2013 TCCTCMPAO - Jurisprudence Handbook (Sept 2013)

8/10/2019 2013 TCCTCMPAO - Jurisprudence Handbook (Sept 2013)

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ImportantLegalPrinciplesPractitionersNeedtoKnow

TableofContents

1. ProfessionalismandSelfRegulation.................................................................... 4

a. Theconceptofselfregulation................................................................. 4

b. Ethics,professionalstandards,professionalmisconduct,incompetence,

incapacity.................................................................................................. 6

2. Communication.................................................................................................... 11

a.

Introduction.............................................................................................. 11

b.

Informedconsent..................................................................................... 12

c.

Boundariesandsexualabuse................................................................... 19

d.

Interprofessionalcollaboration................................................................

26

e.

Billing........................................................................................................ 28

3. Law....................................................................................................................... 30

a.

Typesoflaw.............................................................................................. 30

b. RHPA......................................................................................................... 31

i. Controlledactsanddelegation..................................................... 31

ii. Scopeofpractice.......................................................................... 36

iii. Useoftitles................................................................................... 38

iv. Mandatoryreports....................................................................... 39

v. Publicregister............................................................................... 45

vi.

Professional

corporations.............................................................

46

c. TCMA,regulations,bylaws...................................................................... 48

i.

Registrationregulation................................................................. 49

ii. Professionalmisconductregulation............................................. 51

iii. Recordkeeping............................................................................. 55

iv.

Conflictsofinterest...................................................................... 59

v.

Advertising................................................................................... 62

d.

TheCollege............................................................................................... 64

i.

Registrationprocess..................................................................... 64

ii. Complaintsanddisciplineprocess................................................ 66

iii. Incapacityprocess......................................................................... 72

iv.

Qualityassurance

program...........................................................

75

e. Otherlaws................................................................................................. 78

i. PHIPA............................................................................................. 78

ii. PIPEDA........................................................................................... 85

iii. HealthCareConsentAct............................................................... 86

iv. ChildandFamilyServicesAct........................................................ 87

v. LongTermCareHomesAct........................................................... 89

vi. HumanRightsCodeandAccessibilityforOntariansWithDisability

Act.................................................................................................. 91

vii.

Municipallicensing........................................................................ 96


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IntroductionandOverview

ThepurposeofthisbookandthejurisprudencecourseistoprovideinformationontheethicalandlegalframeworkwithinwhichTCMPractitionersandAcupuncturistspracticeinOntario.

Thisbookwillfirstdiscusstheconceptsofprofessionalismandselfregulation.TheTraditional

ChineseMedicineActisbasedontheseconcepts.Thebookwillthenlookathowproper

communicationwithpatientsandcolleaguesisfundamentaltoaprofessionalpractice.For

example,informedconsentisnotpossiblewithoutcommunication.Thebookwillthenreview

thevariouslawsthatpractitionersaremostlikelytohavetodealwithintheirpractice.

InthisbookthereareanumberofActsthatarereferredtobytheirabbreviationsincludingthe

following:

AODAAccessibilityforOntarianswithDisabilityAct

CFSA ChildandFamilyServicesAct

HCCA HealthCareConsentAct

PHIPAPersonalHealthInformationProtectionAct

PIPEDAPersonalInformationProtectionandElectronicDocumentsAct

RHPARegulatedHealthProfessionsAct

TCMA TraditionalChineseMedicineAct


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1. ProfessionalismandSelfRegulation

Aprofessionisdifferentfromabusiness.Membersofaprofessionbelievethattheyhelppatients,notjustmakemoneyfromthem.Practitionershaveanumberofdutiestothepatients

theyserve.Forexample,practitionershavethedutytobehonestwithpatients.Practitioners

haveadutytoprovidegoodservicetopatients.Practitionershaveadutytotellpatientswhat

theyaregoingtodotothepatientandtoaskforthepatientsconsentbeforedoingit.

Beingamemberofaprofessionalsomeansthatpractitionershaveadutytoothermembersof

theprofession.Practitionershaveadutytobepolitetoeachother.Practitionershaveadutyto

workwithfellowpractitionerstoservethewelfareoftheirpatients.Forexample,practitioners

needtotrytocoordinatethecareofapatienttheyarebothtreatingwheneverpossible(and

thepatient

consents).

PractitionersalsohaveadutytoworkwiththeirregulatoryCollegetoprotectthepublicfrom

dishonestorincompetentpractitioners.Forexample,practitionersarerequiredtocooperatein

aninvestigationofacomplaint.

Professionalsmustalsoobeythelawsthatapplytothem.Therearemanydifferentlawsthat

applytoapractitioner.Thepurposeofthisbookistodescribesomeoftheselawsinageneral

waysothatpractitionersunderstandthebasicprinciples.Itdoesnotcoveralloftheexceptions

andspecialcircumstancesthatariseinreallife.Ifapractitionerhasaspecificlegalquestion

about

their

own

circumstance,

they

should

seek

advice

from

a

lawyer.

a. Theconceptofselfregulation

Theregulationofanactivitymeansthatthelawimposesrestrictionsontheactivitytoensure

thatthepublicarenotharmed,andactuallybenefit,fromit.Therearemanywaysinwhichan

activitycanberegulated.Forexample,thegovernmentcouldcreateoffencesforimproperly

doingtheactivity,orthegovernmentcouldhaveoneofitsMinistriesoverseeingtheactivity.

InOntario,mostprofessionsareselfregulated.Inmanyotherpartsoftheworld,professions

areregulateddirectlybythegovernmentorthroughgeneralconsumerprotectionlaws.Ontario

haschosen

this

model

so

that

those

who

best

understand

the

profession

are

involved

in

its

regulation.

SelfregulationmeansthattheOntariogovernmenthasmadeastatute(oftencalledanAct)

givingthedutytoregulatetheprofessiontoaseparatebody(calledaCollege)themajorityof

whoseCounciliselectedbytheprofession.TheCollegeisaregulatorybody,notaneducational

institution.TheCouncilistheBoardofDirectorsoftheCollege.TheCouncilestablishesthe

policiesoftheCollege(e.g.,itmakestheprofessionalmisconductregulations)andoverseesthe

administrationoftheregulatoryactivitiesoftheCollege(e.g.,itestablishesthebudgetforthe

qualityassuranceprogramoftheCollege).TheCollegeoperatesthroughcommittees(e.g.,the


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RegistrationCommittee,theDisciplineCommittee)themajorityofwhosemembersarefrom

theprofession,withothermemberscomingfromthepublic.

ThemandateoftheCollegeistoservethepublicinterest.Itdoesthisbyregulatingthe

professioninthepublicinterest.Underitsstatute,theCollegehasadutytoserveandprotect

thepublicinterest.TheCollegecannotservetheselfinterestoftheprofession(e.g.,the

Collegecannotsetfeestobechargedtopatients,norcanitadvocatetothegovernmenton

behalfoftheinterestsoftheprofession);thatistheroleofaprofessionalassociation,nota

regulatoryCollege.Selfregulationdoesnotmeanselfinterest;infactitmeansexactlythe

opposite.Selfregulationmeansservingthepublicinterest.Thatis,theCollegeensuresthatthe

professionactshonestlyandcompetently.

Thereare

anumber

of

safeguards

that

ensure

that

the

College

serves

the

public

interest,

includingthefollowing:

i.

TheCouncilandthecommitteesoftheCollegealsohavepublicmembersonthem

(i.e.,nonpractitionersappointedbythegovernment).TheActrequiresthatpublic

memberscompriseasizeableminorityoftheCouncilanditscommittees.

ii. Councilmeetingsanddisciplinehearingsareopentothepublic.Observerscan

attendandwatchwhathappens.

iii. TheCollegemustconsultwithmembersoftheprofessionandthepublicbefore

makingaregulationorbylawaffectingthem.TheCollegemustcirculatefor

comment

the

proposed

wording

of

a

proposed

regulation

and

many

by

laws

for

a

periodofatleast60days.

iv.

DecisionsofthecommitteesoftheCollegecanbereviewedbyotherbodies.For

example,decisionsoftheRegistrationCommitteeortheInquiries,Complaintsand

ReportsCommitteecanbereviewedbytheaffectedindividualstotheHealth

ProfessionsAppealandReviewBoard(HPARB).DecisionsoftheDiscipline

CommitteeortheFitnesstoPractiseCommitteecanbeappealedtotheDivisional

Court.

v.

ThegovernmenthasappointedtwobodieswhoensurethattheCollegeactsinthe

publicinterest.TheOfficeoftheFairnessCommissionermakessurethatthe

Collegesregistrationpracticesaretransparent,objective,impartialandfair.In

addition,the

Minister

of

Health

and

Long

Term

Care

can

refer

concerns

about

the

CollegesregulationsorprogramstotheHealthProfessionsRegulatoryAdvisory

Council(HPRAC)forreview.

vi. TheCollegehastoreporttotheMinister.Ithastomakeanannualreportandsuch

otherreportsastheMinisterrequests.TheMinisterhastheabilitytomake

recommendationsorevenissuedirectionstotheCounciloftheCollege.Ifthereare

seriousconcernstheMinstercanaudittheoperationsoftheCollegeandcan

appointasupervisortotakeoveritsoperations.Thus,whiletheCollegeisseparate

fromthegovernment,itisstillaccountabletotheMinisterofHealthandLongTerm

Care.


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ThesesafeguardshelpensurethattheCollegeservesthepublicinterestinafairandopen

manner.

GiventhepublicinterestmandateoftheCollegeandthesafeguardsthatareinplace,

professionalmemberselectedtotheCouncilneedtobecarefulabouttheirrole.Asmentioned

above,Councilmembersarelikedirectorsofacorporationwhohaveadutyofloyaltyandgood

faithtothemandateoftheirorganization.Councilmembersarenotlikepoliticianswho

representandservethosewhoelectedthem.TheonlyroleofCouncilmembersistorepresent

thepublicandthepublicinterest

SampleExamQuestion

WhatsentencebestdescribestherolesoftheCollegeandprofessionalassociations?

i) TheCollegeservesthepublicinterest;professionalassociationsservethe

interestsoftheprofession.

ii) TheCollegeandtheprofessionalassociationsbothservethepublicinterest.

iii) TheCollegeandtheprofessionalassociationsbothservetheinterestsofthe

profession.

iv) TheprofessionalassociationsdirecttheoperationsoftheCollege.

Thebestanswerisi).TheCollegesmandateistoregulatetheprofessioninorderto

serve

and

protect

the

public

interest.

