The Practice Advice Service provides information to College members and members of the public about relevant Legislation, Regulations, Standards of Professional Conduct, and other practical considerations. Answers are provided by College staff in response to specific inquiries and may not be applicable or generalized to all circumstances. Information is provided to support College members in exercising their professional judgment with respect to ethical matters and is not an appropriate substitute for advice from a qualified clinician or legal professional.
QUERIES
During the third quarter of this fiscal year (December 1, 2023- February 29, 2024), the College’s Practice Advice Service addressed 475 inquiries. The five most common topics queried during this period, in descending order, were:
- Mobility and practice in other jurisdictions; mostly relating to member practice outside of Ontario
- Supervision; mostly relating to the supervision of those who are not members of the College
- Permitting access to client records; mostly relating to consent and the client’s right of access to information
- Fees & Billing; mostly relating to the setting of fees and obtaining pre-payment for services
- Records; mostly relating to retention and destruction of records, planning for succession of a health information custodian and required content of records
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.
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.
consent to permit parental access to client information by a young client with signs of possible incapacity.
Q: I recently conducted a psychoeducational assessment of an 18-year-old client referred by their parents. They present with cognitive abilities at the 1st percentile, although there is variability among subscale scores, with some within the low average ranges.
The client originally provided consent to share results of the assessment with their parents, but subsequently rescinded consent out of fear that their parents would be critical and punish what they may believe represents poor performance.
Would it be appropriate to attempt to engage the client in discussion of the pros and cons of sharing the results with their parents, who appear supportive of the client, or perhaps have a discussion with all three of them together, without sharing the results, about how the parents could respond to the information in a positive, supportive way?
A: The first thing to do in this situation is make a decision about whether the client has the capacity to give direction concerning the release of their personal health information. As you likely know, capacity is not directly tied to IQ scores and must be made solely on the “understand and appreciate” test which is explained in section 21 of PHIPA. It’s important to note that the threshold for capacity is lower with low-risk decisions. The understand and appreciate test was constructed for a wide range of situations covering all of the health professions and for a wide range of situations with more complex information and higher risk decisions to be made, like invasive surgeries.
If the client is not capable of making the decision regarding parental access to the assessment results, it might be better not to give the client the false impression that they have control here and then ignore their wishes if they are deemed incapable and parents are eligible to act as substitute decision makers. Even in situations like this, it is still important to involve an incapable person in the process to the extent possible.
If the client has an understanding of what the relevant information is and means, and also has an understanding of the consequences of sharing or not sharing the information, or in other words is found to be capable, then based upon your own clinical judgment, it could be very helpful to engage the three of them in discussion, with the client’s capable consent, of course.
If the client is not capable, the client would have the right to appeal the decision by the Consent and Capacity Review Board.
Having a discussion with the parents about how to deal with the results, without disclosing the results, would also require the consent of the client and this would require a determination of whether the client has the capacity to grant consent to that. This is a different decision, with perhaps a lower threshold for capacity, than the decision to share the actual results. If the client is capable of granting consent to a discussion of that nature, it could possibly help identify a helpful path forward.
Considering Retirement?
Annual membership renewal time is approaching. As is often the case at renewal time, we are receiving queries about retirement and about arrangements for the transfer of records to new health information custodians and other related matters. Anyone considering retirement may wish to review this article originally published in July, 2020: Preparation for Closing Your Practice and Preparing a Professional Will .
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, the 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 be 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, 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.
You may also like to know that 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 client’s identity, the College staff and Committee members reviewing the results of a Quality Assurance procedure are not given any identifying information about the clients whose files have been reviewed. The focus of the procedure is the registrant and whether the review indicated that the registrant is practicing competently and ethically.