Standard for Consent, 2023

Collaborate with clients using relevant communication and information-gathering methods to determine capacity. Use interpreters or augmentative communication tools if needed. Allow time for clients to understand the information and ask questions before finalizing capacity decisions.

Assume that clients are capable of providing consent unless there is information that indicates otherwise. Do not presume incapacity based on:

1. Age
2. Communication challenges
3. Diagnosis of a psychiatric or neurological condition
4. Disability
5. The fact that a guardian, power of attorney, or substitute decision-maker is in place
6. Language differences
7. Personal bias about social or cultural structures of marginalized groups or communities
8. Refusal of intervention

Assume that clients are capable of providing consent unless there is information that indicates otherwise. Do not presume incapacity based on:

1. Age
2. Communication challenges
3. Diagnosis of a psychiatric or neurological condition
4. Disability
5. The fact that a guardian, power of attorney, or substitute decision-maker is in place
6. Language differences
7. Personal bias about social or cultural structures of marginalized groups or communities
8. Refusal of intervention

Gather relevant information and apply clinical reasoning and judgement to determine the client’s capacity to decide on the proposed services.

If the occupational therapist finds that the client does not have the capacity to provide consent:

1. Explain to or assist the client in exercising their right to have a review of the finding.
2. Use the Health Care Consent Act, 1996 hierarchy of substitute decision-makers (see Appendix) to determine who is to provide consent.
3. Inform the client that the substitute decision-maker will make decisions regarding occupational therapy services. Involve the client in discussions about services whenever possible.

Follow the Health Care Consent Act,1996 to ensure that clients have all the information a reasonable person would need to decide about the occupational therapy services. This information includes:

1. Scope and reason for the referral or services
2. Purpose and nature of the services
3. Expected benefits and risks of proceeding, including any cultural, ecological, or economic considerations
4. Likely consequences of not proceeding
5. Expected outcomes
6. Alternative courses of action
7. The right of clients to withdraw consent at any time
8. How services will be paid for
9. Any legal authority given through a legal process for occupational therapy services

Allow time and opportunity for questions and discussion about the proposed services.

Respect clients’ choice if they decide not to proceed.

Explain each component of the plan, and obtain ongoing consent when moving from one component of services to another.

Use interpreters or augmentative communication tools to support the informed consent process.

Obtain consent from clients to involve others in service delivery, such as students and occupational therapy assistants. Clarify their roles and responsibilities.

Be clear about any fees involved and ensure that they are agreed upon before services start.

Apply an informed consent process to third party referrals (for example, independent examinations or expert reports). Explain that the services are at the request of the third party payer. Describe the nature and scope of the occupational therapist’s role and reporting responsibilities.

Provide professional contact details in case questions arise later about how information was collected, used, and shared during occupational therapy service delivery.

For third party referrals (for example, independent examinations or expert reports):

1. Obtain consent for the disclosure of assessment results, reports, and intervention plans to third party payers, other professionals, partners, and interested parties unless exceptions to this disclosure apply under privacy legislation
2. Obtain consent before reviewing any additional client health information that was provided by the third party after the original assessment services were completed (for example, other medical reports or surveillance material).

Collect only as much client information as is needed to provide the services.

Access only records that apply to the occupational therapist’s role and practice.

Protect the confidentiality of client information, and ensure that all information is secured against unauthorized access, loss, or theft.

Understand privacy legislation and organizational policies and procedures.

In the case of third party referrals, take reasonable measures to ensure that any assessment information shared is accurate and represents the occupational therapist’s professional opinion.

Ensure that documentation is timely (determined by practice factors such as workplace policies, client risk, and reporting priorities) and includes notes on these details:

1. Whether or not the client understood and agreed to all, some, or none of the proposed services and plans of care.
2. Risks, limitations, and benefits of the services discussed.
3. Any limits imposed on the collection, use, and disclosure of the client’s personal information and personal health information.
4. Type of alternative communication methods used or details of interpretation services.
5. Name of the substitute decision-maker. If applicable, include a copy of authorizing documents such as power of attorney for personal care.

Ensure that clients understand their right to withdraw consent and any implications of doing so.

If the client withdraws consent, continue the services only if immediate withdrawal poses a serious risk to the health or safety of the client or others. Explain to the client why the withdrawal cannot be immediate.

Ensure that the record includes all services provided before consent was withdrawn and the reasons the clients withdrew consent (if known).

If the client withdraws consent for disclosure of health information, explain that withdrawal cannot be applied retroactively to information already shared.