Answer

ii)

is

not

the

best

answer

because

professionalassociationsaredesignedtoservetheinterestsoftheirmembers.While

professionalassociationscareaboutthepublicinterestandoftentakeactionsthatassist

thepublicinterest,theyareundernostatutorydutytodosoandareaccountableonlyto

theirmembers.Answeriii)isnotthebestanswerbecausetheCollegeisnotpermittedto

servetheinterestsofitsmembersunderitsstatute.Whileittriestoensurethatit

regulatesitsmemberssensitivelyandfairly,andconsultswithitsmembers,theColleges

mandateisthepublicinterest.Answeriv)isnotcorrect.WhiletheCollegeconsultswith

theprofessionalassociationsandconsidersseriouslytheirviewsandrespectstheir

expertise,theCollegeisnotunderthecontrolofanyprofessionalassociation.

b.

Ethics,professional

standards,

professional

misconduct,

incompetence,

incapacity

AmajorpartoftheCollegesroleistodevelopand,sometimes,enforceaCodeofEthicsand

professionalstandards.TheCollegetakesactionwherethereisprofessionalmisconduct,

incompetenceandincapacity.Eachoftheseconceptsisslightlydifferentinitsroleandpurpose.

Thissectionofthebooklooksateachofthem.

CodeofEthics


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Professionshaveethicalprinciplestoguidetheirmembers.Theseethicalprinciplesinclude

beinghonestatalltimes,respectingtheconfidentialityofapatient,treatingclientswith

sensitivity,maintainingonescompetenceandallowingpatientstomakeinformedchoicesastotheirhealthcare.ManyprofessionalassociationshavedevelopedaCodeofEthicsfortheir

members.

TheCollegeisauthorizedunderitsstatutetodevelopaCodeofEthicsforitsmembers.Assuch,

theCollegesCodeofEthicstakespriorityovertheCodesofEthicsofprofessionalassociations.

ThepurposeoftheCodeofEthicsistosetoutthegoalsoridealsthatpractitionerstrytoreach.

Theprinciplesareoftensetoutaspositivestatements(e.g.,apractitionerwillbehonest).This

isdifferentfromaprofessionalmisconductregulationwhichsetsouttheminimum

practitionersmust

do

to

avoid

discipline

(e.g.,

apractitioner

will

not

issue

afalse

or

misleading

document).ManyprinciplesoftheCodeofEthicsalsoencouragepractitionerstocontinually

improve(e.g.,onecanalwaystrytobemoresensitivetotheclient).

TheCodeofEthicsisnotenforcedthroughthedisciplineprocess.Rather,theirroleistoguide

andencouragethepractitioner.IfapractitionerfollowstheprinciplesoftheCodeofEthics

(e.g.,beinghonest)theywillavoidengaginginprofessionalmisconduct(e.g.,theywillnotissue

afalseormisleadingdocument).

EthicsScenario

PractitionerXisalwayspolitetohispatients,inaformalway.Hefeelsgoodabout

himself.However,heoftensaysGodtoexpresssurprise.Thephrasemeansnothingto

himandnoonehaseverexpressedconcernsaboutit.Oneofhispatients,Paul,has

sharedthatheisveryreligious.WheneverXsaysGodPaulflinchesabit.Xnoticesand

asksPauliftheuseofthewordGodbothersPaul.Paulsaysthat,actuallyitdoes.X

makesapointofnotsayingGodanymoreinfrontofPaul.Afterdiscussingtheincident

withacolleague,Xdecidesthattheethicalthingforhimtodoistostopusingtheword

GodasanexpressionofsurprisewheneverheiswithapatientbecauseXcannottellin

advancewhowillbeoffended.

ProfessionalStandards

Professionalstandardsdescribethewayinwhichpractitionerspractisetheirprofession.For

example,itisaprofessionalstandardtoassessapatientbeforetreatingthem.

OftenthedetailsoftheprofessionalstandardarenotwrittendownanywherebytheCollege.

Forexample,theCollegemaynothaveadocumentdescribingexactlyhowapractitioner

assessesapatient.Indeed,oftenhowthestandardisappliedchangeswiththecircumstances

(e.g.,theanswersthepatientgivestothepractitionersquestionswillchangehowthe

assessmentisdone).Professionalstandardsarelearnedthroughoneseducation,professional


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readingandlearning,experienceinpracticeandindiscussionswithotherpractitioners.

Professionalstandardsarealwayschanging.

However,toassistmembers,theCollegedevelopswrittenpublicationsthatdiscuss

professionalstandards.Thesepublicationscanhavedifferentnames(e.g.,Standardsof

Practice,Guidelines,Policies,PositionStatements)dependingontheircontextandpurpose.

Thepurposeofthesepublicationsistoremindpractitionersaboutthefactorsthatarerequired

topracticesafely,ethicallyandeffectively.ThesepublicationsareontheCollegeswebsiteand

coverawidevarietyoftopics.Whileprofessionalstandardsarenotlawinthesamewaythat

astatuteorregulationis,failingtocomplywithapublishedstandardwilloftenleadtoa

violationofthelaworwillresultinprofessionalmisconduct.

DiscontinuingProfessional

Services

Scenario

PractitionerYwantstostoptreatingapatientbecausethepatienthasstoppedpaying.

ShereadsanarticleintheCollegesnewslettersuggestingthatpatientsshouldbegiven

atleasttwoweekstofindanewpractitionerbeforeonestopstreatingthepatient.Y

cannotseewhysheneedstoseeapatientwhoisnotpayingforherservicesanddoes

notfollowthenewslettersuggestion.Thepatientexperiencespainoncethetreatment

stopsandmissestendaysofworkbeforethepatientcanfindanotherpractitionerto

treathim.ThepatientcomplainstotheCollege.Afterinvestigatingthecomplaintthe

CollegerequiresYtoappearbeforeittoreceiveaverbalcautionbecauseYabandoneda

patient

who

was

in

pain

without

giving

the

patient

adequate

time

to

find

another

practitioner.ThefactthatYwasnotpaiddidnotremoveherdutytothepatientwho

wasinpain.

ProfessionalMisconduct

Professionalmisconductisconductthatfallsbelowtheminimumexpectationsofasafeand

ethicalpractitioner.Professionalmisconductiswrittenineitherthestatuteortheregulations

thatapplytopractitioners.Theprovisionsinthestatuteandregulationsaredescribedinmore

detailbelowonprofessionalmisconductregulations.Asnotedabove,manyCollege

publicationswillassistpractitionerstorecognizehowtoavoidengaginginprofessional

misconduct.

Engaginginprofessionalmisconductcanleadtodisciplinaryproceedingsthatcouldresultin

seriousorders(e.g.,afine,suspensionorevenrevocationofonescertificateofregistration).It

isveryseriousforapractitionertoengageinprofessionalmisconduct.

PermittingIllegalConductScenario


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PractitionerXisregisteredwiththeCollege.XsfatherisnotregisteredwiththeCollege.

PractitionerXsfathersometimesdropsintoXsofficetotreathislongtermpatients.The

officeassistantreferstoXsfatherasDoctorwhenbookingpatients.ApatientcomplainstotheCollegewhenherextendedhealthinsurancerefusedtopayforXs

fathersservicesbecausehewasnotregisteredwiththeCollege.IsPractitionerX

responsibleforhisfathersconduct?

Theanswerisyes.Itisprofessionalmisconducttopermitapersontoholdthemselves

outaspractisingtheprofessionwhentheyarenotregistered.PractitionerXcondoned

theconductthatoccurredathisoffice.PractitionerX,bybeingregistered,gave

credibilityandstatustotheillegalconductofhisfather.Xcouldfaceadisciplinehearing.

Incompetence

Incompetenceiswhereapractitionershowsaseriouslackofknowledge,skillorjudgment

whenassessingortreatingapatient.Itisdefinedinthestatute.Aconcernthatapractitioneris

incompetentcanbeinvestigatedbytheCollegeandcanresultinadisciplinehearing.Ifthe

DisciplineCommitteefindsthatapractitionerisincompetent,itcanimposerestrictionsonthe

practitionersregistration(e.g.,thepractitionercannotpracticeinacertainway,suchaswith

children),oritcansuspendorrevokethepractitionersregistration.

InanyinvestigationofincompetencetheCollegewillusuallylookatthepractitionersrecords.

The

College

will

interview

the

patient

and

the

practitioner

and

ask

other

practitioners

if

they

thinktheconductshowsincompetence.BothoftheCollegecommitteesdealingwiththecase

willhaveotherpractitionersonitwhoknowthedifferencebetweengoodandbadpractice.

IncompetenceScenario

PractitionerYdoesnotreallyassessherpatients.Sheisinahurrytotreatasmany

patientsaspossibleinaday.Shejustasksthepatientwhatiswrongandthenwill

proceedtogivetreatment.Shedoesnotbothertotakepatienthistoryorreview

progressofthepatient.Apatient,Paula,cameinwithaseriouscondition.Ydidnot

recognizeit.Paulabecameunresponsiveduringheracupuncturetreatment.Laterthat

night,Paula

ended

up

in

the

emergency

department

of

the

hospital

with

astroke.

Paula

complainedaboutYsincompetence.TheInquiries,ComplaintsandReportsCommittee

lookedatYspatientrecordsandheardYsexplanationforwhatshehaddone.Itsent

thecasetodiscipline.TheDisciplineCommitteeagreedthatYshowedalackof

knowledge,skillandjudgment.ItorderedYtogobacktoschoolforayear.

Incapacity


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Apractitionerisincapablewhenheorshehasahealthconditionthatpreventshimorherfrom

practisingsafely.Usuallythehealthconditionisonethatpreventsthepractitionerfrom

thinkingclearly.Evenaseverelydisabledpractitionercanpracticesafelysolongasthepractitionerunderstandshisorherlimitsandgetsthenecessaryhelp.Mostpractitionerswho

arefoundtobeincapablearethosewhosufferfromaddictionsorcertainmentalillnessesthat

impairthepractitionersprofessionaljudgment.Forexample,apractitionerwhoisaddictedto

alcoholordrugsmaytrytoseepatientswhentheyareimpaired.

Underthelaw,incapablepractitionersarenottreatedinthesamewayaspractitionerswho

haveengagedinprofessionalmisconductorareincompetent.Theinvestigationlooksatthe

practitionershealthconditionandthetreatmentthattheyarereceiving.TheCollegecan

requirethepractitionertogoforaspecialistexaminationtogetmoreinformationaboutthe

practitionershealth.

If

the

concern

is

justified,

the

practitioner

is

referred

to

the

Fitness

to

PractiseCommitteeforahearing.TheFitnesstoPractiseCommitteecanorderthepractitioner

toundergomedicaltreatment,havemedicalmonitoringandtorestricthisorherpractice.Inan

extremecase(e.g.,wherethepractitionercontinuestoseepatientswhileimpaired)theFitness

toPractiseCommitteecansuspendorrevokethepractitionersregistrationinordertoprotect

thepublic.

