Information from the Practice Advice Service

QUERIES

During the first quarter of this fiscal year (June 1, 2024- August 31, 2024), the College’s Practice Advice Service addressed 383 inquiries. The five most common topics queried during this period, in descending order, were:

1. Supervision; most involving supervision of nonregistered providers, supervision records, and supervision of registered members of other professions
2. Mobility; most involving registrants wishing to practice in other jurisdictions
3. Records; most regarding successor Health Information Custodians, retention, and destruction of records
4. Fees and Billing; setting of fees, prepayment and retainers, and issuing receipts
5. Release of and Access to Information; consent, information about children, and client right of access to information

Many of these  questions, and answers to them, can be found on the Professional Practice FAQ page of the College website which includes the following recent additions.

INFORMED CONSENT; BEHAVIOUR ANALYSTS AND GENERAL INFORMATION

Q: Now that Behaviour Analysts are Regulated Health Professionals, can this group of clinicians now assess capacity to consent and if so, how does one determine capacity to consent to intervention?

A: As regulated health professionals Behaviour Analysts are now regulated by the Health Care Consent Act,1996  which require practitioners to assess clients’ ability to consent to treatment.

The Act states that:

A person is capable with respect to a treatment, admission to a care facility or a personal assistance service if the person is able to understand the information that is relevant to making a decision about the treatment, admission or personal assistance service, as the case may be, and able to appreciate the reasonably foreseeable consequences of a decision or lack of decision.

There are no published procedures that we are aware of for performing such an assessment. The same test applies to all health care providers in Ontario and each practitioner who intends to provide the service must conduct the assessment themselves.

While there is no formal procedure set in legislation, here are some general guidelines registrants may wish to consider when determining whether a client is capable of making a treatment decision:

1.           Review the relevant legislation: Health Care Consent Act.

2.           Provide the information that is relevant to making an informed decision regarding treatment, including the:

•             Nature of the patient’s condition
•             Nature and purpose of the patient’s treatment
•             Risks and benefits of the proposed treatment
•             Risks and benefits of alternative treatments including the option of no     treatment at all

3.           Determine whether the patient understands the information

•             Ask the patient to explain what they have been told, in their own words

4.           Determine whether the patient appreciates the situation and its consequences

•             Ask the patient to describe the condition, proposed treatment and the likely outcome

If the patient passes the “understand and appreciate” test, they may make the decision to either accept or refuse treatment themselves. If the client does not pass the test, the health professional will need to obtain the consent of the appropriate substitute decision maker before anything other than emergency treatment, as set out in the Act, subject to any other circumstances described in the Act as exceptions.

EXISTING CLIENTS EXPERIENCING NEW DIFFICULTIES OUTSIDE OF A MEMBER’S AUTHORIZED AREA OF PRACTICE

Q: I am working with a client to address the client’s longstanding personality disorder. The client has recently experienced a traumatic brain injury, which has resulted in behavioural change, including disinhibition and impulsivity. If I am not authorized to provide services in the area of clinical neuropsychology, may I continue to work with the client?

A: In deciding whether one is authorized and competent to provide a service, the nature of the client’s presenting difficulties will generally determine whether the member has the appropriate and required authorization. In this case, the initial presenting problems did not include the difficulties associated with the traumatic brain injury. It may, however, be difficult to intervene effectively without the knowledge and experience necessary to understand the complexities of central nervous system dysfunction.

As long as the focus of your intervention is the challenges associated with a personality disorder, you may be able to continue to work within your established clinical relationship with the client, if you obtain consultation from a member authorized in clinical neuropsychology, who can help to tailor the interventions to take into account the client’s new challenges. If the task becomes one of helping the client address these new challenges as well, then it may be appropriate to consider a referral for someone authorized in both clinical psychology and clinical neuropsychology.

INFORMED CONSENT WITH RESPECT TO MANDATED DISCLOSURE OF PERSONAL HEALTH INFORMATION IN THE ABSENCE OF CONSENT

Q: In the course of obtaining informed consent with a client, a client informed me that they do not grant consent for me to share information with the College in the event of a Quality Assurance review of their file. I have been selected at random for a Peer Assisted Review and must make my files available so that the Assessor and Reviewer can select files at random. What should I do?

A: This is a difficult situation. If you agreed to such a request, please contact the Quality Assurance team at the College. Depending on the circumstances, they will do their best to assist in finding a creative solution.

The College has the authority to obtain a file in the absence of client consent. This is set out in legislation and is non-negotiable. In obtaining consent to collect personal health information, which must be done before collecting the information, it is important to avoid giving the false impression that the client has any control over whether the College exercises it’s legislated duty to obtain information in procedures designed to protect the public interest, in this case, to ensure that members are practicing competently and ethically.   

While it is understandable that clients want to have control over who has access to what is often their most private information, careful framing of the issue may help avoid at least some difficulties of this nature. It may be best to let clients know that in order to provide the services they are seeking, you must  maintain a file in accordance with the College’s requirements (available on the College’s website) and that, while you will protect their confidentiality where client consent is required before disclosing their personal health information, there are some situations in which legislation mandates disclosure, even in the absence of consent. This is the case when review of information is required in order to protect clients and others from harm. In other words, the question is: do you agree to engage in services with the knowledge that I must keep a clinical record and that in rare circumstances the law allows access to the file without consent?

It may also help to advise that this applies to any service by a regulated health professional in Ontario who is practicing ethically and lawfully. Additionally, the College and all of it’s agents and staff have a strict duty of confidentiality and that in Quality Assurance matters, where the College Assessor and Reviewer may have access to the identity of a client whose file is under review, the Committee members will not be provided with identifying information.