process. Clients and families want to have open and transparent discussions in this partnership involving their healthcare.

Example: The client wants to continue driving so he can remain living at home. The daughter recognizes the importance for his quality of life and sense of purpose. For safety reasons she insists on accompanying her father when driving, but the client prefers to drive alone. 

Organization and Practice Setting 

If occupational therapists are part of an organization, there may be guidance that sets out the expectations for certain types of situations, including policies or other guiding resources (for example, clinical decision-making tools or support processes). There may also be decision-making factors related to the wider healthcare system for consideration, for example, funding allotments for service, or principles of health equity and access to service.

Example: The occupational therapist refers to the organization’s Managing Risk tool. 

Theories and Evidence 

Occupational therapists are expected to use theories and evidence to inform decision, including those based in ethics. Theories are used to guide, plan, address issues, and support decisions, for example, what are the best practices given the situation, risks, and client factors. 

Ethical decisions do not usually present with a simple, or ideal, course of action. Occupational therapists often face ethical dilemmas where there is no clear or right answer. As occupational therapist grapple with the facts of the situation and the weighty implications of their decisions, they can look to the Code of Ethics which describes the fundamental values of respect and trust. Within each of these values, the Code of Ethics outlines key principles to help occupational therapists identify important factors to consider and guide possible actions to take. 

Example: The principle of respecting autonomy requires the occupation therapist to think about the client’s right to make their own choice and in this situation the client wants to keep driving even though it may pose a risk. At the same time, the occupational therapist is held accountable for their assessment as well as actions to lessen the likelihood of these safety risks occurring. Accountability and communication prompt the occupational therapist to discuss the safety concerns with the client and his daughter. The occupational therapist explains the decision to submit a discretionary report and the client has a chance to express his thoughts and to have his concerns addressed. 

Professional Regulations 

Occupational therapists will find out about any regulatory requirements that apply to the situation. The College’s Code of Ethics, the Essential Competencies, and the College’s Standards for Practice describe the required expectations for the day-to-day practice of occupational therapists. Other guidance is available for specific occupational therapy situations, such as the resource to the Child, Youth and Family Services Act for occupational therapists wanting to know more about the obligations for reporting a child who may need protection. 

Example: In this case, the occupational therapist reviews the College’s document on Discretionary Reporting of Fitness to Drive. This orients individuals to the legislation, accountabilities, and other key information, such as documentation, consent, and privacy. 

Healthcare Team 

While occupational therapists are accountable for their own professional decision-making, others, such as those in the circle of care, can add valuable perspectives and contribute to the reasoning and decision-making process. Discussing thought-provoking questions, clarifying facts, and generating options can help to talk through and narrow the course of action to be taken.

Example: The occupational therapist can bring up the situation at clinical rounds or speak separately to interprofessional team members for input. Perhaps this issue is already being addressed or monitored by another member of the healthcare team, such as the treating physician. 

Law 

Certain pieces of legislation directly impact specific aspects of occupational therapy practice. Examples of such legislation include the Child, Youth and Family Services Act, 2017; Health Care Consent Act, 1996; Regulated Health Professions Act, 1991; Personal Health Information Protection Act, 2004, and Highway Traffic Act 1990. 

Example: The occupational therapist reviews a section of Ontario Regulation 340/94: Drivers’ Licences made under the Highway Traffic Act, 1990, “14.2 For the purposes of subsection 203 (2) of the Act, the following are the prescribed persons who may report under that subsection: an occupational therapist, an optometrist, a nurse practitioner and a physician.” This confirms that occupational therapists are able to report concerns about a client’s fitness to drive directly to the Ministry of Transportation. 

Consulting with others who can provide additional expertise in a specific area can be enlightening. This can allow for a widened clinical perspective, brainstorming of possible outcomes, expertise in the domain, and professional support (VanderKaay et al., 2020). As a reminder, occupational therapists need to follow the Standards for Consent and Standards for Record Keeping to ensure client privacy when discussing personal health information. 

Consultation with others can include 

• Colleagues 
• Supervisors 
• Lawyers or legal professionals 
• Ethicists or an ethics board 
• Regulatory bodies 
• Other clinical or non-clinical professionals or subject matter experts 

During the process of contemplating all the information gathered, various options may emerge. Some factors may be weighted differently, such as level of risk, legislation, or preservation of quality of life for the client and their family. Relying on sound professional judgement, occupational therapists will prioritize and choose the best option. 

These prompts can assist in making and justifying the best choice (Winnipeg Regional Health Authority 2015): 

• What makes this the best approach? 
• Does the rationale sound reasonable when you say it aloud? 
• What is your professional instinct telling you? 

Recognize and Address Consequences 

Possible consequences of the decision should be thought out in advance and managed sensitively and appropriately to avoid unintended consequences. It is important to be aware of the impact on the client, their family, colleagues, and stakeholders, along with your ongoing role. The Code of Ethics notes that “values are the ethical building blocks of human behaviour and interaction. They are at the heart of our everyday exchanges, and shape how we relate to and treat others” (p. 2). Principles such as transparency, honesty, and respect can guide the approach to these delicate discussions. For example, it may be appropriate to inform a client about a mandatory report and allow them to express their thoughts and feelings, thereby promoting the need to provide education about the next steps. 

Document 

Document your decision-making process and update the client record appropriately. As outlined in the Standards for Record Keeping, “records should reflect the occupational therapist’s professional analysis and/or opinion, interventions, recommendations and ethical considerations” (p. 2). Standard 3.8 states that any data gathered and used to inform clinical decisions should be documented. 

To promote ongoing competence, take the time to evaluate and reflect on the decision-making process. Recognize the lessons learned and apply these should a similar scenario arise in future. These prompting questions can be used: 

• What was the impact of your decision on those involved? 
• Is there anything in your practice that needs to be adjusted now or in the future? 
• Is there a need for advocacy? 
• Assuming a similar situation presents itself, would you make the same choices? If no, what would you change? 

College of Occupational Therapists of Ontario. (2016). Standards for Record Keeping. https://www.coto.org/resources/standards-for-record-keeping

College of Occupational Therapists of Ontario. (2017). Standards for Consent. https://www.coto.org/resources/details/standards-for-consent-2017

College of Occupational Therapists of Ontario. (2018). Guide to Discretionary Reporting of Fitness to Drive. https://www.coto.org/resources/guide-to-discretionary-reporting-of-fitness-to-drive-2018

College of Occupational Therapists of Ontario. (2020). Code of Ethics. https://www.coto.org/resources/code-of-ethics

Fornari, A. (2015). Approaches to ethical decision-making. Journal of the Academy of Nutrition and Dietetics, 115(1), 119–121. https://doi.org/10.1016/j.jand.2014.10.026

Highway Traffic Act, Revised Statues of Ontario (1990, c. H.8). Retrieved from the Government of Ontario website: https://www.ontario.ca/laws/statute/90h08#BK332 

van Bruchem-Visser, R. L., van Dijk, G., de Beaufort, I., & Mattace-Raso, F. (2020). Ethical frameworks for complex medical decision making in older patients: A narrative review. Archives of Gerontology and Geriatrics, 90, 104160. 

VanderKaay, S., Letts, L., Jung, B., & Moll, S. E. (2020). Doing what’s right: A grounded theory of ethical decision-making in occupational therapy. Scandinavian Journal of Occupational Therapy, 27(2), 98–111. 

Winnipeg Regional Health Authority. (2015). Ethical decision-making framework: Evidence informed practice tool. https://professionals.wrha.mb.ca/old/education/files/EIPT.pdf