IncapacityScenario

PractitionerZhasbeendrinkingalotmorealcoholoverthelastfewmonths.Hehas

been

coming

to

work

with

a

hangover.

More

recently

he

has

been

drinking

at

lunch.

One

dayZcomesbackafterlunchimpaired.Paul,apatient,noticesthatZsmellsofalcohol

andthatZisstumblingaroundtheoffice.PaultellstheCollege.AtfirstZdenieshehasa

problem.However,oninvestigating,theCollegelearnsthatsomeofZscolleagueshave

noticedasignificantchangeinZsbehaviourinrecentmonths.TheCollegealsolearned

thatZhasbeenchargedwithimpaireddriving.TheCollegesendsZtoamedical

specialistwhodiagnosesZwithaserioussubstanceabusedisorder.TheCollege

encouragesZtogofortreatmentattheHomewoodHealthCentre.Zagrees.Thematter

isreferredtotheFitnesstoPractiseCommittee.ZandtheCollegeagreetoanorder

requiringZtostopdrinking,attendAlcoholicsAnonymousgroupmeetings,seehisnew

substanceabusespecialistregularlyandhaveacolleaguewatchZatworkandsend

regularreports

to

the

College.

Conclusion

Eachoftheaboveprovisionslooksatdifferentaspectsofprofessionalpractice.Eachofthese

provisionsalsoservesadifferentpurpose.TheCodeofEthicsdealswiththeidealswhich

practitionerstrytoachieve.Professionalstandardsdealwithwaysinwhichtopractisesafely,

effectivelyandprofessionally.Professionalmisconductdealswiththeminimumconduct

necessarytoavoiddiscipline.Incompetencedealswithhavinganadequatelevelofknowledge,


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skillandjudgmentintheassessmentandtreatmentofapatient.Incapacitydealswithhealth

conditionsthatpreventapractitionerfromthinkingclearly.

SampleExamQuestion

ThesentencePractitionersaresensitivetothewishesoftheirpatientsismostlikelyto

befoundinwhichofthefollowingprovisions?

i.

Thedefinitionofincapacity.

ii. Thedefinitionofincompetence.

iii.

Thedefinitionofprofessionalmisconduct.

iv.

ProfessionalstandardspublishedbytheCollege.

v.

TheCodeofEthics.

Thebestanswerisv).Beingsensitiveisanidealthatpractitionersstrivetowards.Answer

i)isnotthebestanswerbecauseincapacitydealswiththepractitionershealth

condition.Seriouslyinsensitivebehaviourmayaccompanysomeillnesses(e.g.,

addictions),butitistheillnessthatmustbetreatedfirst.Answerii)isnotthebest

answerbecauseincompetencedealswithpractitionershavinganadequatelevelof

knowledge,skillandjudgment.Answeriii)isnotthebestanswerbecauseprofessional

misconductdealswiththeminimumconductthatisnecessarytoavoiddiscipline.The

correspondingprofessionalmisconductprovisionwouldlikelybethatpractitionersshall

notabusetheirpatients.Answeriv)isnotthebestanswerbecauseprofessional

standards

deal

with

ways

in

which

to

practice

safely,

effectively

and

professionally.

A

professionalstandardwouldlikelyprovidepracticalsuggestionsabouthowtopractice

sensitively(e.g.,adviceonhowtolistentothepatientfirstbeforedoinganythingelse).

2. Communication

a. Introduction

Manycomplaintsagainstpractitionerscouldbeavoidedbygoodcommunicationwithpatients,

staffandcolleagues.Goodcommunicationinvolves,first,listeningtoothers.Understandingthe

personswishes,expectationsandvaluesbeforedoinganythingisimportant.Askingquestions

toclarify

and

expand

on

what

the

person

is

saying

also

helps.

Repeating

information

back

to

a

patient,inthepractitionersownwords,canhelpensureunderstandingandreassuresthe

patientthatthepractitionerhasbeenlistening.Goodcommunicationalsoinvolvesmakingsure

theotherpersonknowswhatyouaregoingtodo,whyyouaregoingtodoitandwhatislikely

goingtohappen.Whentheotherpersonisconfusedbywhatyouaredoingorwhy,thereis

miscommunication.Also,peopledonotliketobesurprised(e.g.,bypain,anunexpectedside

effect).Tellingthepersonwhatwillormayhappenremovesthesurprise.Thefollowingsection

ofthisbookdealswithsomeoftheareasinwhichgoodcommunicationislegallyparticularly

important.


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b. Informedconsent

Patientshavetherighttocontroltheirbodiesandtheirhealthcare.Practitionersdonothavetherighttoassessortreatapatientunlessthepatientagreestoit(i.e.,consents).A

practitionerwhoassessesortreatsapatientwithoutthepatientsconsentcanfacecriminal

(e.g.,achargeofassault),civil(e.g.,alawsuitfordamages)orprofessional(e.g.,adiscipline

hearing)consequences.Thissectionofthebookdealswithconsentfortheassessmentand

treatmentofpatients.Otherpartsofthebookdealwiththeneedforconsentwhendealing

withapatientspersonalhealthinformationorforbillingthem.

GeneralPrinciples

Tobe

valid,

apatients

consent

must

meet

the

following

requirements:

RelatetotheTreatment.Thepractitionercannotreceiveconsentforoneprocedure

(e.g.,takingahistoryofthepatientshealth)andthenuseittodoadifferentprocedure

(e.g.,physicallyexaminethepatient).Thepatientsconsentmustbeforwhatisactually

goingtobedone.

BeSpecific.Thepractitionercannotaskforavagueconsent.Forexample,onecannot

askforthepatienttoconsenttoanytreatmentthepractitionerbelievesisappropriate.

Theactualassessmentortreatmentproceduremustbeexplained.Thismeansthatthe

practitioneroftenhastoobtainthepatientsconsentmanytimesasnewprocedures

become

advisable.

This

also

means

that

a

practitioner

cannot

obtain

a

blanket

consent

whenthepatientfirstcomesintocovereveryprocedure.

BeInformed.Itisnecessarythatthepatientunderstandswhattheyareagreeingto.The

practitionermustexplaintothepatienteverythingthepatientneedstoknowbefore

askingthepatienttogiveconsent.Forexample,ifsomeoneasksforyourconsentto

driveyourcarwithouttellingyouthattheyintendtouseittoraceoverrockyfields,

yourconsentwasnotinformed.Tobeinformed,consentmustincludethefollowing:

o NatureoftheAssessmentorTreatment.Thepatientmustunderstandexactly

whatthepractitionerisproposingtodo.Forexample,doesthepractitioner

intendtojustaskquestionsorwillthepractitioneralsobetouchingthepatient?

Ifthepractitionerisgoingtobetouchingthepatient,describewhatthepatient

shouldexpect.

o WhowillbeDoingtheProcedure?Willthepractitionerbedoingtheprocedure

personallyorwillanassistantorcolleaguebeingdoingit?Ifitisanassistantor

colleague,isheorsheregisteredwiththeCollege,anotherCollege,ornot

registeredatall?

o ReasonsfortheProcedure.Thepractitionermustexplainwhyheorsheis

proposingthatprocedure.Whataretheexpectedbenefits?Howdoesthe

procedurefitinwiththeoverallplanofthepractitioner?Howlikelyisitthatthe

hopedforbenefitswillhappen?


13/97

13

o MaterialRisksandSideEffects.Thepractitionermustexplainanymaterialrisks

andsideeffects.Materialrisksorsideeffectsarethosethatareasonable

personwouldwanttoknowabout.Forexample,ifthereisahighriskofamodestsideeffect(e.g.,sleeplessness),thepatientshouldbetold.Similarly,if

thereislowriskofaserioussideeffect(e.g.,deathorsuicide),thepatientneeds

tobetold.

o AlternativestotheProcedure.Iftherearereasonablealternativestothe

procedure(e.g.,amorecautiousapproach),thepatientmustbetold.Evenifthe

practitionerdoesnotrecommendtheoption(e.g.,itistooaggressiveandhasa

higherrisk),thepractitionershoulddescribetheoptionandtellthepatientwhy

thepractitionerisnotrecommendingit.Also,evenifthepractitionerdoesnot

providethealternativeprocedure(e.g.,itisprovidedbyamemberofadifferent

profession,such

as

aphysician),

the

practitioner

must

tell

the

patient

if

it

is

a

reasonableoption.

o ConsequencesofNotHavingtheProcedure.Oneoptionforapatientisdo

nothing.Thepractitionershouldexplaintothepatientwhatislikelytohappenif

thepatientdoesnothing.Ifitisnotclearwhatwillhappen,thepractitioner

shouldsaysoandprovidesomelikelyconsequences.

o ParticularPatientConcerns.Iftheindividualpatienthasaspecialinterestin

someaspectoftheprocedure(e.g.,itsnature,asideeffect),thepatientneeds

tobetold(e.g.,theprocedurewouldviolatethepatientsreligiousbeliefs).

Voluntary.Thepractitionercannotforceapatientintoconsentingtoaprocedure.Thisis

particularly

important

when

dealing

with

younger

or

older

patients

who

may

be

overly

influencedbyfamilymembersorfriends.Thisisalsoimportantwheretheassessment

ortreatmentwillhavefinancialconsequencesforthepatient(e.g.,thepatientwilllose

hisorherjoborwilllosefinancialbenefitsifthepatientrefusestoconsent).The

practitionershoulddiscusswiththepatientthatitisuptothepatientwhethertogive

consentandthatthepatientshouldnotletanyonepressurethemintodoingsomething

thepatientdoesnotwanttodo.

NoMisrepresentationorFraud.Thepractitionermustnotmakeclaimsaboutthe

assessmentortreatmentthatarenottrue(e.g.,tellingthepatientthatatreatmentwill

curethemwheninfacttheresultsareuncertain).Thissituationwouldnotresultina

trueconsent.Patientsmustbegivenaccuratefactualinformationandhonestopinions.

Therefore,consenttoanassessmentortreatmentmustinvolveeffectivecommunication

betweenthepractitionerandthepatient.Thepractitionermustmakesurethatthepatient

understandswhatheorsheisagreeingto.Whileitmaysoundlikealotofwork,mostofthe

timeinformedconsentcanbeobtainedquicklyandeasily.Itisonlywhendealingwithcomplex

orparticularlyriskymattersthatalotoftimeisrequired.


14/97

14

ConsentScenarioNo.1

PractitionerYmeetsanewpatientnamedPaula.Paulacomplainsaboutfeelingstressedandtired.Ysays:Iwouldliketofullyunderstandyourpersonalandfamilybackground

andyourmedicalhistory.Therecouldbealotofthingsmakingyoufeeltiredand

stressedandthisinformationwillhelpmetrytofigureoutwhy.Ifyouareuncomfortable

withanyofmyquestions,pleaseletmeknow.OK?Yhasprobablyjustobtained

informedconsent.

