CAPACITY, RISK & MAKING DIFFICULT

DECISIONS

R Zacharias MD

The Planning Committee for this event has

done the following in the interest of Mitigating

Potential Bias:

• All PPC members and speakers have signed a COI form.

• All speakers have been emailed the certification/accreditation requirements for their presentation.

• Each presentation will be reviewed by the Academic Coordinator prior to its delivery. The coordinator will be looking for any signs of bias including use of brand names and logos of pharmaceutical companies.

• If bias is detected the PPC would review it and the speaker would be notified so that the bias can be corrected before the presentation is given. If the bias cannot be corrected or removed the session would be cancelled.

• If a bias is detected by a planning committee member during the presentation they would question the speaker about it.

• All biases would be reviewed at the next PPC meeting.

GOALS & OBJECTIVES

➤ build collegiality - meet and greet

After attending this session participants will be able to:

➤ define both the Health Care Consent Act (HCCA) & the

Mental Health Act (MHA)

➤ define when it is appropriate to treat without consent

➤ manage intoxicated patients in the ER

➤ discuss chemical restraint options

Conflict of Interest Declaration:

Presenter:

Rose Zacharias MD

Title of Presentation:

Capacity, Risk & Making Difficult Decisions

I have no financial or personal relationships to disclose

REFERENCES

Health Care Consent Act

https://www.ontario.ca/laws/statute/96h02

Mental Health Act

https://www.ontario.ca/laws/statute/90m07

CASE 1

➤ 45y/o male

➤ obviously intoxicated

➤ picked up by OPP for “behavioural disturbance” & brought to ER

➤ heading to the cells but pt states “You can’t keep me here, you’re

all a bunch of quacks, let me go!”

➤ AVSS & screening labs ok except Etoh=45

➤ after 1 hour in A12 asks to pee, security accompanies pt to

bathroom but upon exiting A12 bolts for the door

➤ nurse asks what you want to do with this guy and says “if we are

going to keep him you need to Form him”

CASE 2

➤ 36y/o female brought in by OPP with her 2 young kids from the

scene of a domestic dispute

➤ c/o shoulder pain form being restrained by her partner

➤ hx of depression & anxiety

➤ no beds available at the shelter

➤ tox screen +ve for benzodiazapenes and THC

➤ medically cleared w dx = shoulder sprain, awaiting crisis but

getting impatient, wants to leave

CASE 3

➤ 23y/o male apprehended from scene of MVC, non-belted driver

struck a tree at ~50km/hour on city street

➤ slurring and c/o headache

➤ OPP intend to press charges but brought to ER for medical

assessment

➤ after 30 minutes in A12 becomes belligerent and wants to leave,

states his headache is gone, refusing blood work, shouts “I’m

not going to hurt anybody, just let me go!”

HEALTH CARE CONSENT ACT

➤ an Ontario law that has to do with consent and capacity to

treatment

➤ HCCA states that a person has the right to consent to or refuse

treatment IF they have mental capacity

➤ CAPACITY = the ability to understand and appreciate the

consequences of the treatment decision

CAPACITY

➤ the ability to both UNDERSTAND information relevant

to the decision

➤ & to APPRECIATE the consequences of that decision

CAPACITY

➤ …deals with the process of decision-making and does not

depend on the actual choice made

➤ …is not a single ability that people have or don’t have - we use

different abilities to make different kinds of choices - capacity is

task-specific

MENTAL HEALTH ACT

➤ an Ontario law that governs detention in a psychiatric facility

➤ MHA is applied when a physician believes that a person is:

➤ a harm to self

➤ a harm to others

➤ unable to care for self

➤ AND if the physician believes that the person is suffering from

a mental disorder that will result in any of the above

then that physician may apprehend that person for psychiatric

assessment

EMERGENCY TREATMENT WITHOUT

CONSENT

➤ A treatment may be given without consent to an apparently capable

person IF:

➤ communication isn’t possible (language barrier, disability)

➤ steps have been taken to find means to communicate but still

unsuccessful

➤ the delay required to find means to communicate will prolong the

patient’s suffering or put the patient at risk of sustaining serious

bodily harm

➤ there is no reason to believe that the person does not want

treatment

ALL THIS MUST BE DOCUMENTED BY THE PHYSICIAN

MANAGING INTOXICATED PTS IN ER

➤ what are our legal obligations?

➤ informed consent ever be obtained from an intoxicated pt?

➤ what to do when an intoxicated pt refuses PE or tx?

➤ can an aggressive pt be physically or chemically restrained?

➤ legal responsibilities when an intoxicated pt is discharged from

ER

IT’S A CHALLENGE!

➤ disruptive

➤ beligerant

➤ noisy

➤ difficult to assess

➤ threat to safety

➤ raises stress level of staff and

other pts in ER

*risky b/c urgency can lead to

errors & harm

DUTY TO CARE

➤ by law, ER staff @ any 24/7

public hospital has a duty of

care to all who present for

medical services, including

those who are intoxicated

➤ includes duty to attend, dx,

treat and provide d/c

instructions

*can charge nurse advise pt to

leave?

MANAGING INTOXICATED PTS IN THE ER

➤ appropriate physical restraint may be necessary to complete the

assessment to determine if a medical emergency exists (via

security/OPP)

➤ this must be weighed vs. the pt’s capacity/competence

➤ if a pt can understand the information relevant to the decision

and appreciate the consequences of accepting or refusing,

then they are competent, EVEN IF THEY ARE UNDER THE

INFLUENCE OF ETOH/DRUGS

➤ if pt is not competent, and there is imminent threat to health,

MD has duty to do what is immediately necessary EVEN

WITHOUT CONSENT (consent should be obtained from SDM

ASAP and DOCUMENT!)

QUESTION

➤ If a patient is intoxicated, should they be considered incapable of

giving consent?

“ NO.

Assessment of capacity is a clinical one.

It is not based on a lab value such as

blood alcohol level.

-CMPA

QUESTION

➤ Is it appropriate to fill out a Form 1 when an intoxicated pt

refuses treatment?

“ UNLIKELY. Only where a clear mental

illness coexists with intoxication, and

all the criteria are met, would

involuntary admission be appropriate.

-CMPA

QUESTION

➤ When a pt has been restrained, is the attending MD required to

complete a Form 1?

“ Only if the pt meets the criteria of the

MHA, should a Form 1 be completed (ie:

risk & mental disorder) -CMPA

*prudent to clearly document how the MD

determined incapacity & why restraint was necessary

CASE 1

➤ despite intoxication, determine competency

➤ determine if the process of his decision making is sound

➤ if able to understand the decision & appreciate the

consequences and he still wants to go?

…let him go

CASE 2

➤ screen for risk to self, risk to others, inability to care for self

➤ does her “mental illness” result in risk @ this moment?

➤ if YES - Form 1

➤ if NO - and she is competent (appreciate & understand)

…let her go

notify CAS

CASE 3

➤ concern re:agitation resulting from head injury

➤ determine capacity

➤ chemically restrain for CThead

➤ no need for Form 1

➤ covered by the HCCA

➤ Chemical Restraint Options

➤ Olanzapine

➤ Loxapine

➤ Haldol

➤ Clopixal

➤ Lorazepam

➤ Diazepam

THANKS SO MUCH!

ROSE ZACHARIAS - LEAD PSYCHIATRY HOSPITALIST

MARISSA RODWAY-NORMAN - CHIEF OF PSYCHIATRY

OSMH