SampleExamQuestion

Obtainingabroadconsent(oftencalledablanketconsent)inwritingfromthepatient

onhis

or

her

arrival

at

the

office

is

probably

abad

idea

because:

i.

Thepatientdoesnotknowiftheywillneedsomeonetodrivethemhome

afterwards.

ii.

Thepatientdoesnothaveconfidenceinthepractitioneryet.

iii. Thepatientdoesnotunderstandtowhattheyarebeingaskedtoagree.

iv. Thepatientdoesnotknowhowlongthevisitwillbe.

Thebestanswerisiii).Informedconsentrequiresthepatienttounderstandthenature,

risksandsideeffectsofthespecificprocedureproposedbythepractitioner.Itis

impossibleforthepatienttoknowthesethingsupontheirarrivalattheoffice.Answeri)

is

not

the

best

answer

because

it

focuses

on

a

side

issue

and

does

not

address

the

main

issue.Answerii)isnotthebestanswerbecausehavingconfidenceinthepractitioneris

notenoughfortheretobeinformedconsent.Apatientmaytrustthepractitionerand

thatmaymotivatethegivingofconsent,butthepatientstillneedstounderstandto

whattheyarebeingaskedtoagree.Answeriv)isnotthebestanswerbecauseitfocuses

onasideissueanddoesnotaddressthemainissue.

WaysofReceivingConsent

Therearethreedifferentwaysinwhichapractitionercanreceiveconsent.Eachhasits

advantagesanddisadvantages.

WrittenConsent.Apatientcangiveconsentbysigningawrittendocumentagreeingto

theprocedure.Awrittenconsentprovidessomeevidencethatthepatientdidgive

consent.Onedisadvantageofwrittenconsentisthatpractitionerssometimesconfusea

signaturewithconsent.Apatientwhosignsaformwithoutactuallyunderstandingthe

nature,risksandsideeffectsoftheprocedurehasnotgivenatrueconsent.Also,the

useofwrittenconsentdocumentscandiscouragetheaskingofquestions.Inaddition,

thepractitionermightnotthencheckwiththepatienttomakesurethepatient

understandstheinformationandisintrueagreement.


15/97

15

VerbalConsent.Apatientcangiveconsentbyaverbalstatement.Averbalconsentis

thebestwayforthepractitionerandthepatienttodiscusstheinformationandensure

thatthepatientreallyunderstandsit.Makingabriefnoteinthepatientrecordofthe

discussioncanprovideusefulevidencelateronifthereisacomplaint.

ImpliedConsent.Apatientcangiveconsentbytheiractions.Forexample,inConsent

ScenarioNo.1,above,thepatientPaulacouldjustnodherhead.Thatwouldbeimplied

consentforPractitionerYtobeginaskingherquestions.Themaindisadvantageof

impliedconsentisthatthepractitionerhasnoopportunitytocheckwiththepatientto

makesurethatthepatienttrulyunderstandswhatisgoingtohappen.

ConsentScenarioNo.2

PractitionerX

proposes

that

his

patient

Paul

take

avitamin

and

mineral

supplement.

X

says:Trythese:theywillmakeyouthinkmoreclearly.Paultakesoneimmediatelyand

buysabottlefromthereceptionist.WhenarrivingathomePaulreadsaboutthe

supplementontheinternetandlearnsthatitcontainsmegadosesofVitaminA1which,if

takenforalongperiodoftime,couldleadtoliverandotherdamage.Paulcomplainsto

theCollege.XtellstheCollegethathewasrelyingonPaulsimpliedconsentby

swallowingthefirstpillandbuyingabottlefromthereceptionist.TheInquiries,

ComplaintsandReportsCommitteeissueadecisioncriticalofXfornotobtaining

informedconsentbecause:

Xdidnotexplainthenatureofthepillincludingthatithadmegadosesof

VitaminA;

XdidnotexplainhowthesupplementwouldmakePaulthinkmoreclearly;

Xmisrepresentedthehopedforbenefitofthesupplementastherewaslittle

evidencetosupporthisverystrongstatementthatitwouldmakePaulthink

moreclearly;

Xdidnotexplainthewayinwhichthesupplementwastobeused(howoftento

takethesupplementandforwhatperiodoftime);

Xdidnotexplainthealternativestotakingthesupplementincludingnottaking

anything;and,perhapsmoreimportantly,

XdidnotexplaintherisksoftakingthesupplementtoPaul.

ConsentWherethePatientisIncapable

Apatientisnotcapableofgivingconsentifthepatienteither:

Doesnotunderstandtheinformation,or

Doesnotappreciatethereasonablyforeseeableconsequencesofthedecision.

1AmegadoseofVitaminAprobablyresultsinthesupplementbeingclassedasadrug.Thusthisscenarioalso

raisesissuesaboutwhetherthepractitionerisengaginginacontrolledact.Seethediscussionofcontrolledacts

below.


16/97

16

Forexample,ifthepractitionerrecommendsthatapatienthaveadailyseriesofhalfhour

acupuncturetreatmentsandthepatientinsistsonreceivingonesixhoursessionwithlongerneedlesinstead,itisprettyclearthatthepatientdoesnotappreciatetheconsequencesofthe

decision.

Apractitionercanassumeapatientiscapableunlessthereisevidencetothecontrary.A

practitionerdoesnotneedtoconductanassessmentofthecapacityofeverypatient.However,

ifthepatientshowsthattheymaynotbecapable(e.g.,thepatientsimplycannotunderstand

theexplanationofthepractitioner)thepractitionershouldassessthepatientscapacity.The

practitionercanassessthecapacityofthepatientbydiscussingtheproposedprocedurewith

thepatienttoseeifthepatientunderstandstheinformationandappreciatesitsconsequences.

Theissueiswhetherthepatientiscapableofgivingconsentfortheproposedprocedure.A

patientcanbecapabletogiveconsentforoneprocedurebutnotcapableforanother.For

example,afifteenyearoldpatientmightbecapableofconsentingtonutritionalcounsellingbut

notbecapableofconsentingtotreatmentforamajoreatingdisorder.(Thereisnominimum

ageofconsentforhealthcaretreatment.)

Ifapractitionerconcludesthatthepatientisnotcapableofgivingconsentforaprocedure,the

practitionershouldtellthepatient.Thepractitionershouldalsotellthepatientwhowillmake

decisionsontheirbehalfforexample,acloserelative.Thispersoniscalledasubstitute

decision

maker.

The

practitioner

should

still

include

the

patient

in

the

discussions

as

much

as

possible.Ofcoursetherearecircumstanceswhereinvolvingtheincapablepatientinthe

discussionswillnotbepossible(e.g.,ifitwillbequiteupsettingtothepatient,wherethe

patientisunconscious).

Unlessitisanemergency,thepractitionermustthenobtainconsentfortheassessmentor

treatmentfromasubstitutedecisionmaker.Asubstitutedecisionmakermustmeetthe

followingrequirements:

Thesubstitutemustbeatleast16yearsofage.2Thereisanexceptionwherethe

substituteistheparentofthepatient(forexample,a15yearoldmothercanbethe

substitutedecisionmakerforthecareofherchild).

Thesubstitute

must,

themselves,

be

capable.

In

other

words,

the

substitute

must

understandtheinformationandappreciatetheconsequencesofthedecision.

Thesubstitutemustbeableandwillingtoact.

Theremustbenohigherrankedsubstitutewhoisableandwillingtoact.Therankingof

thesubstitutedecisionmakerisasfollows(fromhighestrankedtolowestranked):

o Acourtappointedguardianoftheperson.

2Whilethereisnominimumageofconsentforacapablepatient,asubstitutedecisionmakermustnormallybeat

least16yearsold.


17/97

17

o Apersonwhohasbeenappointedtobeanattorneyforpersonalcare.The

patientwouldhavesignedadocumentappointingthesubstitutetoactonthe

patientsbehalfinhealthcaremattersifthepatienteverbecameincapable.o ApersonappointedbytheConsentandCapacityBoardtomakeahealth

decisioninaspecificmatter.

o Thespouseorpartnerofthepatient.Apartnercanincludeasamesexpartner.

Itcanalsoincludeanonsexualpartner(e.g.,twoelderlysisterswholive

together).

o AchildofthepatientoraparentofthepatientortheChildrensAidSocietywho

hasbeengivenwardshipofthepatient.

o

Aparentofthepatientwhodoesnothavecustodyofthepatient.

o Abrotherorsisterofthepatient.

o

Anyother

relative.

o ThePublicGuardianorTrusteeifthereisnooneelse.

Hereisascenariothatshowshowtheseruleswork.

ConsentScenarioNo.3

PractitionerYproposesaprocedureforherpatientPaula.Pauladoesnotunderstandthe

proposedprocedureatall.Sheisclearlyincapable.YknowsthatPaulaappointedher

friendPattobeherpowerofattorneyforpersonalcare.However,Patistravelling

outside

of

the

country

and

cannot

be

reached.

Therefore

Pat

is

not

able

to

make

the

decision.YcontactsPaulaselderlymother,butPaulasmotherisfrailherselfanddoes

notfeelconfidentinmakingthedecision.ThusPaulasmotherisnotwillingtoactasa

substitutedecisionmaker.Paulassisteriswillingandabletomakethedecisionon

Paulasbehalfandappearstounderstandtheinformationanditsconsequencesfor

Paula.Paulassisterisabletogivetheconsenteventhoughsheisnotthehighestranked

substitute.

Iftherearetwoequallyrankedsubstitutedecisionmakers(e.g.,twochildrenofthepatient),

andtheycannotagree,thePublicGuardianandTrusteecanthenmakethedecision.

Asubstitute

decision

maker

must

comply

with

the

following

rules:

Thesubstitutemustactinaccordancewiththelastknowncapablewishesofthe

patient,ifknown.Forexample,ifapatientclearlysaid,Neversendmetothehospital

beforehebecamesoillthathecouldnotthinkclearly,thesubstituteneedstoobey

thosewishes.

Thesubstitutemustactinthebestinterestsofthepatientifthesubstitutedoesnot

knowofthelastknowncapablewishesofthepatient.Forexample,ifaproposed

treatmentissimpleandpainless,wouldcauselittleriskofharmbutwouldmakethe

patientmorecomfortablethroughadifficultillness,thesubstitutedecisionmaker

shouldconsenttoit.


18/97

18

Whereitbecomesclearthatasubstitutedecisionmakerisnotfollowingtheaboverulesthe

practitionershouldspeakwiththesubstitutedecisionmakeraboutit.IfthesubstitutedecisionmakerisstillclearlynotfollowingtheaboverulesthepractitionershouldcalltheOfficeofthe

PublicGuardianandTrustee.ThecontactinformationofthePublicGuardianandTrusteeof

Ontarioisavailableontheinternet.

ConsentScenarioNo.4

PractitionerXproposesaprocedureforhispatientPaul.Pauldoesnotunderstandthe

proposedprocedureatall.Heisclearlyincapable.XknowsthatPaulappointedhisfriend

Pattobehispowerofattorneyforpersonalcare.PatisgoingtoinheritPaulsmoney

whenPaul

dies.

Paul

has

alot

of

money.

Paul

is

going

to

die

within

afew

months.

The

proposedprocedureissimpleandpainless,wouldmakethepatientmorecomfortable

throughadifficultillnessandhaslittleriskofharm.PatrefusestogiveconsentforPaul

toundergotheproposedprocedure.XisconvincedthatPatisrefusingtoconsenttothe

treatmentinordertoinheritmoremoney(eventhoughtreatmentisnotveryexpensive).

TherestofPaulsfamilyisveryupsetbecausetheywantPaultoreceivethetreatment.X

suggeststhatthefamilycontacttheOfficeofthePublicGuardianandTrustee.

Theaboverulesonobtaininginformedconsentwhenapatientisincapablecomefromthe

HealthCareConsentAct.Practitionersshouldbefamiliarwiththatstatute.Itisadifficult

statute

to

read.

Practitioners

should

check

the

Colleges

website

as

the

College

will

be

developingpoliciesoninformedconsentasithastime.

SampleExamQuestion

Whichofthefollowingisthehighestrankedsubstitutedecisionmaker(assumingthat

everyonewaswillingandabletogiveconsent):

i.

Apowerofattorneyforpersonalcareforthepatient.

ii.

Thepatientsliveinboyfriend.

iii. Thepatientsmother.

iv. Thepatientsson.

Thebestanswerisi).Onlyacourtappointedguardianishigherrankedthanapowerof

attorneyforpersonalcare.Answerii)isnotthebestanswerbecausethepatients

spouseorpartnerisalowerrankedsubstitutedecisionmaker.Inaddition,itisnotclear

thattheliveinboyfriendisaspouse(undertheHealthCareConsentAct,theymusthave

beenlivingtogetherforatleastoneyear,havehadachildtogetherorhaveawritten

cohabitationagreementtobespouses).Answersiii)andiv)arenotthebestanswers

becausetheyarelowerrankedthanbothapowerofattorneyforpersonalcareora

patientsspouse.Inaddition,thepatientsmotherandsonareequallyrankedsoeither

theywouldhavetogivethesameconsentoronewouldhavetodefertotheother.


19/97

19

Emergencies

Oneexceptiontotheneedforinformedconsentisincasesofemergencies.Therearetwokinds

ofemergencies:

Wherethepatientisincapableandadelayintreatmentwouldcausesufferingor

seriousbodilyharmtothepatient.

Wherethereisacommunicationbarrier(e.g.,language,disability)despiteeffortsto

accommodatethebarrierandadelayintreatmentwouldcausesufferingorserious

bodilyharmtothepatient.

Ineithercasethepractitionermustattempttoobtainconsentassoonaspossible(eitherby

findingasubstitute

decision

maker

in

the

first

example

or

by

finding

ameans

of

communication

withthepatientinthesecondexample).

Emergenciesarerareforpractitionersofthisprofession,butcanoccur.

ConsentScenarioNo.5

PractitionerYisseeingherpatientPaulaattheoffice.Paulasuddenlycollapsesfroman

apparentheartattack.Yhasadefibrillatorintheoffice.Withouttryingtogetconsent

fromasubstitutedecisionmaker,Yusesthedefibrillator.Ywasabletoactwithout

consent

in

these

circumstances.

Acrossthecity,X,apractitioner,isseeinghispatientPaulattheoffice.Paulhasterminal

cancerandhasfilledoutawalletcardsayingthathedoesnotwantanymeasurestaken

toresuscitatehimshouldhehaveacardiovascularaccident.Paulhasmentionedthisto

X.Paulsuddenlycollapsesinanapparentheartattack.Xhasadefibrillatorintheoffice.

Xisnotabletoactwithoutconsentinthesecircumstances.Xalreadyhasarefusalfrom

Paulthatappliestothesecircumstances.

c. Boundariesandsexualabuse

Practitionersmust

be

careful

to

act

as

aprofessional

health

care

provider,

and

not

as

afriend,

topatients.Becomingtoopersonalortoofamiliarwithapatientisconfusingtopatientsand

willmakethemfeeluncomfortable.Patientswillbeuncertainastowhethertheprofessional

adviceorservicesaremotivatedbysomethingelseotherthanthebestinterestsofthepatient.

Itisalsoeasierforapractitionertoprovideprofessionalserviceswhenthereisaprofessional

distancebetweenthem(e.g.,tellingthepatientthetruthaboutthepatientscondition).

Maintainingprofessionalboundariesisaboutbeingreasonableinthecircumstances.For

example,oneshouldbecarefulaboutacceptinggiftsfrompatients,buttherearesome

circumstancesinwhichitisappropriatetodoso(e.g.,asmallNewYearsgiftfromapatient).In


20/97

20

otherareas,however,crossingprofessionalboundariesisneverappropriate.Forexample,itis

alwaysprofessionalmisconducttoengageinanyformofsexualbehaviourwithapatient.

Thefollowingaresomeoftheareaswherepractitionersneedtobeverycautioustomaintain

professionalboundaries.

SelfDisclosure

Whenapractitionersharespersonaldetailsabouthisorherprivatelife,itcanconfusepatients.

Patientsmightassumethatthepractitionerwantstohavemorethanaprofessional

relationship.Selfdisclosuresuggeststhattheprofessionalrelationshipisservingapersonal

needforthepractitionerratherthanservingthepatientsbestinterests.Selfdisclosurecan

resultin

the

practitioner

becoming

dependent

on

the

patient

to

serve

the

practitioners

own

emotionalneeds,whichisdamagingtotherelationship.

SelfDisclosureScenario

PractitionerYistreatingPaulaforworkplacestressrelatedillnesses.Paulaishaving

difficultydecidingwhethertomarryherboyfriendandtalkstoYaboutthisissuealot

duringtreatmentsessions.TohelpPaulamakeuphermind,YdecidestotellPaula

detailsofherdoubtsinacceptingtheproposalfromherfirsthusband.Ytellsofhow

thosedoubtsgraduallyruinedherfirstmarriageresultinginbothherandherhusband

having

affairs.

Paula

is

offended

by

Ys

behaviour

and

stops

coming

for

treatment

for

the

workplacestressrelatedillnesses.Ysselfdisclosurewasinappropriateand

unprofessional.

GivingorReceivingofGifts

Givingandreceivinggiftsispotentiallydangeroustotheprofessionalrelationship.Asmall

tokenofappreciationbythepatientpurchasedwhileonaholiday,aroundNewYears,orgiven

attheendoftreatmentmaybeacceptable.Inaddition,onemustbesensitivetothepatients

culturewhererefusingagiftisconsideredtobeaseriousinsult.However,anythingbeyond

smallgiftscanindicatethatthepatientisdevelopingapersonalrelationshipwiththe

practitioner.The

patient

may

even

expect

something

in

return.

Giftgivingbyapractitionerwilloftenconfuseapatient.Evensmallgiftsofemotionalvalue,

suchasafriendshipcard,canconfusethepatienteventhoughthefinancialvalueissmall.

WhilemanypatientswouldfindaChristmas/holidayseasoncardfromapractitionertobea

kindgestureandgoodbusinesssense,somepatientsmightfeelobligedtosendoneinreturn.

Soevenherethoughtshouldbegiventothetypeofpatientsinonespractice(e.g.,somenew

Canadiansmightbeunfamiliarwiththetradition).


21/97

21

GiftGivingScenario

PractitionerXhasapatientfromanAsianculturewhobringsfoodforeveryvisit.Xthanksher,buttriesnottotreatitasanexpectation.OnonevisitXhappenstomention

hisspecialroastpigrecipe.ThepatientinsiststhatXbringitovertoherhouseforNew

Years.Xpolitelydeclines,givingthepatientawrittenrecipeinstead.Thepatientstops

bringinginfood,islessfriendlyduringvisitsandstartsmissingappointments.Xdidnot

doanythingwronginthisscenario,butitshowstheconfusionthatcanoccurwitha

patientwhentheboundariesstarttobecrossed.

DualRelationships

Adual

relationship

is

where

the

patient

has

an

additional

connection

to

the

practitioner

other

thanjustasapatient(e.g.,wherethepatientisarelativeofthepractitioner).Anydual

relationshiphasthepotentialfortheotherrelationshiptointerferewiththeprofessionalone

(e.g.,beingboththeindividualspractitionerandemployer).Itisbesttoavoiddual

relationshipswheneverpossible.Wheretheotherrelationshippredatestheprofessionalone

(e.g.,arelative,apreexistingfriend),referringthepatienttoanotherpractitioneristhe

preferredoption.Whereareferralisnotpossible(e.g.,inasmalltown,wherethereisonlyone

practitioner),specialsafeguardsareessential(e.g.,discussingthedualrelationshipwiththe

patientandagreeingwiththepatienttobeformalduringvisitsandnevertalkabouttheissues

outsideoftheoffice).Itisneveragoodideatotreatarelative.

DualRelationshipsScenario

PractitionerXhasPaulaasapatient.Paulaisarefugeewithverylittlemoney.Paula

worksparttimeasahousecleaner.XdecidestohirePaulatocleanhishouse.Xalso

recommendsPaulatosomeofhisfriendswhoalsohirePaula.Paulaisextremely

grateful.LaterXrecommendsachangeintreatmentthatwillnotbecoveredbyPaulas

insurance.PaulawonderstoherselfifXisrecommendingthistreatmentinordertoget

backthemoneyforcleaninghishouse.Paulaalsofeelsthatshecannotsaynoorelse

shewillloseherjobcleaningthehousesofXsfriends.Didthedualrelationship

contributeto

Paulas

confusion?

IgnoringEstablishedCustoms

Establishedcustomsusuallyexistforareason.Ignoringacustomconfusesthenatureofthe

professionalrelationship.Forexample,treatmentsessionsareusuallyheldduringregular

businesshoursattheclinicratherthanatarestaurant.Byignoringthiscustom,thepatient

mightbeginthinkingthatthemeetingisasocialvisit.Or,thepatientmightfeelthatheorshe

hastopayforthemeal.Treatingpatientsasspecial,ordifferentfromotherpatients,canbe

easilymisinterpreted.


22/97

22

PersonalOpinions

Everyonehaspersonalopinions.Practitionersarenoexception.However,practitionersshouldnotusetheirpositiontopushtheirpersonalopinions(e.g.,religion,politicsorevenavegan

lifestyle)onpatients.Similarly,stronglyheldpersonalreactions(e.g.,thatapatientis

unpleasantandobnoxious)shouldnotbeshared.Disclosingpersonalreactionsdoesnothelp

theprofessionalrelationship.

PersonalOpinionsScenario

Paul,apatient,discussingworldevents,pusheshispractitionerYforherviewson

immigration.AtfirstYresists,buteventuallysaysshehassomeconcernsaboutthe

abusesof

the

immigration

system.

Ysays

she

has

heard,

often

directly

from

patients,

abouthowtheyhaveliedtotheimmigrationauthorities.Paulloudlycriticizesthe

immigrationauthoritiesforallowingtoomanyimmigrantsintothecountry.Paulis

overheardbyotherpatientsintheclinicatthetime,includingsomewhoarenew

Canadians.Theotherpatientstellotherstaffattheclinicthattheyfeeluncomfortable

witheitherYorPaularound.

BecomingFriends

Beingapersonalfriendwithapatientisaformofdualrelationship.Patientsshouldnotbe

placed

in

the

position

where

they

feel

they

must

become

a

friend

of

the

practitioner

in

order

to

receiveongoingcare.Practitionersbearthemainresponsibilitytonotallowapersonal

friendshiptodevelop.Itisdifficultforallbutthemostassertiveofpatientstocommunicateto

thepractitionerthattheydonotwanttobefriends.

TouchingandDisrobing

Touchingcanbeeasilymisinterpreted,particularlywheredisrobingisinvolved.Apatientcan

viewanactofencouragementbyapractitioner(e.g.,ahug)asaninvasionofspaceorevena

sexualgesture.Extremecaremustbetakeninanytouchingbetweenpractitionersandtheir

patients.Thenatureandpurposeofanyclinicaltouchingmustalwaysbeexplainedfirstandthe

patientshould

always

give

consent

before

the

touching

begins.

Patients

should

be

asked

to

disrobethemselveswhereverpossible.Culturalsensitivitiesshouldbeobserved.Thepresence

ofathirdpartyshouldbepermittedandevenofferedwhereappropriate.Thetouchingmust

alwayshaveaclinicalrelevancethatisobvioustothepatient.

Managingboundariesisimportantforbothpractitionersandpatients.


23/97

23

SexualAbuse

TheRegulatedHealthProfessionsAct(RHPA)isdesignedtoeliminateanyformofsexualcontactbetweenpractitionersandpatients.Becauseofthestatusandinfluenceof

practitioners,thereisthepotentialforanysuchsexualcontacttocauseseriousharmtothe

patient.Evenifthepatientconsentstothesexualcontact,itisprohibitedforthepractitioner.

ThetermsexualabuseisdefinedbroadlyintheRHPA.Itincludesthefollowing:

sexualintercourseorotherformsofphysicalsexualrelationsbetweenthepractitioner

andthepatient;

touching,ofasexualnature,ofthepatientbythepractitioner;or

behaviouror

remarks

of

asexual

nature

by

the

practitioner

towards

the

patient.

Forexample,tellingapatientasexualjokeissexualabuse.Hangingacalendaronthewallwith

sexuallysuggestivepictures(e.g.,womeninbikinis,afirefighterscalendar)issexualabuse.

Nonclinicalcommentsaboutapatientsphysicalappearance(e.g.,youlooksexytoday)is

sexualabuse.Datingaclientissexualabuse.

Thisdefinitionofsexualabuseincludestreatingonesspouse.Therehavebeenanumberof

courtdecisionsthathaveestablishedthatapractitionercannottreathisorherspouse(with

verylimitedexceptions,likeanemergency).Practitionersneedtotransferthecareoftheir

spouseor

lover

to

other

practitioners.

It

does

not

matter

that

the

spousal

relationship

came

first.3

Touching,behaviourorremarksofaclinicalnatureisnotsexualabuse.Forexample,ifitis

necessaryforthetreatmentofapatienttoaskaboutthepatientssexualhistory,itcanbe

done.However,askingaboutapatientsromanticlifewherethisisunnecessaryfortreatment

issexualabuse.Similarly,touchingofthechestorpelvicareaofapatientmustbeclinically

necessary(and,asdiscussedabove,mustbedoneonlyafterreceivinginformedconsent).

Itisalwaystheresponsibilityofthepractitionertopreventsexualabusefromhappening.Ifa

patientbeginstotellasexualjoke,thepractitionermuststopit.Ifthepatientmakescomments

aboutthe

appearance

or

romantic

life

of

the

practitioner,

the

practitioner

must

stop

it.

If

the

patientasksforadate,thepractitionermustsayno(andexplainwhyitwouldbe

inappropriate).Ifthepatienttouchesthepractitionerinawaythatmightbeviewedassexual

(e.g.,akiss),thepractitionermuststopit.

3Therehasbeensomediscussionaboutchangingtherequirementpreventingpractitionersfromtreatingtheir

spouses.However,atthetimeofwriting,thischangehasnotbeenmade.Unlessanduntilthechangeismade,

practitionerscannottreattheirspouses.


24/97

24

SexualAbuseScenarioNo.1

PractitionerYtellsacolleagueaboutherromanticweekendwithherhusbandatNiagaraontheLakefortheiranniversary.Ymakesajokeabouthowwinehasthe

oppositeeffectonthelibidoofmenandwomen.Paula,apatient,issittinginthe

receptionareaandoverhears.WhenbeingtreatedbyY,Paulamentionsthatshe

overheardtheremarkandiscuriousastowhatYmeantbythis,asinherexperience,

winehelpsthelibidoofbothpartners.HasYengagedinsexualabuse?Yclearlyhas

crossedboundariesbymakingthecommentinaplacewhereapatientcouldoverhearit.

However,theinitialcommentwasnotdirectedtowardsPaulaandwasnotmeanttobe

heardbyher.ItwouldcertainlybesexualabuseforYtoanswerPaulasquestion.Y

shouldapologizeformakingthecommentinaplacewherePaulacouldhearit.Yneeds

tostate

her

focus

is

on

Paulas

treatment.

Becausesexualabuseissuchanimportantissue,Collegesmusttakeitveryseriously.Each

Collegemusttakestepstopreventsexualabusefromoccurring.Forexample,thePatient

RelationsCommitteeoftheCollegemustdevelopasexualabusepreventionplanthatwill

educatepractitioners,trainingprograms,employersofpractitionersandthepublicabout

avoidingsexualabuse.

Inaddition,practitionersarerequiredtomakeareportwherethepractitionerhasreasonable

groundstobelievethatanotherhealthproviderhasengagedinsexualabuse.Thereportis

made

to

the

Registrar

of

any

health

College

where

the

other

health

provider

is

a

member.

For

example,ifapatienttellsapractitionerthatherphysiotherapistfondledher,thepractitioner

mustmakeawrittenreporttotheRegistraroftheCollegeofPhysiotherapistsofOntario.This

reportingobligationisdiscussedinmoredetailbelow,undertheheadingMandatoryReports.

Therearealsoanumberofspecialprovisionsdealingwiththehandlingofsexualabusematters

inthecomplaintsanddisciplineprocess.Suchcomplaintsarealwaystakenseriously.Ifthe

complaintinvolvessexualtouchingandifthereisevidencetosupportthecomplaint,areferral

todisciplineforahearingislikely.Atthedisciplinehearingtheidentityofthepatientis

protected.Thepatientmayevenbegivenaroleatthedisciplinehearing(e.g.,tomakea

statementontheimpactofthesexualabuseonthepatientifafindingismade).Wherethe

sexualabuse

involved

sexual

intercourse,

or

similar

sexual

acts,

and

afinding

is

made,

the

practitionersregistrationwillberevokedforaperiodofatleastfiveyears.Inallcaseswherea

findingofsexualabusehasbeenmade,thepractitionerwillbereprimanded.Ifafindingof

sexualabusehasbeenmade,thepractitionercanbeorderedtopayforthecostsofany

counsellingandtherapyofthepatient.

TheCollegeisalsoresponsibletopayforthecostsofanycounsellingortherapyneededbythe

patientifafindingofsexualabuseismade.


25/97

25

Practitionersshouldthereforeconsiderwaysofpreventingsexualabuse(oreventhe

perceptionofsexualabuse)arising.Experienceindicatesthatmostsexualabuseisnotdoneby

predators.Rather,inmostcasesthepractitionerandthepatientdevelopromanticfeelingsforeachotherandthepractitionerfailstostopit.

Whereanyromanticfeelingsdevelop,thepractitionerhastwochoices:

putastoptothemimmediately,or

transferthecareofthepatienttoanotherpractitionerimmediately.

Othersuggestionsforpreventingeventheperceptionofsexualabuseincludethefollowing:

Donot

engage

in

any

form

of

sexual

behaviour.

Ifapatientinitiatessexualbehaviour,putastoptoit.Besensitive,butfirmwhendoing

so.

Donotdatepatients.

Avoidselfdisclosure.

Avoidcommentsthatmightbemisinterpreted(Youarelookinggoodtoday).

Donottakeasexualhistoryunlessthereisagoodclinicalreasonfordoingso.Ifone

musttakeasexualhistory,explainwhyfirstandbeveryclinicalinonesapproach.

Donottouchapatientexceptwhennecessaryforassessingortreatingthem.Ifone

musttouchapatient,explainthenatureofthetouchingfirst,thereasonforthe

touchingand

be

very

clinical

in

ones

approach

(e.g.,

wear

gloves).

Consider

having

a

thirdpersonintheroomifexaminingorotherwisetouchingadisrobedpatient.

Donotcommentonapatientsappearanceorromanticlife.

Documentwellanyclinicalactionsofasexualnatureoranyincidentsofasexualnature.

Datingformerpatientsisasensitiveissue.Technically,itisnotsexualabusebecausetheperson

isnolongerthepractitionerspatient.However,itcanstillbeunprofessionalwherethe

practitionerstillhaspoweroverthepatient.Thereshouldbeanappropriatecoolingoff

period.Thelengthofthecoolingoffperiodwilldependonthecircumstances(e.g.,howlong

thepersonwasapatient,howintimatetheprofessionalrelationshipwas).

SexualAbuseScenarioNo.2

PractitionerXisattractedtohispatientPaula.Xnoticesthatheislookingforwardto

workingonthedayswhenPaulawillbethere.Xextendsthesessionsafewminutesin

ordertochatinformallywithPaula.XthinksPaulamightbeinterestedaswellbythe

waythatshemakeseyecontact.XnoticesthatheistouchingPaulaonthebackandthe

armmoreoften.XdecidestoaskPaulatojoinhimforacoffeeafterhernextvisitto

discusswhetherPaulaisinterestedinhim.IfPaulaisinterested,hewilltransferPaulas


26/97

26

caretoacolleague.IfPaulaisnotinterestedthenhewillmaketherelationshippurely

professional.Xdecidestoaskacolleague,Y,foradvice.

Y,correctly,tellsXthathehasalreadyengagedinsexualabusebylettingtheattraction

developwhilecontinuingtotreatPaula.YalsosaysthatitisimportantforXtotransfer

thecareofPaularightawayandcertainlybeforetheygettogetherforcoffee.

SampleExamQuestion

Whichofthefollowingissexualabuse:

i.

Takingasexualhistorywhenitisclinicallynecessarytodo.

ii.

UsingglamourshotsofscantilydressedHollywoodstarsasyourinteriordesign

themein

order

to

attract

younger

patients.

iii.

Tellinganemployeeasexualjokewhentherearenopatientsaround.

iv. Datingaformerpatient.

Thebestanswerisii).Thesepicturessexualizetheatmosphereattheclinicwhichis

inappropriateinahealthcaresetting.Answeri)isnotthebestanswerbecausetakinga

sexualhistoryisappropriatewhenitisneededtoassessthepatientanditisdone

professionally.Answeriii)isnotthebestanswerbecausethesexualabuserulesonly

applytopatients.Sexualbehaviourwithemployeesmay,however,constitutesexual

harassmentundertheHumanRightsCodeandcouldotherwisebeunprofessional.

Answer

iv)

is

not

the

best

answer

because

the

person

is

not

a

patient

at

the

time

of

dating.However,itmightstillbeunprofessionaltodateaformerpatientsoonafterthey

stopbeingapatient(or,sometimesever),particularlyifthepractitionerhadanintense

orintimateroleinthetreatmentofthepatient.

d. Interprofessionalcollaboration

Itisinthebestinterestofpatientsifalloftheirhealthcareprovidersworkwitheachother.

Membersofdifferentprofessionsworkingtogethertoservethesameclientiscalled

interprofessionalcollaboration.Suchcollaborationwouldhelpensurethattreatmentsare

coordinatedandaseffectiveaspossible.Collaborationwouldalsoreducethechancesofthere

beingconflicting

or

inconsistent

treatment

(e.g.,

drug

and

herb

interactions,

phasing

out

a

patientsdrugprescriptionsasotherformsoftreatmentbegintowork).Collaborationcould

alsoreducethechancesofpatientsreceivinginconsistentinformationandadvice.

TheRegulatedHealthProfessionsActrequirestheCollegetopromoteinterprofessional

collaboration.TheCollegetriestomodelthiscollaborationbyworkingtogetherwithother

healthColleges(e.g.,sharinginformationoninvestigations,developingstandardstogetherto

promotetheirconsistency).Inaddition,theCollegeattemptstohelppractitionerscollaborate

withmembersofotherhealthcareprofessionswhentreatingthesamepatients.


27/97

27

Thepatientcontrolstheextentofinterprofessionalcollaboration.Ifapatientisuncomfortable

withit,thepatientcandirectpractitionersnottosharethepatientspersonalhealth

informationwithothers.ThepractitionermustcomplywithsuchadirectionunlessoneoftheexceptionsinthePersonalHealthInformationProtectionAct(itisdiscussedinmoredetail

below)applies.

Practitionersshoulddiscussanyplannedinterprofessionalcollaborationwiththepatientwhen

possible.However,therearecircumstanceswherepriorpatientconsentisnotpossible(e.g.,

whenthepatientgoestothehospitalinanemergencyandthehospitalcallsaskingaboutwhat

treatmentthepatienthasreceived).Practitionerscandiscloseinformationneededforthe

treatmentofthepatientwithoutconsentsolongasthepatienthasnotprohibitedthe

practitionerfromdoingso.

Interprofessionalcollaborationonlysucceedsifpractitionersrespecttheircolleagues.Evenif

thepractitionerdoesnotagreewiththeapproachestakenbytheothercolleague,

communicationsshouldbepolite.Practitionersshouldshareinformationandcooperatewith

theircolleagueswheneverpossible.Reasonableattemptstocoordinatetreatmentshouldbe

made.Compromisesmaysometimesneedtobemade(e.g.,astowhichtreatmenttotryfirst).

Interprofessionalrivalriesshouldbesetaside;itisthepatientsbestintereststhatshouldcome

first.Attemptsshouldbemadetoavoidforcingthepatienttochoosewhichhealthcare

providertouse(avoidsaying:eithershegoesorIgo).

Where

interprofessional

collaboration

involves

working

in

a

multi

disciplinary

setting

(i.e.,

a

placewheremembersofdifferentprofessionsworktogetherandwherepatientsareoften

seenbymultiplehealthcareproviders),otherissuesarise,includingthefollowing:

Willthesettinghavesharedrecordsorwilleachpractitionerhaveseparaterecords?

Iftherecordsareshared,willthepractitionerkeepanyprivatenotesoutsideofthe

sharedrecord?Ifsohowwillthepractitionermakesurethattheotherhealthcare

providershaveaccesstotheinformationtheyneed?

Howdoesthesettingdealwiththewordingusedintherecords?Forexample,will

everyoneusethesameabbreviations?

Whathappenstotherecordsifthepractitionerleavestopractiseelsewhere?Willthe

patientbe

told

where

the

practitioner

has

gone?

Will

another

practitioner

from

the

settingtakeoverthepatientscare?Willthepatientbegivenachoice?Thepatient

reallyshouldbegivenachoicealthoughsomesettingswillonlydosoifthepatientasks.

Whoisthehealthinformationcustodianthatownstherecords?

Willtherebeonepersonwhohasoverallresponsibilityforthecareofthepatient?Ifso

who?Ifnot,howwillthepatientscarebecoordinated?

Howwilldisagreementsintheapproachtothecareofthepatientbedealtwith?Ifitis

thepractitionerwhoisindisagreement,whenandhowdoesthepractitionertellthe

patient?


28/97

28

Isthepatientawareofalloftheabove?

Thisisoneofthemanyareascoveredinthisdocumentinwhichapractitionershouldconsider

consultingwithhisorherownlawyer.

Whileinterprofessionalcollaborationwillbemorecomplicatedandchallengingforthe

practitioner,thisisthewayhealthcareisnowpractisedinOntario.Itisalsointhebestinterest

ofmostpatients.

InterprofessionalCollaborationScenario

PractitionerXpractisesalone.Heprovidesherbalandacupuncturetherapies.His

patient,Paula,

also

has

afamily

MD.

Paulas

family

MD

calls

unexpectedly

to

say

that

PaulaisnotrespondingtohermedicationastheMDhadexpected.TheMDhasjust

learnedthatXisalsotreatingPaula.TheMDwondersifanythingthatXisdoingmight

interferewithPaulasmedication.XremembersthathehashintedtoPaulathatheis

notsupportiveofthemedicationthatPaulaistaking.XwondersifPaulahasstopped

takingthemedicationwithouttellingtheMD.WhatshouldXsay?

Inmanyrespects,therehasalreadybeenafailureofinterprofessionalcollaborationin

thiscase.Xshouldhavediscussed thebenefitsofinterprofessionalcollaborationwith

Paula.RatherthanhintingathisconcernsaboutthemedicationthatPaulaison,X

should

have

discussed

the

concerns

openly

with

Paula

and

requested

permission

to

speakwithPaulasMD.Atthispoint,however,XshouldprobablyspeaktoPaulafirst

beforetalkingtotheMD.ItisnotclearthatPaulawouldwantsuchadiscussiontotake

placeanditisnotanemergency.XshouldobtainPaulaspermissiontospeaktotheMD.

e. Billing

TheCollegedoesnotsetfeesforpractitionerstocharge.Establishingfeesisnotpartofthe

mandateoftheCollege.Infact,theCollegedoesnotregulatetheamountapractitionercanbill

thepatientunlessthefeeisexcessive.Afeeisexcessivewhenittakesadvantageofa

vulnerablepatientorissohighthattheprofessionwouldconcludethatthepractitioneris

exploitingapatient.

However,theCollegedoesregulatethewayinwhichpractitionersbillpatients.Billingmustbe

openandhonest.Patientsmustbetoldtheamountofthepractitionersfeesbeforetheservice

isprovided.Thisincludesthecostofanyproductsbeforetheyaresoldtothepatient.Thebest

waytotellpatientstheamountofthefeesistogivepatientsawrittenlistordescriptionofthe

feesofthepractitioner.However,thepatientcanalsobetoldverballyortherecanbeasign

clearlydisplayingthefeesinthereceptionareaofthepractice.Theproblemwiththose

methodsofnotificationisthatthepatientmightforget.Thelistordescriptionofthefeesmust

includeallchargesincludinganypenaltiesforlatepayment.


29/97

29

Apractitionermustprovideanitemizedbillforanypatientwhoasksforit.Thebillmust

describetheservicesthatwereprovidedandtheproductsthatweregiven.Anydocumentrelatingtofees(e.g.,abillorareceipt)mustbeaccurate.Forexample,itwouldbeinaccurate

forthedocumenttodothefollowing:

Indicatethatthepractitionerwasprovidedtheservicewhensomeoneelsedid.

Indicatethewrongdatefortheservice.Forexample,itisunprofessionaltoputinadate

whenthepatienthadinsurancecoverageratherthantheactualdateofservicebecause

thepatientwouldnothaveinsurancecoverage.

Indicatethatoneservicewasperformedwhen,infact,anotherservicewasprovided.

Forexample,itisunprofessionaltoindicatethatacupuncturewasperformedwhenin

factaherbal

remedy

was

provided.

Billforservicesatmorethanthepractitionersusualratebecausetheserviceisbeing

paidforbyaninsurancecompany.

Indicatethataservicewasperformedwhen,infact,noservicewasperformed.For

example,itisunprofessionaltoindicatethatapatientvisitoccurredwhen,infact,the

patientmissedtheappointmentandalatecancellationfeeisbeingbilled.

Billforaproductformorethanitsactualcost.Theactualcostcanincludeareasonable

amountforthestafftimeforstorageandhandling.

Nofeecanbebilledwhennoservicewasprovided.Theonlyexceptionisthatafeecanbe

billedwhen

apatient

misses

an

appointment

or

cancels

the

appointment

on

very

short

notice.

Practitionerscannotofferareductionintheamountofabillifitispaidimmediately.That

wouldgivewealthypatientsanadvantageoverotherpatients.However,apractitionercan

chargeinterestinoverdueaccountsbecausethereisanactualcosttopractitionersincollecting

them.

Somepractitionersofferfreeinitialconsultations.Thisisoftenmoreofanadvertisingissue

thanabillingissue.Seethediscussionofadvertisingbelow.Themainpointisthatanysuch

offersmustbecompletelyhonest.Theinitialconsultationmustbecompleteandnotjusta

partialservice.Theremustbenorequirementtoattendasecondtime(e.g.,togettheresults).

Theremustbenohiddencharges.Theoffermustbeopentoeveryone.

BillingScenario

PractitionerX,hasapostedrateof$120pervisitinthereceptionareaofhisoffice.In

fact,ifthepatientispayingfortheservicepersonallyanddoesnothaveextendedhealth

insurancecoverage,Xwillprovideacreditreducingtherateto$99pervisit.Ifapatient

hasspecialfinancialneeds,Xwillconsiderreducinghisrateevenfurther;infacthehas

threeregularpatientswhopayonly$5pervisit.


30/97

30

Theabovescenarioiscontrarytotheprofessionalmisconductregulation.IneffectXs

postedfeesarenothonestandaccurate.Xis,ineffect,billingpatientswithinsurance

morethanhisactualregularrate.

Itisacceptable,however,forXtolowerhisactualfeeinindividualcasesoffinancial

hardship.Xhastodothisonacasebycasebasisandnotthroughageneralpolicy

intendedtohidehistruefee.

3. Law

a.

Typesoflaw

Thereare

anumber

of

sources

of

law.

They

include

the

following:

Statutes.Mostoftenwhenonethinksoflaw,onethinksofstatutes(alsocalledActs).

ThereareoverridingstatutesthattakepriorityoverotherstatutessuchastheCanadian

CharterofRightsandFreedoms.Thestatutesthatpractitionerswillneedtobemost

awareofaretheRegulatedHealthProfessionsActandtheTraditionalChineseMedicine

Act.StatutesaremadebytheLegislativeAssembly(inOntario,theLegislativeAssembly

isoftencalledQueensPark).

Regulations.Regulationsaremadebythegovernmentwhenastatutepermitsthemto

bemade.UndertheRegulatedHealthProfessionsActregulationscanbeproposedby

the

College

(e.g.,

registration,

professional

misconduct,

quality

assurance)

or

by

the

MinisterofHealthandLongTermCare(e.g.,controlledacts,professionalcorporations).

Bylaws.BylawsaremadebytheCollege.Theydealprimarilywiththeinternal

operationsoftheCollege.Somebylawsaffectmembers(e.g.,fees,professionalliability

insurance,informationthatmustbeprovidedbypractitionerstotheCollege,additional

informationthatcouldbeputonthepublicregister,electionofpractitionerstothe

CounciloftheCollege).

CaseLaw.Courtdecisionsareusedasaguidebylawyersandjudgeswhensimilarissues

ariseinthefuture.Courtstrytobeconsistent,solongastheresultisnotunfair.Court

decisionsareparticularlyimportantinguidingtheprocedureofCollegecommittees

(e.g.,investigationsbytheInquiries,ComplaintsandReportsCommittee,theDiscipline

Committee).

Guidingdocuments.TheCollegepublishesofficialdocumentscalledStandardsof

Practice,Guidelines,PolicyStatementsandPositionStatements.Thesedocumentsare

notactuallylaw.However,theyhelppractitionersandCollegecommittees

understandandinterpretthelaw.Assuchthesedocumentscanbeveryusefulfor

practitionerstoreadandunderstand.Thesedocumentsaresometimescalledsoft

law.

Belowisadiscussionofthelawsthataremostapplicabletothedailylifeofpractitioners.


31/97

31

b. RHPA

TheRegulatedHealthProfessionsActappliesequallytoall26healthColleges.ItsetsoutthedutiesandresponsibilitiesoftheMinisterofHealthandLongTermCare,theCollegesandeach

ofitscommitteesandofpractitioners.TheprofessionspecificstatuteofeachCollege

integratestheRegulatedHealthProfessionsActintothatstatutesothattheycanbetreatedas

oneAct.

i. Controlledactsanddelegation

Therearecertainhealthcareproceduresthatarepotentiallydangerousandshouldonlybe

donebyaproperlyqualifiedperson.Thesepotentiallydangerousprocedureshavebeenlisted

inthe

Regulated

Health

Professions

Act.

They

are

called

controlled

acts.

No

one

can

perform

controlledactswithoutlegalauthority.

Thefourteencontrolledactsareasfollows:

1. Communicatingtotheindividualorhisorherpersonalrepresentativeadiagnosis

identifyingadiseaseordisorderasthecauseofsymptomsoftheindividualin

circumstancesinwhichitisreasonablyforeseeablethattheindividualorhisorher

personalrepresentativewillrelyonthediagnosis.

2. Performingaprocedureontissuebelowthedermis,belowthesurfaceofamucous

membrane,

in

or

below

the

surface

of

the

cornea,

or

in

or

below

the

surfaces

of

the

teeth,includingthescalingofteeth.

3. Settingorcastingafractureofaboneoradislocationofajoint.

4. Movingthejointsofthespinebeyondtheindividualsusualphysiologicalrangeof

motionusingafast,lowamplitudethrust.

5. Administeringasubstancebyinjectionorinhalation.

6. Puttinganinstrument,handorfinger,

i. beyondtheexternalearcanal,

ii.beyondthepointinthenasalpassageswheretheynormallynarrow,

iii.beyondthelarynx,

iv.beyondtheopeningoftheurethra,

v.beyond

the

labia

majora,

vi.beyondtheanalverge,or

vii.intoanartificialopeningintothebody.

7. Applyingororderingtheapplicationofaformofenergyprescribedbytheregulations

underthisAct.

8. Prescribing,dispensing,sellingorcompoundingadrugasdefinedintheDrugand

PharmaciesRegulationAct,orsupervisingthepartofapharmacywheresuchdrugs

arekept.

9. Prescribingordispensing,forvisionoreyeproblems,subnormalvisiondevices,

contactlensesoreyeglassesotherthansimplemagnifiers.


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32

10. Prescribingahearingaidforahearingimpairedperson.

11. Fittingordispensingadentalprosthesis,orthodonticorperiodontalapplianceora

deviceusedinsidethemouthtoprotectteethfromabnormalfunctioning.12. Managinglabourorconductingthedeliveryofababy.

13. Allergychallengetestingofakindinwhichapositiveresultofthetestisasignificant

allergicresponse.

14. Treating,bymeansofpsychotherapytechnique,deliveredthroughatherapeutic

relationship,anindividualsseriousdisorderofthought,cognition,mood,emotional

regulation,perceptionormemorythatmayseriouslyimpairtheindividuals

judgment,insight,behaviour,communicationorsocialfunctioning.4

TheseventhcontrolledactreferstoformsofenergysetoutintheMinistersregulation.That

regulationlists

the

following

forms

of

energy

that

cannot

be

used:

1.Electricityfor,

i.aversiveconditioning,

ii.cardiacpacemakertherapy,

iii.cardioversion,

iv.defibrillation,

v.electrocoagulation,

vi.electroconvulsiveshocktherapy,

vii.electromyography,

viii.

fulguration,

ix.nerveconductionstudies,or

x.transcutaneouscardiacpacing.

2.Electromagnetismformagneticresonanceimaging.

3.Soundwavesfor,

i.diagnosticultrasound,or

ii.lithotripsy.

Sinceonlydiagnosticultrasoundisprohibited,thatmeansthattherapeuticultrasoundisnota

controlledact.

Theeighth

controlled

act

refers

to

the

definition

of

adrug

in

the

Drug

and

Pharmacies

RegulationAct.Thatisanimportantdefinitionforpractitionerstoknow.Itreadsasfollows:

drugmeansanysubstanceorpreparationcontaininganysubstance,

(a) manufactured,soldorrepresentedforusein,

4Itisanticipatedthatthelastcontrolledact,providingpsychotherapy,willbecomelawaroundthespringof2013.


33/97

33

(i)thediagnosis,treatment,mitigationorpreventionofadisease,disorder,

abnormalphysicalormentalstateorthesymptomsthereof,inhumans,

animalsorfowl,or(ii)restoring,correctingormodifyingfunctionsinhumans,animalsorfowl,

(b) referredtoinScheduleI,IIorIII,

(c) listedinapublicationnamedbytheregulations,or

(d) namedintheregulations,

butdoesnotinclude,

(e) anysubstanceorpreparationreferredtoinclause(a),(b),(c)or(d)

manufactured,offeredforsaleorsoldas,oraspartof,afood,drinkorcosmetic,

(f) anynaturalhealthproductasdefinedfromtimetotimebytheNaturalHealth

ProductsRegulationsundertheFoodandDrugsAct(Canada),unlesstheproductisa

substancethat

is

identified

in

the

regulations

as

being

adrug

for

the

purposes

of

this

Actdespitethisclause,eitherspecificallyorbyitsmembershipinaclassoritslisting

oridentificationinapublication,

(g) asubstanceorpreparationnamedinScheduleU,

(h) asubstanceorpreparationlistedinapublicationnamedbytheregulations,or

(i) asubstanceorpreparationthattheregulationsprovideisnotadrug;

Unfortunately,thisdefinitionreferstoanumberofotherprovisions.Practitionersmayneedto

dosomeresearchorobtainadvicewhendealingwithaspecificsubstance.Ageneralruleisthat

ifasubstancehasaDIN(drugidentificationnumber)itisusuallyconsideredtobeadrug.5

Itisimportantforpractitionerstobefamiliarwiththeabovelistofcontrolledacts.

ControlledActsScenarioNo.1

PractitionerXseeshispatientPaul.Paulmentionsanearachethathehashadfortwo

days.Xtakesalookandseesthatabughasgottenintohisearandhasbeenjammed

deepintotheinnerearcanal,perhapswithacottonstick.Xtakessometweezersand

gentlyworkshiswayintotheinnerearcanalandremovesthebug.Paulisgrateful.X

mentionstheincidenttoacolleaguewhoadvisedXthathehasjustperformeda

controlledactthatisnotauthorizedtoTCMpractitioners.X checkstheRegulatedHealth

ProfessionsAct

and

realizes

that

his

colleague

is

correct.

Therearefourwaysinwhichahealthcareprovidercanreceivelegalauthoritytoperforma

controlledact:

5Somenondrugsubstanceshavedifferentkindsofdrugnumberings,forexample,aNaturalProductNumber

(NPN)orHomeopathicMedicineNumber(DINHM).


34/97


35/97

35

Delegation.Ahealthcareproviderwhoispermittedtoperformacontrolledactcan

delegatethecontrolledacttoothers.Forexample,inthecontrolledactscenario

describedabove,ifXhadcalledPaulsphysicianandthephysicianhaddelegatedtoX

theremovalofthebugfromtheinternalearcanal,Xwouldbeauthorizedtoperform

theprocedure.Delegationcanbemadetoanotherhealthcareproviderortoan

unregisteredperson.Delegationissubjectto anumberofrules,includingthefollowing:

o Thepersongivingthedelegationislimitedbyanyreg